A DWF Study of the Madwaleni
HIV Wellness and ARV Operating Model
as of February 2010
Lynne Wilkinson
Only for distribution authorised by the author and/or the Donald Woods Foundation
1
Contents
1. Introduction ........................................................................................................................... 12
2. Brief overview of current Madwaleni HIV programme........................................................ 13
2.1
Government programme supported by private partnerships ................................................................. 13
2.2
Location ......................................................................................................................................................... 13
2.3
Catchment population and estimated HIV infection rates ...................................................................... 13
2.3.1
Characteristics of catchment population ........................................................................................... 13
2.3.2
Estimated catchment population ........................................................................................................ 14
2.3.3
Estimated HIV positive rate in catchment population ..................................................................... 14
2.4
HIV programme services ............................................................................................................................. 14
2.4.1
At each operational site ....................................................................................................................... 14
2.4.2
At the district hospital ........................................................................................................................... 15
2.5
Overview of HIV programme outcomes .................................................................................................... 16
2.5.1
Baseline characteristics of patients ................................................................................................... 16
2.5.2
Viral load and CD4 Interval Analysis ................................................................................................. 17
3. Cornerstones of Madwaleni HIV programme ...................................................................... 18
3.1
Promotion of HIV wellness – early access to healthcare and social support...................................... 18
3.1.1
Meaning of HIV wellness programme ............................................................................................... 18
3.1.2
Why focus on enrolling in the HIV programme when a community member is still well? ......... 18
3.2
Decentralisation to PHCs – bringing care closer to our community ..................................................... 18
3.2.1
Improving access to services ............................................................................................................. 18
3.2.2
Spreading the patient load .................................................................................................................. 19
3.2.3
Phased approach to decentralisation ................................................................................................ 19
3.3
Task shifting at all levels: Nurse led programme..................................................................................... 19
3.3.1
Why? ...................................................................................................................................................... 19
3.3.2
What do we mean by task shifting? ................................................................................................... 19
3.3.3
Nurse led HIV and ARV services ....................................................................................................... 19
3.3.4
Task shifting between categories of staff ......................................................................................... 20
3.3.5
Task shifting as practiced at Madwaleni ........................................................................................... 21
3.4
Peer educators form the backbone to the HIV programme ................................................................... 21
3.5
Patient advocacy through support groups ................................................................................................ 21
3.6
Creating a non-heirarchical staff structure ............................................................................................... 22
3.6.1
Regular opportunity to provide input into the development of the programme ........................... 22
3.6.2
Access to and teaching of HIV related knowledge .......................................................................... 22
3.7
Our patients all need to be ‘expert patients’ ............................................................................................. 22
3.8
Full community involvement ....................................................................................................................... 23
3.9
System support for all team members ...................................................................................................... 23
2
4. Extent of HIV services at Madwaleni Hospital in January 2005 ......................................... 24
4.1
Funding .......................................................................................................................................................... 24
4.2
Infrastructure ................................................................................................................................................. 24
4.3
Staffing ........................................................................................................................................................... 24
4.4
Available HIV services ................................................................................................................................. 24
5. Considerations in set up/development of the HIV programme ......................................... 25
5.1
Buy-in of government stakeholders ........................................................................................................... 25
5.1.1
Hospital management .......................................................................................................................... 25
5.1.2
Sub-district management .................................................................................................................... 26
5.1.3
District management ............................................................................................................................ 28
5.1.4
Provincial HIV Directorate ................................................................................................................... 28
5.2
Attracting donor funding and support partnerships ................................................................................. 29
5.2.1
Apply for employment in a vacant position at the hospital ............................................................. 29
5.2.2
Volunteer in this role ............................................................................................................................ 29
5.2.3
Obtain donor funding to fund role ...................................................................................................... 29
5.2.4
Set up NGO ........................................................................................................................................... 29
5.3
Managing donor funding.............................................................................................................................. 30
5.3.1
Key considerations ............................................................................................................................... 30
5.3.2
Funding management system ............................................................................................................ 30
6. Accreditation of hospital as an Eastern Cape accredited ARV site .................................. 32
6.1
Background ................................................................................................................................................... 32
6.2
Recent policy changes to accreditation process ..................................................................................... 32
6.3
Accreditation process and tools ................................................................................................................. 33
6.4
Accreditation of feeder PHCs/CHCs ......................................................................................................... 33
7. Human resource recruitment and retention ........................................................................ 34
7.1
Introduction .................................................................................................................................................... 34
7.2
Doctors to work at rural district hospital including for the HIV programme ......................................... 34
7.2.1
Obstacles to recruitment and retainment in rural areas ................................................................. 34
7.2.2
Strategies for recruitment and retainment in rural areas ................................................................ 35
7.3
Professional Nurses to work for the HIV programme ............................................................................. 37
7.3.1
Obstacles to recruitment and retainment in rural areas ................................................................. 37
7.3.2
Strategies for recruitment and retainment in rural areas ................................................................ 38
8. Human resource allocation to components of HIV programme ........................................ 40
8.1
Background ................................................................................................................................................... 40
8.2
HIV programme staffing .............................................................................................................................. 40
8.2.1
ECDOH staffing .................................................................................................................................... 40
8.2.2
Madwaleni HIV programme staffing .................................................................................................. 40
3
8.2.3
8.3
Optimal staffing ..................................................................................................................................... 41
Madwaleni HIV programme organogram (including OVC and HBC) ................................................... 41
8.3.1
Role of the HIV/OVC S&D manager .................................................................................................. 41
8.3.2
Role of HIV/ARV co-ordinator............................................................................................................. 42
8.4
Optimise human resource capacity - splitting up the working week ..................................................... 42
9. Flow chart of adult outpatient journey ................................................................................ 43
10.
Voluntary counselling and testing (VCT) ......................................................................... 44
10.1
Introduction .................................................................................................................................................... 44
10.2
VCT counsellor team ................................................................................................................................... 44
10.3
Where HIV testing is available ................................................................................................................... 44
10.3.1
At health facilities daily ........................................................................................................................ 44
10.3.2
At scheduled VCT community outreach days .................................................................................. 44
10.4
Protocols for pre- and post- test HIV counselling .................................................................................... 45
10.5
Outpatients department (OPD) at hospital ............................................................................................... 45
10.5.1
Background ........................................................................................................................................... 45
10.5.2
Scale up of VCT services in OPD ...................................................................................................... 45
10.6
Hospital wards .............................................................................................................................................. 46
10.6.1
Background ........................................................................................................................................... 46
10.6.2
Scale up of VCT in wards.................................................................................................................... 46
10.7
HIV department at hospital ......................................................................................................................... 46
10.8
Primary healthcare clinics (PHCs) ............................................................................................................. 47
10.8.1
Background ........................................................................................................................................... 47
10.8.2
Scale up of VCT at PHCs.................................................................................................................... 47
10.8.3
Strategies that have been successful in increasing VCT at PHCs ............................................... 48
10.9
VCT Community Outreach .......................................................................................................................... 49
10.9.1
Introduction ............................................................................................................................................ 49
10.9.2
Social welfare grant points .................................................................................................................. 49
10.9.3
Other VCT outreach sites .................................................................................................................... 52
10.9.4
VCT outreach sites that have been less successful ....................................................................... 53
10.9.5
VCT outreach data collection, follow up and monitoring system .................................................. 54
10.9.6
Considerations when conducting VCT community outreach ......................................................... 55
10.9.7
VCT outreach lessons learnt .............................................................................................................. 56
10.9.8
Long term outcomes of increased VCT outreach in the community ............................................ 57
11.
HIV support group.............................................................................................................. 58
11.1
Entry point into HIV wellness programme ................................................................................................ 58
11.1.1
Purpose of HIV support group ............................................................................................................ 58
11.1.2
Why mandatory attendance?.............................................................................................................. 60
4
11.2
Definition of HIV support group in the Madwaleni sense ....................................................................... 61
11.3
Exceptions to attending HIV support group to join the HIV wellness programme.............................. 61
11.4
HIV support group attendance requirements to enrol on HIV wellness programme ......................... 62
11.5
Continued attendance of the HIV support group not mandatory .......................................................... 62
11.6
HIV support group model ............................................................................................................................ 63
11.6.1
HIV support group membership ......................................................................................................... 63
11.6.2
Confidentiality within HIV support group ........................................................................................... 63
11.6.3
Format of HIV support group session ............................................................................................... 64
11.6.4
Splitting the HIV support group .......................................................................................................... 64
11.6.5
Strategies to keep experienced support group members coming back ....................................... 64
11.6.6
Training peer educator to provide group education on new topics ............................................... 65
11.6.7
Clinical referral from HIV support group ........................................................................................... 65
11.7
Setting up an HIV support group................................................................................................................ 66
11.7.1
Background ........................................................................................................................................... 66
11.7.2
Strategy used to set up HIV support groups .................................................................................... 66
12.
Adult HIV wellness and ARV programme......................................................................... 69
12.1
Enrolling in the HIV wellness programme................................................................................................. 69
12.2
Return HIV wellness visit to ascertain CD4 count ................................................................................... 72
12.3
Return HIV wellness visits thereafter ........................................................................................................ 74
12.4
ART preparation visits ................................................................................................................................. 75
12.5
ART adherence counselling and home visit ............................................................................................. 76
12.6
ART initiation ................................................................................................................................................. 77
12.6.1
Why still centrally .................................................................................................................................. 77
12.6.2
Preparation for patients scheduled for ART initiation ..................................................................... 78
12.6.3
Process on ART initiation date ........................................................................................................... 79
12.7
Continued management of adult patients on ART .................................................................................. 81
12.7.1
Preparation for patients scheduled for repeat ART supply ............................................................ 81
12.7.2
Process on ART repeat visit date ...................................................................................................... 82
13.
Decentralisation to PHCs .................................................................................................. 85
13.1
Background ................................................................................................................................................... 85
13.2
Preparation steps prior to phasing in decentralised HIV wellness and ARV services at PHCs ....... 85
13.2.1
Buy-in required...................................................................................................................................... 85
13.2.2
Peer educators selection and allocation ........................................................................................... 86
13.2.3
Training of staff ..................................................................................................................................... 86
13.2.4
Equipping ARV outreach team and PHCs ........................................................................................ 87
13.3
First phase: Set up HIV wellness and ARV readiness clinics at PHC ................................................ 87
13.3.1
Select a day once a week to run the HIV programme at each PHC ............................................ 87
5
13.3.2
Set up a HIV support group at PHC .................................................................................................. 87
13.3.3
Set up HIV wellness and ARV readiness clinic ............................................................................... 88
13.3.4
By completion of first phase................................................................................................................ 88
13.4
Second phase: Set up doctor-led ARV clinic .......................................................................................... 89
13.4.1
Period of second phase ....................................................................................................................... 89
13.4.2
Prior preparation at PHC ..................................................................................................................... 89
13.4.3
Set up ARV outreach team ................................................................................................................. 89
13.4.4
Schedule ARV clinic days ................................................................................................................... 89
13.4.5
Transfer existing ART patients to PHC ............................................................................................. 89
13.4.6
ARV outreach team preparation prior to leaving for PHC .............................................................. 90
13.4.7
System at PHC doctor-led ARV clinic ............................................................................................... 90
13.4.8
Procedure at the end of ARV clinic at PHC ...................................................................................... 91
13.4.9
Procedure at the end of ARV clinic by ARV outreach team at hospital ....................................... 92
13.5
Third phase: Remove hospital HIV dept nurse from ARV outreach team .......................................... 92
13.6
Fourth phase: Introduction of nurse-led ARV clinic ............................................................................... 92
13.6.1
Introduction ............................................................................................................................................ 92
13.6.2
Transfer of stable ART patients ......................................................................................................... 92
13.6.3
Pharmacy preparation for nurse-led ARV clinic............................................................................... 93
13.6.4
System at PHC nurse-led ARV clinic ................................................................................................ 93
13.7
Last phase: Fully decentralised HIV wellness and ARV clinic at each PHC ....................................... 93
13.7.1
ART initiation at the PHCs .................................................................................................................. 93
13.7.2
Further introduction of nurse-led ARV clinics................................................................................... 94
13.7.3
Continued monitoring of patient load at each PHC ......................................................................... 94
13.7.4
Completion of final phase to decentralisation of ARV services ..................................................... 94
14.
Prevention of mother to child (PMTCT) services ............................................................ 95
14.1
PMTCT patient flow chart ................................................................................................. 95
14.2
Background ................................................................................................................................................... 96
14.3
HIV testing of pregnant women .................................................................................................................. 96
14.3.1
Determining strategies with PHC staff to increase VCT uptake.................................................... 96
14.3.2
HIV testing reporting forming part of monthly peri-natal mortality meeting ................................. 97
14.4
HIV management prior to initiation of prophylactic ART ........................................................................ 97
14.4.1
Fitting into HIV wellness programme at PHC................................................................................... 98
14.4.2
Continued ante-natal care at PHC ..................................................................................................... 98
14.5
Referral system for low CD4 count or high risk pregnancy ................................................................... 99
14.6
Dual ARV therapy initiated and monitored at PHC ............................................................................... 100
14.6.1
CD4 count above guideline threshold and no high risk factors ................................................... 100
14.6.2
No CD4 count and no high risk factors ........................................................................................... 100
6
High Risk PMTCT clinic at Madwaleni .................................................................................................... 100
14.7
14.7.1
PMTCT HIV support group ............................................................................................................... 101
14.7.2
First visit at 26 weeks ........................................................................................................................ 101
14.7.3
Second visit at 27 weeks (not necessary if previously part of HIV wellness programme) ...... 102
14.7.4
ART initiation ....................................................................................................................................... 102
14.7.5
Continued management – ART repeats ......................................................................................... 102
Delivery at hospital or CHC ...................................................................................................................... 103
14.8
14.8.1
Background ......................................................................................................................................... 103
14.8.2
Maternity system ................................................................................................................................ 104
HIV exposed infant follow up (IFC) .......................................................................................................... 105
14.9
14.9.1
Birth recording system ....................................................................................................................... 105
14.9.2
PCR testing at PHC ........................................................................................................................... 105
14.9.3
PCR recording and follow up system .............................................................................................. 106
14.9.4
Giving the result to the mother ......................................................................................................... 106
14.9.5
Referral into the paediatric HIV (PART) clinic ................................................................................ 106
PMTCT patient monitoring and follow up ........................................................................................... 107
14.10
14.10.1
HIV and IFC database ................................................................................................................... 107
14.10.3
Follow up of PMTCT women and infants .................................................................................... 107
14.10.4
Communication system between HIV department and PHCs ................................................. 108
15.
Paediatric HIV wellness and ARV services .................................................................... 109
15.1
Paediatric patient flow chart...................................................................................................................... 109
15.2
HIV testing of children................................................................................................................................ 110
15.2.1
Protocols for HIV testing in children ................................................................................................ 110
15.2.2
Focus areas for HIV testing in children ........................................................................................... 110
15.3
Enrolling in the HIV wellness programme............................................................................................... 110
15.4
Return HIV wellness visit to ascertain CD4 count ................................................................................. 113
15.5
Return HIV wellness visits thereafter ...................................................................................................... 115
15.6
ART initiation ............................................................................................................................................... 116
15.7
Continued management of paediatric patient on ART ......................................................................... 116
15.7.1
15.8
Monitoring of paediatric HIV programme and its patients .................................................................... 117
15.8.1
16.
Down referral to PHC ......................................................................................................................... 117
HIV database ...................................................................................................................................... 117
Inpatient programme ....................................................................................................... 119
16.1
Background ................................................................................................................................................. 119
16.2
Inpatient flowchart ...................................................................................................................................... 119
16.3
Brief explanation of group 1, 2 and 3 ...................................................................................................... 120
16.3.1
Group 1 – Palliative step-up group .................................................................................................. 120
7
16.3.2
Group 2 – Fast track inpatients ........................................................................................................ 120
16.3.3
Group 3 – Discharged patients......................................................................................................... 120
16.4
System for delivery for HIV services to inpatients ................................................................................. 121
16.5
Staff allocation to inpatient programme .................................................................................................. 121
16.5.1
Peer educators work in wards on Mondays ................................................................................... 121
16.5.2
Doctor/pharmacy assistant/HIV dept nurse on Thursday ............................................................ 121
Communication tools used in inpatient programme .............................................................................. 122
16.6
16.6.1
Group 2 counsellor form .................................................................................................................... 122
16.6.2
Inpatient programme list – doctor communication tool ................................................................. 122
16.6.3
Doctors discharge summaries .......................................................................................................... 122
Monitoring of inpatient programme .......................................................................................................... 123
16.7
16.7.1
Monday report back meeting ............................................................................................................ 123
16.7.2
HIV database ...................................................................................................................................... 123
17.
Patient monitoring systems ............................................................................................ 124
HIV programme database ......................................................................................................................... 124
17.1
17.1.1
Introduction .......................................................................................................................................... 124
17.1.2
Principle elements .............................................................................................................................. 124
17.1.3
Ad hoc queries .................................................................................................................................... 125
17.1.4
Data capturing requirements ............................................................................................................ 125
17.2
Clinical meetings with professional staff ................................................................................................. 126
17.3
Report back and follow up meetings with peer educators/CHWs....................................................... 126
17.3.1
Introduction .......................................................................................................................................... 126
17.3.2
Report to professional staff ............................................................................................................... 127
17.3.3
ARV readiness follow up meeting .................................................................................................... 127
End of HIV wellness and ARV clinic meeting at PHCs ......................................................................... 127
17.4
18.
Appendices ....................................................................................................................... 129
18.1
Map of Madwaleni- Xora area .................................................................................................................. 129
18.3
Xora/Elliotdale location within Eastern Cape ......................................................................................... 130
18.4
Examples of task shifting used at Madwaleni ........................................................................................ 131
18.5
NDOH accreditation form/tool .................................................................................................................. 132
18.6
Accreditation criteria .................................................................................................................................. 133
18.7
Optimal HIV programme staffing.............................................................................................................. 138
18.8
Organogram HIV/OVC/HBC within hospital structure 2009 ................................................................ 140
18.9
Role of HIV/OVC S&D Manager within hospital/sub district/district structure 2009 ......................... 141
18.10
HIV/OVC strategy and decentralisation manager – job description ............................................... 142
18.11
HIV/ARV site co-ordinator – job description ....................................................................................... 146
18.12
Administrator – job description ............................................................................................................. 152
8
18.13
Data capturer – job description ............................................................................................................ 154
18.14
Splitting the working week to optimise human resources ................................................................ 155
18.15
Guideline for selection of peer educators/VCT counsellors and community health workers...... 157
18.16
HIV pre and post-test counselling protocols....................................................................................... 160
18.17
VCT statistic monthly record submitted by PHC to Madwaleni HIV programme .......................... 162
18.18
Summary of monthly PHC VCT statistics ........................................................................................... 163
18.19
Checklist for VCT community outreach............................................................................................... 164
18.20
VCT outreach testing site layout .......................................................................................................... 165
18.21
VCT consent form in English and Xhosa ............................................................................................ 166
18.22
VCT data collection stat sheet.............................................................................................................. 167
18.23
Referral letter .......................................................................................................................................... 168
18.24
Invitation to adolescent HIV support group ........................................................................................ 169
18.25
Example of annual VCT statistics ........................................................................................................ 170
18.26
VCT outreach follow up register ........................................................................................................... 171
18.27
VCT outreach outcomes evaluation tool ............................................................................................. 171
18.28
List of HIV support group topics for 2009 ........................................................................................... 172
18.29
Peer education training information ..................................................................................................... 173
18.30
Adult HIV wellness form – page 1........................................................................................................ 176
18.31
Adult HIV wellness form – page 2........................................................................................................ 178
18.32
Paediatric and Adult HIV wellness form – page 3 ............................................................................. 179
18.33
Cotrimoxazole pill count training sheet ............................................................................................... 180
18.34
Cotrimoxazole pill count form ............................................................................................................... 180
18.35
Protocol for Cotrimoxazole prophylaxis – HIV positive adults ......................................................... 181
18.36
Nurses guideline for clinical visit when patient joins HIV wellness programme ........................... 182
18.37
Danger signs in adults ........................................................................................................................... 183
18.38
Red flag symptoms in adults ................................................................................................................ 184
18.39
Useful nurse protocols for HIV wellness – Syndromic management of STIs................................ 185
18.40
Useful nurse protocols for HIV wellness – Diagnosing TB in HIV positive patients ..................... 187
18.41
Routine blood investigations protocol ................................................................................................. 188
18.42
INH prophylaxis protocol ....................................................................................................................... 189
18.43
ECDOH nutrition guideline for patients with HIV & AIDS ................................................................. 190
18.44
Peer educator 12 point guideline to adherence counselling ............................................................ 192
18.45
ART patient treatment file ..................................................................................................................... 193
18.45.1
English cover page......................................................................................................................... 193
18.45.2
English patient time and ART choice .......................................................................................... 194
18.45.3
English: Side effect explanation ................................................................................................... 195
18.45.4
English: Side effect explanation ................................................................................................... 196
9
18.45.5
English: ART drug diary ................................................................................................................ 197
18.45.6
English: side effect explanation.................................................................................................... 198
18.45.7
English: patient appointments ...................................................................................................... 199
18.45.8
Xhosa: cover page ......................................................................................................................... 200
18.45.9
Xhosa: patient time and ART choice ........................................................................................... 201
18.45.10
Xhosa: ART explanation................................................................................................................ 202
18.45.11
Xhosa: Side effect .......................................................................................................................... 203
18.45.12
Xhosa: ART drug diary .................................................................................................................. 204
18.45.13
Xhosa: side effect diary ................................................................................................................. 205
18.45.14
Xhosa: patient appointments ........................................................................................................ 206
18.46
Xhosa: Home visit form ......................................................................................................................... 207
18.47
ART start list ............................................................................................................................................ 209
18.48
ART start tag ........................................................................................................................................... 210
18.49
ART initiation consent forms: English version ................................................................................... 211
18.50
ART initiation consent forms: Xhosa version ..................................................................................... 212
18.51
ART prescription form ............................................................................................................................ 213
18.52
ART clinical monitoring forms – page 1 .............................................................................................. 214
18.53
ART clinical monitoring forms – page 2 .............................................................................................. 215
18.54
Simplified clinical guideline to ART initiation and prescription ........................................................ 216
18.55
Guideline to ART initiation and repeat adherence visits by pharmacy assistant .......................... 217
18.56
Diagrammatic representation of ARV patient journey to assist nurses.......................................... 223
18.57
Guideline nurse consultations .............................................................................................................. 224
18.58
High viral load guideline for nurses ..................................................................................................... 225
18.59
Short term side effect guideline for nurses ......................................................................................... 226
18.60
Useful nurse protocols for HIV wellness/ART management............................................................ 227
18.61
Repeat ART file list ................................................................................................................................ 229
18.62
Repeat ART dispensing list .................................................................................................................. 230
18.63
PHC down referral consent ................................................................................................................... 230
18.64
Medication labels .................................................................................................................................... 231
18.65
ART stock requisition ............................................................................................................................. 232
18.66
ART repeat file tags ............................................................................................................................... 233
18.67
Guideline to HIV wellness and ARV readiness programme procedure at clinics ......................... 236
18.68
Guideline to blood specimen and result procedure for PHCs ......................................................... 238
18.69
PHC blood investigations submission form ........................................................................................ 239
18.70
Drug requisition for doctor’s PHC box ................................................................................................. 240
18.71
Example of PHC nurse dispensing list ................................................................................................ 242
18.72
Guideline to doctor and nurse-led ARV clinic at PHC from pharmacy perspective ..................... 243
10
18.73
Nurse guideline to issuing ART to patients at PHC .......................................................................... 244
18.74
Guideline to PMTCT counselling by community health workers/peer educators ......................... 245
18.75
PMTCT referral consent form ............................................................................................................... 250
18.76
Patient journey through visit to PMTCT clinic at hospital ................................................................. 251
18.77
First PMTCT visit tag ............................................................................................................................. 252
18.78
Repeat PMTCT visit tag ........................................................................................................................ 252
18.79
Maternity ward tag .................................................................................................................................. 253
18.80
PMTCT follow up tag ............................................................................................................................. 253
18.81
Birth and infant follow up information – HIV database ..................................................................... 254
18.82
Infant follow up form ............................................................................................................................... 255
18.83
PART clinic referral form ....................................................................................................................... 257
18.84
PMTCT PHC feedback .......................................................................................................................... 258
18.85
Example of PMTCT PHC feedback extracted from HIV database ................................................. 259
18.86
HIV testing in children < 18 months protocol ..................................................................................... 260
18.87
HIV testing in children > 18 months protocol ..................................................................................... 261
18.88
Paediatric HIV wellness form – pg1..................................................................................................... 262
18.89
Paediatric HIV wellness form – pg2..................................................................................................... 263
18.91
Cotrimoxazole (Bactrim) prophylaxis in children ............................................................................... 267
18.92
PART Clinic Blood Draw ....................................................................................................................... 268
18.93
Development assessment guideline – PART clinic........................................................................... 269
18.94
Guidelines to paediatric patient journey < 12 months at diagnosis ................................................ 271
18.95
Guidelines to paediatric patient journey > 12 months at diagnosis ................................................ 273
18.96
HIV wellness tag for paediatric patient 1-3yrs ................................................................................... 278
18.97
HIV wellness tag for paediatric patient > 3yrs.................................................................................... 278
18.98
PART – WHO Staging ........................................................................................................................... 279
18.99
Danger signs in sick children ................................................................................................................ 280
18.100
Paediatric ART prescription and dispensing record ...................................................................... 282
18.101
Antiretroviral (and other) Drug Dosages Chart for Children (Madwaleni October 2009) ........ 286
18.102
Growth charts used in PART clinic .................................................................................................. 288
18.103
Nurse protocol – treating anaemia in children ............................................................................... 292
18.104
Doctor protocol – management of lipodystrophy in children on HAART ................................... 293
18.105
Group 1 ART initiation – doctor protocol......................................................................................... 294
18.106
Guideline to inpatient programme .................................................................................................... 295
18.107
Group 2 – counsellor form................................................................................................................. 298
18.108
Inpatient programme list – doctor communication tool ................................................................ 299
11
1. Introduction
The Madwaleni HIV wellness and ARV programme (Madwaleni HIV programme) outcomes have made it
worth describing the model in order that others may understand and consider any operational strategies
and/or mechanisms employed which may assist with similar programme development elsewhere in South
Africa and potentially Sub Saharan Africa.
This document will attempt to write up the current model used by the Madwaleni HIV programme including
all guidelines, protocols and other tools developed and utilised by the programme.
I will reflect retrospectively on considerations that if taken into account earlier may facilitate identifying
areas for programme establishment and/or ways in which to tackle aspects of programme development. It
will also note approaches that were tried along the way that either failed or were less successful.
People with varying roles within the provision of HIV services in the public sector may refer to this guideline
for different forms of guidance.
The first two sections provide an overview of the Madwaleni HIV programme, its background and its four
year outcomes.
The following six sections deal with broader strategic considerations used by programme within the context
of a district rural hospital.
The remaining sections deal with the detailed mechanics adopted in the delivery HIV care, treatment and
support services to the adults, children and pregnant women in the Madwaleni – Xora area of the Eastern
Cape, South Africa.
To ensure universal access for all South Africans to HIV testing, HIV wellness and ARV services, we need
every possible person’s assistance. This often means people not trained in public health and/or medicine
but those with varying backgrounds and skill sets. Many of the considerations, strategies and mechanisms
outlined in this document may be well known to you. I learnt most of them along the way and hope that it
proves useful to those of you who find yourselves in a similar situation to the one I found myself in five
years ago.
12
2. Brief overview of current Madwaleni HIV programme
2.1
Government programme supported by private partnerships
The Madwaleni HIV programme is an Eastern Cape Health Department (ECDOH) accredited and
funded HIV wellness and ARV programme. The programme is facilitated and supported by private
donor partnerships1.
2.2
Location
The Madwaleni HIV programme is based at Madwaleni district hospital, the Xora/Elliotdale
Community Health Centre (CHC) and Xora sub-district primary healthcare clinics (PHCs) in the
Mbashe sub-district of the Amathole district of the Eastern Cape (formerly part of the ‘Transkei’
homeland of the Apartheid government.
The district hospital operates both as the referral centre for the CHC and PHCs and as a PHC for its
own feeder area. The programme therefore consists of a referral centre and 8 operational sites in
total. (See maps of Madwaleni–Xora area and the location of Xora/Elliotdale within Eastern Cape in
appendices 18.1 and .18.2)
2.3
Catchment population and estimated HIV infection rates2
2.3.1
Characteristics of catchment population
The people living in the area are of African descent and are generally referred to as belonging
to the ‘Cape Nguni’ population group. The vast majority of people speak isiXhosa. The area
remains culturally traditional and is run by traditional chiefs and headman. The population
resides in scattered settlements usually on high lying ground and now more commonly, along
transport routes.
The catchment population is the poorest in South Africa. They predominantly reside in the
Elliotdale/Xora magisterial district which is regarded as the poorest magisterial district in South
Africa3.
Due to limited work opportunities in the area, the majority of the economically active population,
temporarily migrate outside of the area mostly to Gauteng (gold and coal mines) and Cape
Town4. They usually do not have the opportunity to take their spouses and/or children with
them. Many of the children are therefore cared for by their grandparents while their father (and
in some cases, mother) work in other places of South Africa. This migrant portion of the
population usually returns to the area for the Easter and Christmas holiday periods. They also
return permanently if they become too sick to work.
The most common sources of cash income are state welfare grants (child support grants,
disability grants and old age pensions). Other forms of income streams come from migrant
1
Aurum Institute for Health Research (PEPFAR) from October 2005 and the Donald Woods Foundation from March 2007.
2009
3
StatsSA (2007a) Measuring Poverty in South Africa 2007. Pretoria, Statistics South Africa
4
StatsSA(2009), Mid year population estimates, reflects the following highest estimated migration streams for 2006-2011
occuring in the Eastern Cape (the majority of outmigration likely to be occurring from the former Transkei homeland):
2
Province
EC
EC
-
FS
14 700
GP
93 400
KZN
84 200
LP
10 200
MP
12 500
NC
3 400
13
NW
27 900
WC
143 800
Out-migration
390 100
In-migration
116 500
Net migration
-273 600
remittances, limited local permanent work (e.g. general labourers, domestic workers and
cleaners), local occasional work (e.g. plastering houses, fixing kraals and weeding), forms of
self-employment (e.g. building, carpentry and informal trading) and the sale of livestock5.
2.3.2
Estimated catchment population
The estimated population in the direct catchment area (i.e. Madwaleni hospital, the CHC and 7
PHCs it services) is approximately 80 0006. Where the catchment population is increased to
account for persons outside the direct catchment area who are likely to be accessing services
at Madwaleni hospital, the total catchment population is estimated to increase to approximately
100 0007. The adult proportion of the population in the Eastern Cape is estimated at
approximately 60%8 while the proportion above 2 years of age is estimated at 94%.
2.3.3
Estimated HIV positive rate in catchment population
The 2008 national estimated HIV prevalence rate in the age group 15–49 is 16.9% while in the
Eastern Cape is 15.2%9. If the adult proportion of the population is estimated at 60% then this
provides a rough estimate of 7300 –9150 people in this age group infected with HIV in the
Madwaleni catchment area.
While the same data estimates the HIV prevalence rate in the population over the age of 2 years
nationally as 10.9% and in the Eastern Cape 9%. Therefore suggesting a rough estimate of
people infected with HIV in the Madwaleni catchment over 2 years of age as 6700 – 8500.
Therefore accurately estimating the total number of people in the Madwaleni catchment area
infected with HIV is difficult but could be roughly estimated as falling within the range of 7000 –
10000.
The HIV positive rate calculated from the 41 859 people tested by the Madwaleni HIV
programme from January 2005 to end December 2009 is 16.1%10.
2.4
2.4.1
HIV programme services
At each operational site




Voluntary counselling and testing (VCT) services;
Infant follow up services (testing of HIV exposed infants);
HIV support group (entry point into programme – see para 11 ниже);
HIV wellness services for adults (including TB services);
5
TIMMERMANS, H. (2004) Rural Livelihoods at Dwesa/Cwebe: Poverty, Development and Natural Resource Use on the Wild
Coast, South Africa. Institute of Social and Economic Research. Grahamstown, Rhodes University.
6
DHIS 2007 catchment population estimates for each PHC (including PHC on hospital premises) increased to account for
population growth rate 2007-2008 = 1,1 and 2008-2009 = 1,07 (from StatsSA(2009), Mid year population estimates).
7
This includes certain percentages of catchment populations of neighbouring PHCs also obtained from DHIS 2007 and increased
for population growth rates. 100% Ngwenya PHC, 100% Jalamba PHC, 50% Mpozolo PHC, 20% Phakamile, Msendo and Gwadu
PHCs.
8
Stats SA estimates the population for Eastern Cape in 2009 as 6 648 600 of which 2 231 600 are younger than 15 i.e. adult
population 15 – 80+ = 4 417 000 which is 66.44% (from StatsSA(2009), Mid year population estimates) . While DHIS 2007
estimates the adult population for the same catchment area around the PHCs as 58% (due to deep rural area more likely to be
higher number of children than general Eastern Cape).
9
National HIV Prevalence Incidence, Behaviour and Communication Survey 2008.
10
The programme does not have the data for the age spread of the people tested but the majority are adults.
14





ARV readiness11, treatment and monitoring services for adults and children;
Prevention of mother to child transmission (PMTCT) services;
Women’s health services specifically pap smears;
Home based care (HBC) services for HIV and/or TB patients who are unable to attend clinic;
and
Orphans and vulnerable children (OVC) services which includes children orphaned due to
the death of their mother/parents or a child infected with HIV.
Current staffing  Nursing staff employed by the PHC (no additional nursing staff employed) – based full time
at PHC (ranges from 1 – 3 professional nurses).
 5 – 8 community health workers (lay community members appointed to each PHC – based
full time in community/at PHC (differs between clinics)
 2 – 3 peer educators (HIV positive lay community members who are members of the HIV
programme and who were identified in the HIV support groups and subsequently trained) –
based at the HIV department (hospital) and attend their assigned PHC for one day a week
 Doctor, nurse mentor12 and pharmacy assistant – based at the hospital and attends the PHC
for half a day once a month (CHC for half a day twice monthly)
(all underlined staff appear under operational sites and district hospital as they are shared
between the hospital and the PHCs)
2.4.2
At the district hospital





Management and administration hub of all 8 operational sites HIV, OVC and HBC services;
Referral HIV clinic for operational sites;
Inpatient ARV readiness and treatment programme;
Paediatric HIV wellness, ARV readiness and ARV clinic; and
High risk PMTCT clinic.
Current Staffing  1 HIV/OVC strategy and decentralisation manager (HIV S&D manager) – based at HIV
department (hospital) overseeing all operational sites
 1 HIV/ARV co-ordinator – based at HIV department (hospital)
 1.5 - 2 doctor13 – based at the hospital but 1 doctor working at PHCs 2 half days a week
 1 nurse mentor14 - based at HIV department (hospital) but working at PHCs 2 days a week
 3 professional nurses, 1 staff nurse, 1 nursing assistant – based at HIV department (hospital)
 1 administrator – based at HIV department (hospital)
 1.5 data capturers – based at HIV department (hospital)
 2 - 3 pharmacy assistants – based at the hospital but working at PHC 2 days a week
 5 Community health workers (lay community members appointed to each ARV site) – based
full time at HIV department (hospital) and in the community
11
Paediatric ARV readiness programme only available at Xora CHC once monthly otherwise only at hospital.
Nurse mentor post was introduced as a one year initiative to work with the head HIV clinician to improve HIV management
nurse competencies both at HIV department at the hospital and at the PHCs. A nurse mentor was employed on contract from
Jun 09 – Jun 2010 and therefore only became part of this team recently.
13
1 full time doctor who also carries responsibility for 1 infectious diseases ward in the hospital. A further doctor from the
hospital is assigned to assist this doctor on Tuesdays (adult HIV clinic at hospital), Wednesdays (paediatric clinic at hospital and
principal doctor at PHC) and Thursdays (PMTCT clinic at hospital and principal doctor at PHC). More recently (late 2009) as part
of recruitment and retention strategy for foreign infectious disease doctors, these doctors have been assigned to facilitate
certain of the PHCs ARV clinics under the guidance of the head HIV clinician.
14
See footnote 8 on previous page.
12
15

2.5
15 Peer educators (HIV positive lay community members who are members of programme
and were identified and trained from HIV support groups) – based at HIV department
(hospital) but also working 2 days a week at their assigned PHCs
Overview of HIV programme outcomes
At 31 December 2009, the HIV programme had enrolled 4394 patients of which 2312 have been
initiated on ART. This includes 290 children under the age of 19 years of which 268 are under the
age of 15 years.
In a soon to be published paper, the following 4 year outcomes of Madwaleni HIV programme’s
adult cohort (19 years and older) will be reported. This analysis ends 30 September 2009.
2.5.1
Baseline characteristics of patients
Madwaleni Cohort
On ART
Group 1
Overall
Cohort
Subset
Number of patients
Age
Sex
When
Median
IQR
Missing
Female
Male
Unknown
Patient status at end of
study period
Current
Dead
LTFU
Transferred
CD4+ cell count
When
Median
IQR
Missing
When
Median
IQR
Missing
When
Median
IQR
Missing
TNF+FTC+EFV
D4T+3TC+EFV
AZT+3TC+EFV
D4T+3TC+NEV
AZT+3TC+NEV
AZT+DDI+LPV/r
Viral load (log10)
Weight (kg)
Starting regimens or
regimens transferred in
on
At starting ART
Duration in program
Duration on ART
Duration to ART
(months)
On TB therapy
Pregnant
Median
IQR
Median
IQR
Median
IQR
Transfer in
On ART
(subset of
Overall + On
ART-see para
16.3.1 ниже)
(not included in
overall cohort)
1804
Registration
33
(27 to 42)
2
69%
31%
10
71
Registration
33
(2 to 39)
27
60%
30%
9
72%
11%
6%
11%
33%
53%
6%
8%
97
Registration
33
(27 to 42)
2
64%
36%
55%
11%
7%
26%
Registration
**
Baseline
123
(55 to 184)
Registration
**
Baseline
4.8
(4.3 to 5.4)
1403
Baseline
56
(49 to 63)
730
<1%
85%
1%
14%
0.2%
0%
Registration
47
(20 to 81)
26
Registration
5.0
(4.5 to 5.0)
60
Not available
3315
Registration
31
(26 to 38)
18
73%
27%
12
Registration
**
NA
NA
NA
NA
16
32%
10%
18
(9 to 31)
13
(6 to 25)
2
(1 to 5)
<1%
68%
8%
18%
4%
1%
76%
4%
6
(1 to 20)
24
(11 to 39)
NA
0%
68%
8%
18%
4%
1%
24
(11 to 39)
AZT = zidovudine, 3TC = lamivudine, D4T = stavudine, DDI = didanosine, LPV/r lopinivr and ritonivir, NEV =
neviripine, EFV = efavirenz
2.5.2
Viral load and CD4 Interval Analysis
Interval Due Taken
6
1325 1044
12
983
764
18
699
538
24
500
390
30
332
242
36
203
159
42
107
81
48
37
24
Interval
6
12
18
24
30
36
42
48
Viral Load
% of
Suppressed
79%
984
Due
78%
724
77%
492
78%
359
73%
225
78%
147
76%
76
65%
23
Total due
1315
979
698
501
332
201
108
39
CD4 count
Taken
1053
781
551
390
243
160
81
28
17
% Suppressed
94%
95%
91%
92%
93%
92%
94%
96%
% of Due
80%
80%
79%
78%
73%
80%
75%
72%
Median
260
292
350
383
442
453
489
621
3. Cornerstones of Madwaleni HIV programme
3.1
3.1.1
Promotion of HIV wellness – early access to healthcare and social support
Meaning of HIV wellness programme
The entire Madwaleni HIV programme is referred to as the HIV wellness programme with the
ART programme falling within the wellness programme.
This may seem like semantics but integrally supports the long term goal to enrol all HIV positive
community members in the Madwaleni-Xora area in the HIV programme while such people are
still well and do not require ART. The focus of the programme is not on ART alone but ART as
part of HIV wellness. This will ultimately mean that no member of the community should ever
have to progress to having AIDS15. They will be prepared for ART while they are still well16.
When they clinically require ART, it will be a simple step to start treatment immediately.
3.1.2
Why focus on enrolling in the HIV programme when a community member is still well?
By a patient enrolling in the HIV wellness programme as soon after diagnosis as possible,
allows:




3.2
3.2.1
time for psychosocial self acceptance by the patient;
time for adherence related education in support group setting;
optimisation of staff resources; and
for less acute care which enables decentralisation bringing the service closer to the patient
and improving long term retention in care (see outcomes in para 2.5 выше) 17.
Decentralisation to PHCs – bringing care closer to our community
Improving access to services
15
Defined as CD4 count less than 200 or WHO stage 4 illness.
HIV positive patients with CD4 count lower than 100 have a higher mortality rate and worse immunological recovery when
started on ART
17
Where a patient has received clinical management since early on in their HIV diagnosis, the patient is less likely to require
extensive acute clinical care at any point. While a patient enrolling in the programme with a CD4 count of less than 100 will
utilise far more staff, pharmaceutical and other healthcare related resources.
16
18
The poverty of the catchment population, poor roads, cost prohibitive local transport and
topography make continued attendance at the district hospital very difficult for patients with
chronic conditions such as HIV. The closer such HIV services are to their homes, the more
likely that the patients will be able to meet their review dates for clinical monitoring and
continued ART supply.
The Madwaleni model has therefore focused on rolling out HIV wellness and ARV services at
the PHCs in partnership with the PHC staff (see details in section 13 ниже).
3.2.2
Spreading the patient load
Decentralisation of services to the PHCs reduces congestion at the centralized hospital facility
by spreading the increasing patient load between health facilities in the area. This allows the
HIV department at the hospital, the time necessary to manage more complicated clinical cases
and provide ongoing mentorship and outreach support to the PHCs.
3.2.3
Phased approach to decentralisation
The decentralisation of the HIV wellness and ARV services was implemented in a phased
approach to obtain the buy-in of PHC staff and to build the requisite capacity at the PHCs. It
also developed an acknowledged facilitation and support role for the HIV department at the
hospital. See detailed description of decentralisation process in section 13 ниже.
3.3
3.3.1
Task shifting at all levels: Nurse led programme
Why?
The biggest barrier to capacitating district health facilities to provide quality HIV related services
to all those in the community who need such services is the lack of professional human capital.
While innovative ways to recruit and retain professional staff need to be continually considered
and implemented (see section 7 ниже), alternative sustainable strategies are required to
provide the requisite capacity. Task shifting is such a strategy which has been implemented
with successful outcomes in ARV programmes in rural sub-Saharan Africa18.
3.3.2
What do we mean by task shifting?
A number of daily time consuming activities conducted by doctors, pharmacists and nurses can
be assigned to other categories of staff provided they are trained adequately to do so. In simple
terms, the lowest level worker who legally allowed to perform a task should be allocated such a
task and trained accordingly.
Based on the number of doctors, pharmacists, professional nurses, other categories of nurses
and lay staff (with or without qualifications) available to the South African healthcare system, the
cost of employing them and their willingness to take up employment in rural areas, it is far
easier to recruit and retain professional nurses than doctors and similarly lay community
members than more professional nurses.
3.3.3
18
Nurse led HIV and ARV services
See MSF ARV programmes in Khayalitsha and Lusikisiki, South Africa and Tyolo, Malawi
19
The importance of the availability of decentralised services, increasing patient loads and
scarcity of doctors in the public sector (especially in rural areas) mean that HIV services can
only be sustainable in the long term if principally managed by professional nurses at the PHC
level. However it is essential that professional nurses are capacitated and supported to
competently be able to provide such services.
In the Madwaleni model this support is principally achieved through:
 patient administrative support from the hospital;
 continual mentoring of nurses’ HIV management skills;
 doctor support at the PHCs monthly and for cases warranting referral, at the hospital; and
 human resource support through the services of the counsellors and pharmacy assistants.
These are all explained in further detail below. It is however important to highlight the focus
placed by the HIV programme on the continual mentoring of the professional nurses HIV
management skills both at the HIV department (in the hospital) and at the PHCs. In our
experience, formal short course training or ad hoc teaching sessions have not generally
improved the clinical HIV care rendered by nurses19. The HIV programme has improved such
care by routine mentoring in terms of which the doctor (or more recently the nurse mentor20) sits
with the professional nurse and guides her/him in the application of his/her clinical knowledge
and skills to the patient’s case before him/her21.
This mentoring approach and the phasing in of nurse led HIV and ARV services at the PHCs
has also meant that the Madwaleni model has the requisite capacity to initiate and clinically
monitor the large group of patients in the HIV wellness programme that will qualify for ART in
terms of the new guidelines expected in April 2010 which includes patients with a CD4 count of
less than 350 co-infected with TB.
3.3.4
Task shifting between categories of staff
The most common task shifting occurs between the following groups of staff:
 doctors to professional nurses
 professional nurses to junior categories of nursing staff and lay staff
 pharmacist to pharmacy assistants
Shifting HIV and ARV patient monitoring tasks away from doctors to nurses has optimised
limited doctor capacity to manage patients with complicated clinical presentations. It also
provides nurses with continued mentoring and therefore professional development which in the
long term, facilitates retention.
The scarcity of pharmacists in the public sector means that it is only feasible to dispense ART to
the patient load at various sites in a decentralized programme through the use of pharmacy
assistants (whether formally qualified or not).
Similarly a large number of specific tasks including counselling and co-ordinating patients can
be done by lay workers. It is important when employing a ‘task shifting’ strategy that lay
workers are not being trained to be nurses i.e. being trained on a broad set of skills. A lay
worker is effective where he/she is trained to complete a limited and specific task well.
19
There are exceptions to this statement but overall such training is not applied routinely in the management of HIV positive
patients.
20
Contracted for 1 year (mid 2009 – mid 2010) to further entrench the mentoring done by the head HIV clinician to date.
21
Over time this is increased the quality of the nursing care and the efficiency of the HIV wellness and ARV clinics with less
unnecessary referrals to a doctor.
20
By way of example, it takes a lot of a nurse’s time to counsel a mother on appropriate formula
feeding once she has opted for formula feeding i.e. how to mix formula correctly, how to ensure
using clean water, how to sterilize bottle, how important it is not to mix feed with breast milk etc.
A lay worker can be trained in the key points to this specific counselling session. The specific
lay worker will counsel the mother each time she collects her next supply of formula feed to
ensure any changes to the mixing the formula are fully understood22. Implementing such a
counseling session by a lay worker has a compounded benefit. Not only does it save nurse
time but often ensures that the mother receives more comprehensive counselling.
3.3.5
Task shifting as practiced at Madwaleni
See examples of task shifting practiced in appendix 18.2.
3.4
Peer educators form the backbone to the HIV programme
The Madwaleni programme has identified active members of the HIV support groups to become part
of the HIV programme team. These HIV positive members of the community demonstrated
leadership qualities within the HIV support group context and have been approached to become
peer educators on the HIV programme. They have undergone both formal training on a number of
topics including voluntary counseling and testing (VCT) and ART adherence counselling and have
received continual in-service training and mentorship by the professional staff. For further
information on the selection, training and incentives paid to the peer educators, see appendix 18.14
and para 13.2.2 ниже).
The peer educators23 are central to the functioning of the HIV programme in that:
 they provide a direct channel of communication for the HIV programme into the community;
 they provide the HIV programme with valuable input on community culture and views which
impact on programme interventions;
 they have become a community resource on the HIV related issues24;
 they allow for optimisation of professional staff resources by taking on many of the tasks that
would otherwise take up time of nurses and doctors;
 they often have better communication and counselling techniques than professional staff with
the HIV positive patients as they are also infected with HIV and come from similar backgrounds
with a common language and heritage;
 they provide valuable support to all professional staff;
 their motivation and enthusiasm for their work in assisting with the provision of HIV services to
their communities has a positive impact on all staff; and
 they are the most mobile portion of the team operating equally at the hospital and the PHCs
thereby also strengthening the team approach between the staff at the HIV department at the
hospital and the PHCs.
3.5
Patient advocacy through support groups
Madwaleni HIV programme has 8 functioning weekly HIV support groups, one at each operational
site which each patient is required to attend when they first enrol in the programme. These HIV
22
This particular application of taskshifting in the Madwaleni HIV department has had positive results for decreasing infants
presenting with illness associated with incorrect formula feeding.
23
The CHWs at the HIV department are regarded as part of this group although they may not have HIV and do not travel to the
PHCs.
24
Many of the peer educators are consulted at their homes on weekends by community members on HIV related questions and
issues.
21
support groups provide not only psychosocial support and group counselling opportunities but also
communication and advocacy networks.
The patients who attend the HIV programme at their PHC come from the same villages and attend
the same HIV support group. They have largely of their own accord formed small supportive teams
who provide valuable information to the programme on each other’s whereabouts or difficulties.
This communication channel is of vital importance in a deeply rural area with limited access to
telecommunications and transport for patient follow up25.
3.6
Creating a non-heirarchical staff structure
The Madwaleni model functions on the principle that each member of the team has:
3.6.1
Regular opportunity to provide input into the development of the programme
Every member of the team’s input into the development of the programme is encouraged. This
has been achieved through the following forums:
 weekly meeting of programme staff including all lay staff26;
 a monthly counsellor support group facilitated by the hospital social worker; and
 various ad hoc discussion groups held with the counsellors regarding their input on specific
planned programme developments.
3.6.2
Access to and teaching of HIV related knowledge
In our community the most effective means of increasing the communities’ knowledge and
understanding relating to prevention and treatment of HIV (including the treatment of
opportunistic infections) is through ensuring that every member of the team has access to and
receives training (both formal and informal) on all HIV related knowledge27. Counsellors are
encouraged to impart this knowledge to their patients in the HIV support group setting. This
principle is closely linked with creating ‘expert patients’ discussed below.
Every 6 months, the entire team meets and each person is requested to submit at least one
topic which he/she feels he/she would like to gain a better understanding. These requests are
then included in the training provided by doctors, nurses, pharmacists and programme
management throughout the following 6 month period.
3.7
Our patients all need to be ‘expert patients’
It is essential in a poorly resourced rural area that the programme is able to rely on our patients’
knowledge of their illness, its treatment and the monitoring of their health. This takes more time in a
setting such as Madwaleni with widespread illiteracy28. However taking the time up front to ensure
as greater an understanding as possible by each patient has had large scale benefits for the
programme’s long term outcomes.
25
Such groups of patients have also on a number of occasions worked as a team when weather conditions resulting in limited
transport or flooding rivers have made it impossible for all to attend to collect their ART supply.
26
Programme management that facilitates this meeting actively encourages contributions and input from the counsellor team
each Monday.
27
It is our experience that district hospital hierarchical structures often actively oppose junior level staff from obtaining an
understanding of clinical information which is traditionally regarded as falling into the professionall realm of doctors or nurses.
28
Teaching people to tell the time and ways of remembering the names of the ARVs (e.g. R5 for Efavirenz) when then they
cannot read etc takes up substantial counsellor time.
22
Each patient is expected to be able to provide an explanation of how HIV works, his/her ARVs
(including the names thereof and how they are taken), an understanding of achieving a suppressed
viral load, the importance of monitoring their CD4 count and danger signs to report to medical staff.
Both group education in the HIV support group setting and individual adherence counselling is used
to repeat and confirm an understanding of this information29.
3.8
Full community involvement
The wider community involvement is vital if the programme is to attain its goal of enrolling every HIV
positive member of the community and achieve full coverage in the catchment population.
The model has used the following strategies for obtaining wider community involvement:





3.9
absorbing HIV positive community members into the HIV team;
communicating with the local chiefs through the traditional leader meetings and obtaining their
permission, buy in and active support of initiatives in their communities30
communicating with politically elected ward counsellors and church leaders and requesting their
assistance with initiatives in their communities;
training groups in the community such as the traditional healers; and
involving other community services such as the police/prison services/education departments.
System support for all team members
The HIV programme database provides a patient management system which ensures that all team
members are provided with reports which facilitate them doing their jobs effectively. See section
17.1 ниже31. This takes away a large amount of time consuming work which would have had to be
carried out on an ongoing basis to determine ART drug requirements of the programme, where the
patients collect their ART, which patients have collected their treatment, which patients have blood
results that require action etc.
29
The HIV support groups are proud of their knowledge. This is evidenced when a person is transferred into the programme
from elsewhere and knows very little about his/her ARV treatment. Great satisfaction is taken by active members of the support
group from teaching these people who come from the cities about their HIV and its treatment.
30
Examples of such initiatives have been: 1) the community noticeboards advertising the HIV services which were put up on the
properties of the local chiefs and headman 2) obtaining their blanket permission for running HIV testing stations at all communit
events including at the social welfare grant points.
31
This system was only written and implemented in 2007. It was written by me and the then community service pharmacist
with a programming background and is tailored to the Madwaleni model. Prior to that a more basic systems using an excel
workbook was used (this was imported into the access database).
23
4. Extent of HIV services at Madwaleni Hospital in January 2005
4.1
Funding
Madwaleni hospital is old missionary hospital which was bought from the church by ECDOH.
Madwaleni hospital and all its services including HIV were solely funded and supported by the
ECDOH.
4.2
Infrastructure
The hospital had assigned a ward in the Female TB ward to the HIV programme. This was one
ward, split by a half wall which could take 6 beds on either side.
4.3
Staffing
1 professional nurse was allocated to the HIV programme.
4.4
Available HIV services
In January 2005 a community member could access the following HIV services at Madwaleni
hospital:
 a HIV test upon request on arrival at the hospital. The person would be referred to the VCT
department in the TB ward for such test;
 if the person tested HIV positive, he/she would be given a date to come back for a CD4 test and
then a further date to come back for their CD4 result;
 provision of prophylactic treatment (Cotrimoxazole, Vitamin Bco and Folic acid) to HIV positive
patients;
 referral to the out patients department (OPD) if a person was sick;
 a small support group for people living with HIV which the professional nurse ran weekly to
discuss healthy living.
24
5. Considerations in set up/development of the HIV programme
5.1
Buy-in of government stakeholders
The four tiers of government stakeholders who need to be consulted and whose buy-in is required
are:




5.1.1
hospital management
health sub-district management
district management
HIV Directorate at provincial level
Hospital management
Senior district hospital management includes the hospital manager, the clinical head (managing
chief medical officer/clinical manager (medical)32), the nursing head (nursing services manager)
and the administration head (middle manager administration).
It is important to meet with all the above members of hospital management and understand how
they see their current HIV programme (most district hospitals will have some form of HIV
programme by now due to national and provincial pressure) and how receptive the hospital will
be to facilitation, assistance and integration into hospital rendered services33.
Buy-in from hospital management while strategically essential is also important for a number of
daily operational reasons:
 making infrastructure at the hospital available – space needs to be identified and made
available for use (where there is none) or for expansion (where the current space is
inadequate).
 cross departmental staff use – it is important that the HIV programme not be considered as
separate from the rest of the hospital. Optimising staff by using doctors, nurses,
pharmacists and pharmacy assistants from the hospital to support the programme is
essential (see para 8.2.3 ниже).
 funding and procurement of goods and services – the National Department of Health
(NDOH) allocates conditional grants to fund priority programmes such as HIV. This means
that provincial government receives both their equitable share budget and additional
conditional grants to facilitate certain priority programmes. The ECDOH HIV Directorate
therefore allocates ARV sites a portion of the conditional grant and this appears separately
on the hospital budget. As the number of patients on ARV treatment has increased and the
number of sites has increased in the Eastern Cape, the conditional grant available for
allocation to ARV sites at district hospitals has shrunk to negligible amounts34.
Unfortunately as this funding was reflected separately, many hospitals consider ARV sites
to be funded from this budget alone and do not consider it their responsibility to fund
operational costs of the ARV site from the hospital’s portion of the equitable share budget
which is used for all other operational costs of the hospital. It is important that the hospital
management acknowledges that it is responsible for the operational costs of the
programme. It consequently helps that the same processes are followed for procurement
as the rest of the hospital. It needs to be agreed up front that the hospital can first use the
32
New title under Occupation Specific Dispensation (OSD)
In my case I also obtained provincial HIV Directorate support of my role which assisted with hospital management with
adopting a different strategy from the norm to develop their HIV programme.
34
R30 000 for 2008/2009 budget year.
33
25
conditional grant funding to pay for goods and services procured by the ARV site and will
thereafter use the hospital budget.
 pharmacy role – pharmacy departments are understaffed and often badly managed in rural
hospitals. It is therefore important that the hospital management understands the
dependence of the ARV site on support of the pharmacy department. Inclusion of the head
pharmacist in all HIV management related meetings is important.
 integration of HIV services into other hospital services - including hospital wards, the
maternity unit and the outpatients department.
 hospital board and community support – hospital management understands the community
leadership structures and their assistance is vital to form a working relationship with the
board and the community leadership.
5.1.2
Sub-district management
In the Eastern Cape, the clinic structure falls under the management of the health sub-district.
Both the district hospital and the health sub-district fall under the management of the district.
This means that the hospital and sub-district management systems have separate reporting
lines to district and in many cases do not work together.
A decentralised HIV programme is set up through the district clinic structure. It is therefore
equally important to obtain the buy-in of the sub-district management. In addition, vital to the
success of such an HIV programme is the facilitation of the co-operation between the district
hospital and the sub-district in order that the hospital and sub-district clinics provide an
integrated health service35.
The key persons within the health sub-district management team are:








the sub-district Health Manager
the All Programmes Manager
the HIV Comprehensive Care and Treatment (CCMT) Manager
the HIV Prevention Manager
the Mother and Child Women’s Health (MCWH) Manager
the Nutrition Manager
the Middle Manager for the Health Centre
the Clinic Supervisor (responsible for PHCs)
Madwaleni HIV programme is run by the HIV/OVC strategy and decentralisation manager (HIV
S&D manager – see para 8.3.1 ниже for role and responsibilities). Central to this role is
facilitating team work between the hospital and sub-district to provide a seamless HIV service to
the community.
To run a decentralised programme, the sub-district’s buy-in is also necessary for effective
utilisation of the PHC staff. By actively involving them, it becomes more common place for
them to involve the HIV programme in sub-district health HIV related initiatives36.
Strategies used to facilitate this team approach include:
35
Madwaleni HIV programme stuggled from 2005 to 2009 when the hospital and its feeder PHCs fell into separate sub districts
(KSD and Mbashe respectively) under separate districts (OR Tambo and Amathole respectively).
36
Without this active focus, it is common for the sub-district to implement a new HIV related policy/initiative at the PHCs
without involving the HIV programme despite its central role in the provision of HIV and ARV related services.
26
Quarterly meetings The buy-in to the importance of such meetings between the HIV programme senior
management and the sub-district needs to be obtained. These will usually need to be arranged
and followed up by the HIV/OVC S&D manager to ensure they take place. In addition, detailed
minutes of the meeting need to be taken and circulated37. This forum is used for:
 informing each other of current HIV service related initiatives of either the HIV programme or
the sub-district and how these can be supported by both;
 to brain storm effective implementation strategies for new initiatives38;
 to follow up on initiatives or elements of programme implementation that are not working
well;
 to determine where the support of the either party would assist the other party to improve its
HIV related service39; and
 to determine an action list for all members that needs to be reported on at the next meeting.
Regular contact with the relevant sub-district manager/clinic supervisor It is necessary to facilitate the continual communication between the HIV programme and the
sub-district managers especially the middle manager of the CHC and the clinic supervisor40.
This cultivates a team approach creating interdependence on each other.
Examples of such are:
 requesting the clinic supervisor to allocate the VCT outreach team (i.e. a PHC professional
nurse and 2 community healthworkers) on the social grant days (see para 10.9.2 ниже).
This increases capacity for these 2 days month and also includes the sub-district in providing
these services (the responsibility for the provision of such services falls under the sub-district
not the hospital).
 continual contact with regard to running the HIV wellness and ARV clinics at the PHCs
including the staffing of PHCs on the relevant day (see 13 ниже). A common problem at
PHCs is lack of staffing but this is compounded by sub-district and district demands which
pull the staff from the PHCs for many days in the month41. It is important to be aware of the
PHC staffing for the scheduled day and involving the clinic supervisor in solving the
problem42.
Fostering a united front at ground level In our experience, the nurses at the PHCs have for many years had an increasing burden of
care placed on them with little active support. By providing this support and assisting them to
provide quality HIV services to their patients, has resulted in them buying into the HIV
programme and their role in it. Examples of this are:
37
In our experience the minutes need to be documented by a high level manager who is able to succinctly summarise the points
made in these meetings.
38
By way of example, the effective implementation of the PMTCT dual therapy at PHC level to ensure these women are
captured into the HIV programme for their own long term health.
39
By way of example, the home based care programme relies on the PHC community healthworkers however they were not
responding to direction from the HBC co-ordinator. The sub-district was able to call a meeting and explain that they were
supporting the home based care programme to assist the sub-district to provide effective home based care and that the HBC coordinator was their superior in this regard. Conversely, VCT at the PHCs is often holted by the lack of HIV testing kits. It was
therefore agreed through the HIV programme that the hospital pharmacy would assist with the emergency provision of these
kits to ensure a continuous VCT service.
40
This is time consuming and initially may not reap any rewards but in the long term facilitates sustainable programme
development.
41
Examples of this are attendane of training and meetings (whether relevant to the particular PHC or not), delivery of statistics
in person to the sub-district etc.
42
In many instances the HIV programme has taken the staffing problem upon itself, creating staff shortages elsewhere and
tension amongst its own staff. Involving the clinic supervisor in solving their problem and where necessary meeting half way to
find a solution has resulted in the sub-district taking some responsibility for its demands on PHC staff.
27
 regarding the PHC staff as part of the HIV team at all points;
 prioritising the funding needs of the PHC to enable it to provide its services43;
 providing additional staff resources especially in the form of counsellors and pharmacy
assistants on the HIV wellness and ARV clinic days at the PHC;
 putting telecommunications44 in place so that the PHC staff can contact the HIV programme
management and doctors;
 providing feedback to the PHC staff regarding their patients;
 involving the PHC staff in showing off the HIV programme as it functions at their PHCs within
the community and also to donors, press etc.
5.1.3
District management
The stronger the district management is, the more it will be able to support the decentralised
service provided by the sub-district clinic system with the support of the district hospital.
The buy-in of the district management should be obtained by the hospital and sub-district
management. However the HIV programme management keeping the district in the loop will be
advantageous.
5.1.4
Provincial HIV Directorate
Both a donor and a donor funded NGO working in a district hospital and sub-district will require
approval from the HIV Directorate and the Superintendant General (SG) of the provincial
department of health.
This approval has to be recorded by the signature of a Memorandum of Agreement (MOU)
between the donor/NGO and the ECDOH. The MOU will set out the extent of the support that
will be provided including the specifics of any funding provided. In addition, it will importantly
stipulate the time frame of such support.
The HIV Directorate ensures that such assistance is spread through government hospitals and
is therefore unlikely to support such partnership at sites where other major donors are already
involved.
The HIV Directorate in the Eastern Cape has a head HIV Comprehensive Care and Treatment
(CCMT) Manager. This person in turn manages region specific CCMT managers (these
regions incorporate a number of districts45). Establishing an open communication channel with
the responsible sub CCMT manager is useful46.
The HIV Directorate also runs centralised ARV site meetings47. These are useful forums for
obtaining an understanding of new HIV related policies, government funding for ARV sites, ARV
43
While the programme functioned at the PHCs before, Madwaleni HIV programme was fortunate enough to be able to raise
funding to build community counselling buildings at each PHC over 2008 and 2009 to increase space at the PHC thereby
prioritising the PHCs needs within the HIV programme.
44
Initially most of the PHCs in this area had no telephone lines. A cell phone was purchased for each with an allotted amount of
airtime to contact a fixed list of contacts.
45
The Eastern Cape has been split into 2 regions with 2 region specific CCMT managers.
46
Although often dependant on the encumbent individual. Establishing a good personal relationship has helped Madwaleni
obtain information which it may not otherwise have been notified of. For example, when the HIV Directorate plans to centrally
procure equipment or advertise all vacant posts at ARV sites, Madwaleni can utilise the oppportunity to submit its list of
equipment reqired or vacant posts etc.
47
In 2005-2007, all ARV sites were called to a quarterly meeting. With the increase in the number of sites, this is now happening
per district. However these meetings are less frequent and no longer provide a direct channel to the head of the HIV Directorate
as was the case in the early days under the management of Ms Makwadini.
28
supply issues, National Health Laboratory Service (NHLS) issues, human resource issues
including barriers to appointments etc48. It also creates an opportunity to establish a network of
contacts between the Eastern Cape ARV sites which helps with keeping all those working at
ground level informed49 and with the transfer of patients on ART around the province.
5.2
Attracting donor funding and support partnerships
It is not always possible to involve a donor or an external non profit organisation (NGO) in the early
stages of setting up a comprehensive HIV programme. It is often necessary for either an external
person/s or a person/s already working at the health facility to become involved in the facilitation
thereof so as to demonstrate to donors the potential within the specific government funded health
facility or programme.
For an external person/s to do so, the following options could be considered:
5.2.1
Apply for employment in a vacant position at the hospital
After discussion with the hospital management regarding the external person’s purpose and
their support thereof, the hospital could indicate which posts are vacant that could be used for
this purpose50. Such person could apply for the post and thereby officially be part of the hospital
structure and staffing. This provides a good base for such work.
5.2.2
Volunteer in this role
This option is often the only possibility in the beginning. It is important to ensure that the
hospital management buys into the external person’s role despite its voluntary nature and that
this only a temporary solution while obtaining a permanent government post or requisite
funding.
5.2.3
Obtain donor funding to fund role
It is vitally important that if a donor funds this role, it is agreed with the hospital management
that the external person will be seconded to the hospital/government. How this person will fit
into the government organogram needs to be agreed up front with the requisite reporting lines
in place51.
5.2.4
Set up NGO
A further option is to set up an NGO (whether funded or unfunded) that works alongside the
hospital in this role. The risk that needs to be closely managed in this case is any perceived
division between the government funded hospital and NGO run HIV programme. This may
impede full integration of the HIV services within the hospital which may lead to long terms
sustainability issues.
48
It is important to follow up with the HIV Directorate when the next meeting will take place as rural hospitals are often not
invited or invited at the last minute.
49
It is often through colleagues at other ARV sites that Madwaleni has become aware of an important meeting to attend or an
opportunity to obtain training for staff or the procument of goods/donations.
50
Such a vacant post is likely not to be at the management level involved in setting up the programme but is a good base from
which to operate. In my case I first volunteered and then applied for the post of the HIV site co-ordinator. The head nursing
post in the ARV organogram (initially a level 9 but now level 10 ECDOH).
51
If this is not agreed up front, it may well later cause an unnecessary division between the HIV programme and the hospital or
district management structures.
29
Once the HIV programme’s potential can be demonstrated, attracting donor funding to support a
government operated HIV programme is easier then obtaining funding for independent NGOs
providing HIV services to a community. Donors prefer to partner with government in the
development of such programmes for purposes of long term sustainability of such services.
Where it is possible to involve a donor or an external NGO early on, it is similarly important to
consider how the relationship between it and the health facility is set up to promote integration and
oversome any perceived division between the two. Introducing a separate entity with its own staff
and budgets that works alongside the public sector facility to assist with the operation or to directly
operate the HIV programme has had negative results for HIV programmes in the Eastern Cape. As
far as possible, staffing, funding and facilitation needs to be operated through the public sector
structures and systems.
5.3
Managing donor funding
While this guideline will not detail the processes involved in obtaining donor funding and the
management of donor required reporting, it will set out the way in which the Madwaleni HIV
programme manages the funding obtained from donors within the context of a public sector HIV
programme.
5.3.1
Key considerations
The key considerations for the Madwaleni HIV programme in determining the most appropriate
mechanism included:
 requiring immediate access to funds without the extensive bureaucracy and paper work
involved in utilising government funding and to a large extent limiting the operational ability of
public sector programmes;
 limiting the need to co-ordinate the payment of each expense incurred directly by a donor;
 not creating a separate NGO which could result in failing to integrate the HIV programme
into the public health facility structures and system and would further require audited
accounts (and the management and funding thereof); and
 ensuring that all stakeholders (government and donors) were satisfied with the system
adopted and the transparency thereof.
5.3.2
Funding management system
Setting up a bank account In order to manage cash flows, the Madwaleni HIV programme required a bank account. It
therefore opted to request one of its principle donors to open a sub account to its own bank
account. The donor must be a registered section 21 company in terms of South African law.
This account would be utilised for the daily cash flows of the programme and would be audited
by the donor but managed by authorised staff members at Madwaleni hospital. Any transaction
requires the signature of any two of the authorised signatories52.
Reimbursement system The majority of donors, other than small personal donations, agree budgets for the year ahead
upfront. Instead of such donors paying these budgets to the Madwaleni HIV programme at the
beginning of each year, the programme accounts at the end of each month for the expenses
52
Signatories include the HIV/OVC S&D manager, the hospital managing CMO, the head HIV clinician and the HIV/ARV site coordinator.
30
incurred in terms of agreed budgets and claims the reimbursement of these expenses from the
donors. The donors then reimburse the cash into the account.
The account is therefore largely used only for cash flow purposes.
Payment of expenses during the month Expenses are therefore incurred and paid:
 by individuals at the hospital who are reimbursed after reimbursement is received from the
donor53; and
 from the bank account by utilising advances received and paid into the Madwaleni HIV
programme account from the donors which are set off at month end against expenses
incurred.
Monthly accounting The HIV/OVC S&D manager is responsible for the monthly accounting for each expense and
submits such accounts to each donor monthly54. In addition, these accounts are made
available to the hospital and district management.
53
Initially the entire programme was funded by a few staff members who claimed the expenses they incurred on behalf of the
programme back at month end. Later as the funding grew and additional staff were employed this was no longer possible and
advances are paid to key staff each month in order that they have cash available for the incurral of daily operational expenses.
These advances are off set against their expenses incurred each month to calculate any refunds owing to them.
54
Initially this person kept the accounts. Now a donor funds a bookkeeper to do so and the HIV/OVC S&D manager is
responsible for the review of the accounts and sending them to the donors for reimbursement.
31
6. Accreditation of hospital as an Eastern Cape accredited ARV site
6.1
Background
Before any health facility could commence with its ARV programme (i.e. start prescribing, procuring
and dispensing ART), it required formal ARV site accreditation. The process of accrediting sites
was managed by the NDOH55. The provincial health department (with MEC sign off) recommended
certain sites for the NDOH’s Strategic Management Team (SMT) to assess and accredit56.
It was the intention of NDOH in its Operational Plan57 that this process would later be taken over by
the provincial health departments, in this case ECDOH. This has not happened to date but is likely
to happen shortly due to the recent changes agreed regarding this process by Dr Thobile
Mbengashe, the Chief Director, HIV and AIDS, STI, NDOH (see para 6.2 ниже).
Each province has quarterly site accreditation targets and therefore if a site is able to prepare to
meet the requirements of accreditation especially in an area where access to ARV services is
limited, obtaining accreditation as an ARV service point is possible in a relatively short space of
time58.
Initially NDOH made funds available to sites during the preparation phase i.e. once a site was
identified by ECDOH, a budget was allocated from the conditional grant funding which allowed for
the appointment of key staff, basic equipment etc. This meant that the site could use this funding to
procure goods and employ the staff required to meet the accreditation requirements59.
Once the site was accredited a further budget was allocated for staffing, laboratory and ARV drug
costs per site. These latter costs were later centralised and paid directly from the HIV Directorate’s
budget with only a small operational budget submitted through to the hospital60.
6.2
Recent policy changes to accreditation process
In December 2009, the NDOH accreditation team agreed to the following changes to the
accreditation process:




NDOH will no longer be accrediting sites but providing assistance to provinces for assessment
of readiness of facilities to provide ART services.
NDOH will assist provinces with a new national policy for all PHC services to prepare to provide
ART initiation and maintenance of ART patient on treatment.
NDOH will revise the criteria for assessing site readiness for ART services to make it a simpler
process which is within reach of most facilities.
Requirements to have a dietician and other specialised services for sites to be accredited must
no longer be criteria for site readiness.
55
The formal process of accreditation has been severly criticised for limiting access to health care services unreasonably and it
has been recommended that provinces be entrusted with the function of accreditation, NDOH introduce a more flexible
paradigm for accreditation and NDOH rather assist provinces with facility strengthening so that over time all facilities will meet
the ‘gold standard’.
56
This was the system when Madwaleni hospital was accredited.
57
Operational Plan for Comprehensive HIV and AIDS Care, Management and Treatment for South Africa, Nov 2003.
58
Not without continual pressure on the HIV Directorate.
59
This preparation process however was severely hampered by delays involved in government procurement despite available
funding. Where donor assistance can be obtained, this process can be fast tracked.
60
Now almost non existent due to funding shortages.
32
These are welcome and long overdue changes to NDOH policy and implementation thereof at a
provincial level are eagerly awaited across South Africa.
6.3
Accreditation process and tools
While waiting for the ECDOH and its HIV Directorate’s plan for implementation of the above
changes to the accreditation process, the previous NDOH requirements and guidelines for
accreditation as set out in Chapter 4 and Annex 4 to the Operational Plan can continue to be used
to guide a health facility in its preparation for assessment.
There is no separate accreditation process for operating a paediatric or pregnant women ART
programme.
The NDOH has set out 23 requirements for accreditation as the ‘gold standard’, see criteria in
appendix 18.5. However one should bear in mind that NDOH’s request to simplify criteria will
amount to leniency towards many of the onerous current requirements.
Each facility applying for accreditation was required to complete the application for accreditation.
See appendix 18.4.
6.4
Accreditation of feeder PHCs/CHCs
The question arises whether feeder PHCs or CHCs require separate accreditation. While the
Operational Plan does not make this clear, practice and guidance61 provided by the NDOH
demonstrates a ‘service point’ as defined in the Operational Plan to include ‘a group or network of
linked health facilities operating through a hospital or clinic in a defined catchment area’62.
Therefore provided the feeder PHC/CHC is part of the structure of the hospital which seeks
accreditation, such facilities can be used as down referral sites without requiring separate
accreditation. As the hospital is the accredited site, only it will qualify for:



a budget associated with running an ARV site;
an organogram of staff to capacitate the ARV site; and
the authority to procure ARV drugs from the government pharmaceutical depots.
Where increased staffing and direct procurement of ARV drugs is sought for PHCs, in the past each
PHC required accreditation in its own right. The policy changes as set out above, may now relax
this requirement or make accreditation of the PHCs, specifically after they have operated as a down
referral site, a simpler process.
61
www.nelsonmandela.org/index.php/publications - A dialogue on ART delivery, Dr David Kalombo Project Manager of the
South African national Department of Health’s Comprehensive HIV and AIDS Care, Management and Treatment Plan pg. 33
62
www.doh.gov.za/docs/pr/2003/pr1119.html
33
7. Human resource recruitment and retention
7.1
Introduction
The majority of rurally based government operated district hospitals are under resourced in terms of
both human capital and funding. Increasing human resources in deep rural areas is mostly not
limited by the availability of funding for such posts from government or donors but the ability to
attract professionals to live in deep rural Africa and then retain them in this challenging work
environment.
The ability of a district hospital generally to attract professional staff has obvious implications for the
staffing required to operate a functioning HIV programme.
While many of the difficulties or obstacles to attracting different categories of professional staff are
the same, there are some notable differences. Strategies for combating these have also been found
to differ. Recruitment and retention strategies for doctors and nurses will therefore be discussed
separately below.
7.2
7.2.1
Doctors to work at rural district hospital including for the HIV programme
Obstacles to recruitment and retainment in rural areas
Widespread understaffing of doctors in the public sector Doctors (especially South Africans) are often found to be hesitant to take up work in rural
hospitals as past experience has shown that the public sector is frequently operating on a
skeleton staff of doctors and this is more pronounced in district hospitals located in rural
areas63. Consequently doctors find themselves working in a continuous crisis situation. While
effort can be put into recruiting doctors who are prepared to work in such circumstances,
doctors realise that they will only be able to maintain working in such environments for a year or
two. They will therefore only commit to a short period of time before moving on to more
sustainable long term working environments. This form of recruitment therefore requires a lot of
time and frequently only results in retaining doctors for a year or two. Any sustainable model for
doctor retention requires focus being placed on filling the entire doctor complement of posts.
Limited amenities –
District hospitals in many cases have limited staff accommodation. As doctors usually relocate
to live full time to these areas64, bad living conditions negatively impact on recruitment and
retention capacity. In addition, living in deep rural areas is also a difficult lifestyle with limited
local amenities such as schools, shops, banks etc. In certain cases this is compounded by
electricity and water shortages.
Rural doctor added package benefits limited and likely to reduce further –
The NDOH implemented a policy to attract doctors to rural areas by paying them an additional
rural allowance on top of their basic salaries. However the demarcation of recognised rural
areas in some instances similarly remunerates those opting for peri-urban and rural areas in the
63
Report on the Stakeholders Meeting on the Facilitatin of the Recruitment and Placement of Foreign Healthcare Professionals
to work in the Public Sector in South Africa, 17 April 2008, Joint Venture between the Rural Health Initiative and the Placement
Project.
64 This is often different from nurses whose homes are often in neighbouring towns and who therefore go home for
weekends/days off.
34
same manner as deep rural. As can be expected, this detracted from the intended incentive to
attract doctors to deep rural areas.
In addition, in the past, due to vacant senior posts in district hospital’s organograms, less
experienced doctors could apply for more senior posts with less years of experience than
standardly required. This assisted rural hospitals in recruiting staff. However this strategy has
proved to be a double edged sword, specifically because it was not linked to a formalised period
of commitment to the district hospital. Certain doctors were attracted by the benefits of the
increased salary package with little commitment to the work involved. After a short period of
working at the district hospital, now qualifying for a higher level post elsewhere, such doctors
transferred to hospitals in per-urban and less rural areas quickly.
Furthermore, the NDOH is in the process of introducing ‘Occupational Specific Dispensation’
(OSD) remuneration policy changes to the package structure for doctors. This policy does away
with doctor posts set at different levels with corresponding increasing pay packages by rather
linking a doctor’s pay package with years of experience. While this will benefit district hospitals
with a number of senior doctors and limited higher level posts, it will detract from the capacity to
recruit of the majority of rural hospitals with no senior staff.
Limited mentorship by senior more experienced doctors All doctors but more so, junior doctors, highly value the continued mentorship and development
of their clinical skills. As many district hospitals are understaffed and often do not have the
services of senior experienced doctors, this factor further limits recruitment capacity. In addition
younger doctors are placed under excessive amounts of pressure and stress when they have to
handle a medical situation for which they have not been adequate trained and do not have the
ability to call for supervision or experienced clinical input.
HIV programme staffing limited by its separate organogram –
The South African government’s emergency response to HIV included channelling additional
funding to facilities to provide HIV related services through the conditional grant (see para 5.1.1
выше). This grant also covered additional human resource capacity. However the additional
staff posts were added through creating a separate organogram to run ARV departments at
hospitals. This organogram created posts for a doctor and 2 professional nurses. As the
organogram was reflected separately, most hospitals did not regard these as additional posts to
provide them with additional capacity to provide the services but rather a separate staff for
managing HIV.
7.2.2
Strategies for recruitment and retainment in rural areas
Full complement of doctors Importantly, this is a phased approach that has been implemented at Madwaleni over a few
years. In our experience it is difficult to attract senior doctors, who are often more weary of the
challenges, without a stable backbone of junior doctors.
Most district hospitals rely on the services of community service doctors obligated by the South
African government to work for a year in the public sector before being allowed to practice in
South Africa. However it cannot be relied upon that these doctors will automatically be
appointed to work at all rural district hospitals. These newly qualified doctors are given some
choice between hospitals at which to do their community service, at least one of which is in a
designated rural area. It is therefore important to ensure that these doctors are aware of your
district hospital’s existence. We achieved this by:
35
 setting up relationships with certain of the South African medical schools, so that Madwaleni
was offered as a hospital at which a medical student could choose to do an elective65;
 we also went to the same medical schools to do a presentation on choosing to do your
elective and then potentially later your community service at Madwaleni hospital.
This resulted in medical students at least knowing about the hospital and more importantly
placing Madwaleni hospital on the map for the medical school generally by those who
experienced working there during an elective66.
However, Madwaleni only has 3 community service posts. It requires at least a further 3
doctors to form the backbone of clinical care at the hospital.
A further strategy adopted was to utilise the opportunity presented by the infectious disease
profile of patients in South Africa. There are many foreign doctors who are unable to gain the
same experience of working with the infectious diseases of HIV and TB as within the South
African public sector. Madwaleni advertised its posts at some of the infectious disease medical
schools in the UK, specifically to attract doctors who had completed further training in infectious
diseases and in many cases were looking for opportunities to gain clinical experience in the
developing world with little guidance as to where and how this was possible.
Madwaleni worked with African Health Placements to assist with the administration involved in
obtaining work visas and HPCSA registrations67.
Once there is a rolling group of community service and foreign infectious disease doctors
working at the hospital for 1-2 year periods, it is easier to attract long term senior doctors. This
is an ever strengthening cycle as once senior doctors are attracted to Madwaleni, the easier it is
to keep attracting community service and foreign infectious disease doctors.
Creating a team spirit –
Working in isolated rural hospitals can be a lonely and difficult environment. Attracting doctors
who can form part of the team and take part in the team spirit greatly improves job satisfaction
and putting up with difficult circumstances.
Enhancing limited amenities –
Government budgets and bureaucracy often limit the ability of the hospital management to
improve accommodation and other living conditions. It is however important not to lose sight of
how much this influences retention of staff especially longer term senior staff.
Madwaleni has always included in its priority funding requirements, the building of additional
doctor accommodation but has also used the following strategies:
 many old district hospitals have only a few large residences for doctors. At Madwaleni, we
obtained funding to split each of these in two. This meant we had a single bedroom semidetached house for a couple and three bedroom semi-detached house to be shared by 3
single doctors/other allied health professionals or a family.
 identifying houses in the community that can be leased. These are usually not fully
inhabitable and require renovation. The renovation cost is set off against the rental
obligation over the first few years of the lease agreement. Thereby increasing the pool of
accommodation.
65
Later on in 2008, Madwaleni became a recognised rural site for Stellenbosch medical students to do their family medicine
practical.
66
This has resulted in applications for community service at Madwaleni increasing from zero to being over subscribed. We then
refer them to neighbouring district hospitals.
67
In a number of cases, AHP has also sourced and referred infectious disease doctors to Madwaleni.
36
 promoting the importance of funding ‘quality of life’ items as part of the retention and
recruitment budgets requested from donors. These are often small costs that make a big
difference68.
HIV programme staffing: Integration with hospital staffing As discussed above, one of the pull factors for working in a district hospital is the experience to
be gained in infectious diseases by foreign doctors. It is therefore important to provide these
doctors with as much of this experience as possible but also utilise them to fulfil clinical duties
outside of the HIV and TB programmes both in the hospital outpatients department and wards.
Our experience of having a doctor as the head HIV clinician working with and mentoring the
less experienced foreign infectious disease doctors works well69. It also creates a team
approach across clinical services and results in both the HIV services and other clinical services
being covered irrespective of who is on leave or whether a post is vacant at any particular time.
7.3
7.3.1
Professional Nurses to work for the HIV programme
Obstacles to recruitment and retainment in rural areas
Widespread understaffing in the public sector and limited amenities These obstacles are largely the same as for doctors discussed above.
HIV programme staffing: Limited by its separate organogram Similarly to the discussion above, the addition of two professional nursing posts on the
hospital’s ARV department organogram has meant that at many ARV sites in the Eastern Cape,
these two nurses have had to manage the hospital’s entire ARV service especially for
programmes that have not been decentralised to the PHCs. Even in the case of hospitals that
have down referred their ARV patients to the PHCs, these ARV department nurses continue to
be responsible for six monthly clinical monitoring and the supply of ARVs to the PHCs.
Significantly increased workload for nurses created by HIV epidemic and limited mentorship The majority of the burden of delivering HIV services has fallen to South African nurses. Focus
has been placed on decentralising HIV and ARV services to the PHCs and task shifting away
from doctors to nurses70. However the majority of PHCs nursing staff complements have not
increased and the recruitment of nurses to fill existing PHC posts has largely failed71.
Professional nurses are therefore expected to take on this massive additional workload with no
additional capacity and often without facilitation and support. It is unsurprising that they are
often unmotivated to do so.
Negative impact of OSD on professional nurses in ARV departments at hospitalsThe OSD remuneration policy was introduced for nurses in mid 2008. In terms of this policy
nurses would receive salary increases for both years of experience and for certain
68
At Madwaleni, items such as water pumps to ensure continual supply of water to the residences and a DSTV licence have
helped.
69
Initially in 2005, a single doctor was employed on the ARV department organogram and managed HIV services. In early 2006,
a further doctor was utilised from the hospital to work with this doctor on a Tuesday to run the adult HIV clinic. Once the
programme became decentralised, the doctor employed on the ARV department organogram started to go out to clinics for 2
days a week and therefore the doctor managing the paediatric ward was pulled in to run the Paediatric HIV clinic on a
Wednesday and the Maternity ward doctor to run the PMTCT clinic on a Thursday. More recently the head HIV doctor runs the
entire HIV service but South Africans with an interest in infectious diseases and foreign infectious disease doctors each take on
one/two of the PHC’s ARV clinics days.
70
Both clinical monitoring and now more recently with nurse initiated treatment expected to be rolled out in April 2010.
71
Many rural PHCs operating with one professional nurse.
37
specialisations. HIV management was not regarded as a specialisation72 while working in
primary healthcare, theatre, maternity and paediatric settings was (with the corresponding pay
increases). This resulted in it being very difficult to attract and retain nursing staff to take up
posts in ARV departments at hospitals73.
7.3.2
Strategies for recruitment and retainment in rural areas
Focusing on training HIV specialist nurses –
The strategy adopted by Madwaleni HIV programme to counteract the negative impact of OSD
on the nurse staffing of the ARV department at the hospital and to encourage the nurses at the
PHCs to take an interest in the HIV and ARV management of their patients, has been to
establish Madwaleni’s HIV programme as a centre for training to become an HIV specialist
nurse74.
This has been achieved through a number of mechanisms:
 obtaining funding for 3-4 bursaries a year for nurses working in the HIV programme whether
at the ARV department at the hospital or PHCs to complete the 1 year post-basic certificate
in Advanced Clinical Management of HIV/AIDS for professional nurses75. Nurses are chosen
based on their motivation and work in the HIV programme to date.
 the acceptance of these bursaries by the nurses is linked to a 3 year work obligation to the
HIV programme (whether at the ARV department in the hospital or at their PHC).
 the hospital and sub-district have agreed to give the nurses the time off every month to
attend the lectures at Fort Hare University, attend the practical week at Tygerberg hospital in
Cape Town and write their exams.
 the infectious disease focused doctors facilitate the daily application by these nurses of their
theoretical knowledge gained. This is done both through sitting together with these nurses
seeing patients during an ARV clinic and assisting with course assignments (which require
application of clinical knowledge in daily clinical duties).
 setting up an advanced training week in 2nd and 3rd year at Tygerberg hospital to add to the
clinical skills obtained in the first year in a tertiary setting.
 obtaining a year of funding to appoint a HIV nurse mentor, a nurse with HIV specialist skills
to work with the head HIV clinician to continually mentor nursing staff at the ARV department
and at the PHCs in the clinical management of HIV positive patients. This includes quarterly
evaluations of their skill set.
 weekly clinical meetings including case presentations after the adult, paediatric and PMTCT
clinics for discussion between infectious disease doctors and the nurses.
In addition to attracting nursing staff, this strategy has had the added benefit of capacitating
nurses to effectively run a nurse-led HIV programme (and in the future initiate ART).
HIV programme staffing: Integration with hospital staffing –
72
While there is merit in regarding the provision of HIV and ARV services to be the domain of all professional nurses, there is
also a risk in not recognising professional nurses who have decided to specialise in this field of medicine.
73
Zithulele hospital neighbouring Madwaleni hospital lost all its professional nursing staff with the implementation of OSD for
nurses.
74
While OSD does not recognise HIV as a speciality, it is hoped that national advocacy will change this. In addition there are a
number of work opportunities outside of district hospitals created for HIV specialist nurses. While this may lead the nurses to
only stay for a three year period, this also pushes more HIV specialist nurses into circulation in the public sector.
75
Through Fort Hare University’s Department of Nursing in collaboration with the International Centre for AIDS Care and
Treatment Programs of Columbia University’s Mailman School of Public Health and Stellenbosch University Centre for Infectious
Diseases.
38
Similarly to doctors, it is important that the hospital regard the HIV and ARV services as part of
the hospital’s responsibility and that the staffing of this programme cannot be limited to the ARV
department’s organogram i.e. two professional nurses.
However differently to the doctor scenario and as discussed above, the single most effective
recruitment strategy for professional nurses is mentoring their professional development so that
they have the opportunity to become HIV specialist nurses. This has meant that professional
nurses working in the ARV department are allocated full time and do not rotate three/six
monthly through the ARV department as other nurses do between wards in the hospital.
The same approach has not been adopted for enrolled nurses and nursing assistants that do
rotate through the ARV department to acquire a basic level of HIV management skills that can
then filter into each of the hospital wards once they have transferred.
The majority of district hospitals have a large number of vacant professional nurse posts with
very little recruitment skill or capacity. Obtaining the buy-in of the hospital management to
utilise these posts for professional nurses that want to work in the ARV department is essential
to increasing the nursing staff complement of the HIV programme. It also means that the
hospital is training a larger group of HIV specialist nurses. This will have significant benefits for
increasing the level of HIV care not only within the HIV and ARV programme but within all levels
of hospital care. There is no downside for the hospital unless its professional nurse posts are
fully utilised.
Mentoring and supporting increased workload for nurses created by the HIV epidemic Both through focusing on training HIV specialist nurses and the general mentoring of nursing
staff not only at the hospital but at the PHCs on the ARV clinic day has meant that nurses feel
supported in managing this additional workload.
In addition, the splitting of the week (see para 8.4 ниже) into HIV service focused days at the at
the PHCs and introducing HIV and ARV decentralised services in a phased approach (see
paras 13.2 ниже 13.3 ниже) have assisted in supporting the nursing staff and consequently
motivating them to take on the additional work load with good outcomes for the HIV programme
and its patients.
39
8. Human resource allocation to components of HIV programme
8.1
Background
The strategies discussed above for recruiting and retaining staff take time and cannot be waited
upon to set up or develop a decentralised HIV service. In addition, a system needs to be put in
place which can operate on as few staff as possible in times of staff shortages. In addition, despite
programme development and the consequent ability to demonstrate positive outcomes, increased
funding is often unable to keep pace with the increase in patient demand for HIV related services. It
is therefore necessary for such programmes to work out ways in which to optimise the staff time
available to achieve the services that need to be provided.
The Madwaleni HIV programme experience has demonstrated how it is possible to stretch very
limited professional staff to manage the ever increasing patient load. This section will attempt to
describe how this has been achieved. Obviously, where more staff, transport and other resources
is available to a programme, many of the services set out below will be able to be offered every day
of the week.
Poorly resourced programmes often need to depend on using professional staff that are already
overloaded and are often hesitant to take on further work load. It has also been our experience that
obtaining buy-in from professional staff at the PHCs to assist with such a programme is easier if it is
only taking up 1 day a week rather than trying to the full extent of services each day.
8.2
8.2.1
HIV programme staffing
ECDOH staffing
The ECDOH organogram for a district hospital ARV site includes:








1 x HIV/ARV co-ordinator
2 x professional nurses
1 x enrolled nurse
1 x nursing assistant
1 x administrator
1 x data capturer
1 x HIV clinician
5 x lay counsellors
This is a total of 13 additional staff (of which only 5 are clinical roles) who are required to provide
HIV services to an HIV positive population of approximately 8 500 – 10 500 people. This
organogram does not change according to the number of patients who are receiving HIV
wellness or ARV services76.
8.2.2
Madwaleni HIV programme staffing
The Madwaleni HIV programme experience has shown that as a minimum the following
additional staff are required:



76
1 x HIV/OVC S&D manager
1 x VCT outreach professional nurse
1 x professional nurse
Currently an ARV site with 100 patients or 2000 patients on ART qualifies for the same staffing structure.
40




0.5 x HIV clinician (with paediatric experience)
1 x filing clerk
3 x drivers
20 x peer educators
In addition, the programme utilises the following staff from the hospital:




0.3 x pharmacist
3 x pharmacy assistants
0.5 x HIV clinician
0.5 x social worker
The following staff from the CHC (one day per week):



2 professional nurses
1 enrolled nurse
2 lay counsellors
The following staff from the PHC (twice monthly):



8.2.3
2 professional nurses
1 enrolled nurse
2 lay counsellors
Optimal staffing
For optimal staffing see appendix 18.6.
8.3
Madwaleni HIV programme organogram (including OVC and HBC)
See 2009 organogram in appendix 18.7.
8.3.1
Role of the HIV/OVC S&D manager
The principle difference to other ECDOH HIV programmes organograms is the recognition in
the Madwaleni model for a senior management role which links the hospital and district HIV
wellness and ARV programme77.
The role of the HIV/OVC S&D manager oversees the combination and integration of the HIV,
OVC and HBC programme services at the hospital and works closely with the district team and
PHC staff to ensure that these programmes are fully decentralised and supported at the PHC
level. See hospital and district management organogram in appendix 18.8.
This position requires a person with project management skills and experience rather than
clinical skills78. A close working relationship with the clinical staff including the HIV/ARV coordinator and HIV clinician ensures that the programme is developed in accordance with clinical
77
For the first 3 years of the set up and development of the Madwaleni HIV programme, there was an HIV/ARV site co-ordinator
who assumed the roles and responsibilities of both the HIV/OVC S & D manager and the HIV/ARV site co-ordinator. This was not
sustainable especially as the HIV, OVC and HBC programmes expanded and further decentralised but was possible as a starting
point.
78
A combination of the two skills sets would be ideal but the focus is placed on project management skills and track record.
41
demands. For a broad job description with a detailed breakdown of roles and responsibilities of
this person see appendix 18.9.
8.3.2
Role of HIV/ARV co-ordinator
The HIV /OVC S& D manager position importantly allows the HIV/ARV co-ordinator the time to
effectively run the daily HIV wellness and ARV services and operations at the hospital full
time79. For broad job description with detailed breakdown of roles and responsibilities of this
person see appendix 18.10.
In addition, the job descriptions of both the programme administrator and data capturer are also
attached to clarify tasks taken on in support of HIV/ARV site co-ordinator. See appendices
18.11 and 18.12.
8.4
Optimise human resource capacity - splitting up the working week
The table attached in appendix 18.13 represents the way in which the Madwaleni HIV programme
provides different services on different days of the week in order to optimise resource allocation. It
also reflects which staff are utilised for this purpose.
79
Currently the ECDOH ARV sites require the HIV/ARV co-ordinator (a professional nurse) to manage the hospital ARV site
operations and the down referral system to PHCs. This has in many cases caused the down referral to PHCs and effective
support of patient management at PHCs to be slow and often ineffectively implemented.
42
9. Flow chart of adult outpatient journey
The flow chart below sets out the patient journey for any adult outpatient who tests for HIV. This
section will follow the flow chart and explain each block in detail including the various clinical protocols,
staff guidelines and administrative tools that are used.
If HIV-
VCT
3 months later - repeat VCT
If HIV+
SG Visit 3
SG Visit 2
Join HIV Support Group (SG)
WK1
WK2
Receive education in group counselling sessions and referral to nurse if unwell
WK 2
Join HIV wellness programme
 Open file
 Initial individual counselling
session
 Nurse clinical consultation
incl. TB screening
(referral to Dr if necessary)
 Take ELISA, CD4, FBC, ALT,
RPR, Cr, HBV, Urine dipstick
 Dispense prophylactic
treatment
 Conduct or refer for pap
smear
 Provide nutrition if necessary
o
Refer to social
worker if
necessary


If CD4>200
WK3/4
If CD4<200
(if CD4< 50 further
nurse consultation)
WK3/4
Determine if patient has met individual
commitment issues prepared for in HIV
wellness programme specifically including:

has identified a treatment partner

disclosing HIV status to a partner/family
member

Cotrimoxazole pill count is correct
6 months
YES
NO

Take CD4 again
st
1 individual adherence counselling (by
counsellor)
Home visit to prepare family for starting ART
Continued individual counselling regarding the
individual commitment issues to ensure ART
readiness
WK4/5


2 weekly HIV wellness visits:

Attend HIV support group

Individual counselling
session relating to living
with HIV and readying for
ARVs

Basic clinical screening incl.
for TB symptoms

Referral for and treatment
of opportunistic infections

Cotrimoxazole pill counts to
prepare for ART

Provide nutrition if
necessary
(after 6 months – once monthly)
Clinical assessment for ART initiation by doctor
2nd individual adherence counselling by
pharmacy assistant (PA) – ARVs dispensed
Baseline bloods taken if DTT blood results more
than 3 months old
2 weekly
adherence
visit
ART
adherence
checked by
PA and
referral to
PHC
1 + 2 + 3 month
clinical visits
 Nurse clinical visit
 adherence
checked (incl. pill
count (PC)) and 1
month repeat ART
dispensed by PA
 blood
investigations if on
NVP, TDF, AZT
Thereafter
 Attend monthly/three monthly
for ART supply
 Nurse check up 6 monthly at
18/24/30/36 months when
blood investigations taken
 Nurse clinical visit one month
later at 19/25/31/37 months
incl. review of blood
investigations
YES
4 + 5 month check
up visit
 Nurse check up
visit
 Adherence
checked (4
month last PC if
correct) and 1
month repeat
ART dispensed
by PA
13 month clinical visit
 Nurse clinical visit incl.
review of 12 month
blood investigations
 adherence checked,
nurse and PA
considered for 3 month
supply of ART
 1 or 3 month repeat
ART dispensed by PA
Yellow blocks = takes place at hospital
White blocks = takes place at PHC
43
Reassessment of individual commitment on a
weekly basis through continued individual
counselling
6 check up month
visit
 Nurse check up
 adherence
checked and 1
month repeat ART
dispensed by PA
 6 month blood
investigations
taken incl. CD4,
viral load
12 month visit
 adherence
checked and 1
month repeat
ARVs dispensed
by PA
 6 month blood
investigations incl.
CD4, viral load
Blue area = HIV wellness prior to ART
Orange area = ART programme
7 month clinical
visit
 Nurse clinical visit
incl. review of 6
month blood
investigations
 adherence
checked and 1
month repeat ART
dispensed by PA
8 +9+10 + 11
month visit
 adherence
checked and 1
month repeat
ARVs
dispensed by
PA
10. Voluntary counselling and testing (VCT)
If HIV3 months later - repeat VCT
VCT
If HIV+
10.1
Introduction
South African national health policy requires HIV testing to be voluntary and makes both pre-test
and post-test counselling compulsory for each person who requests a test. A person can decide not
to continue with the HIV test after he/she has received pre-test counselling.
The Madwaleni HIV programme’s VCT services have focused on providing access to and the
marketing of HIV testing services in the community. The programme attempts to ensure that HIV
testing is:



10.2
available as close to the community as possible;
easily accessible by the community; and
offered routinely to all community members who access facilities or sites where VCT services
are being provided.
VCT counsellor team
VCT counsellors are selected by the experienced peer educators running the HIV support groups at
the PHCs from such support groups.
The peer educators are asked bi-annually to select 2-3 active HIV support group members in each
of the 8 HIV support groups, who are in volunteering their time, to join the next VCT training
session.
After completing such training, the HIV team together with the trainers select peer educators and
VCT counsellors from the VCT training attendees. For detailed understanding of selection of VCT
counsellors see appendix 18.13.
The selected VCT counsellors make up the VCT outreach team together with VCT outreach coordinating nurse80.
10.3
10.3.1
Where HIV testing is available
At health facilities daily




10.3.2
the outpatients department at the district hospital;
every hospital ward at the district hospital (including TB wards and maternity ward);
the HIV department at the district hospital; and
each PHC.
At scheduled VCT community outreach days
 social welfare grant points;
80
2009 - donor funded retired professional nurse.
44




10.4
schools;
OVC clinics;
various community gatherings; and
district mobile primary healthcare clinics with set dates in villages.
Protocols for pre- and post- test HIV counselling
See appendix 18.15.
10.5
10.5.1
Outpatients department (OPD) at hospital
Background
Most OPDs in government hospitals now have VCT services available. However this does not
make access to such services easy nor do such services routinely target each OPD attendee.
Doctors and nurses in OPD settings are usually very busy with emergency patients and
hundreds of outpatients that have been referred by the feeder PHCs. Where the offering and
take up of VCT services in the OPD is left solely up to doctors and nurses, such services are
likely only to be offered to a patient who is presenting with an illness or infection associated with
HIV. Such patients are then usually referred to a further nurse for VCT who may also be busy.
A long wait for VCT often results in the patient leaving without being tested81.
The OPD is a vital point at which to encourage the take up of VCT services not only by the
patients attending for medical care but also their relatives or friends who are escorting them to
the hospital.
10.5.2
Scale up of VCT services in OPD
Infrastructure  one private room allocated for HIV counselling and testing in the OPD setting (not in another
part of the hospital nor for referral to the HIV department – patients get lost on the way or
loose motivation after attending long queues in OPD).
 clear posters in the appropriate language indicating that VCT testing is available in this
department, the patient need only ask any member of staff in the OPD.
Additional staffing  2 VCT counsellors82 are rostered daily in OPD.
Role of VCT counsellors  VCT counsellor #1 is allocated for group counselling in waiting areas of OPD. His/her role is
to address patients waiting for medical care on the advantages of testing for HIV. This can
be done by addressing the group as a whole or sitting next to a few patients at a time in the
queue. It is essential that should a person decide to test, his/her place is kept in the queue
for medical care (this can either be done by the counsellor sitting in their place or by a card
system). Failure to provide a system for holding a place in the queue is likely to result in
patients refusing to have an HIV test83.
81
Our VCT counsellors experience difficulty motivating a patient to wait for the nurse to conduct the rapid test once he/she has
agreed to test and has been pre-test counselled. Without such continued motivation, the patients leave without the test
despite having agreed to test and undergone the pre-test counselling.
82
Initially HIV programme used peer educators and CHWs for this task but since 2009 taken over by VCT counsellors forming
part of VCT outreach team.
83
Patients in district hospital settings can often queue for the entire day to be seen by a doctor. As a result, patients are very
negative to partaking in any activity which may result in them losing their place in the queue.
45
 VCT counsellor # 2 is allocated to the VCT counselling room, where he/she will provide preand post-test counselling to all patients referred for VCT. This counsellor will also arrange for
the nurse to come to conduct the actual finger pricking and reading of rapid test result, once
3-5 patients have received pre-test counselling84.
VCT needs to be offered by the following key role players in the OPD –
 VCT counsellor # 1 in waiting area of OPD;
 nursing assistant/student nurse taking vital signs and weight prior to being seen by a
professional nurse;
 the professional nurse who screens all patients and either treats such patient or refers such
patient to the doctor; and
 the doctor who sees sick referred patients.
10.6
10.6.1
Hospital wards
Background
Historically at Madwaleni hospital wards, patients were not routinely offered VCT even in the TB
wards despite the co-infection rate between TB and HIV. The incorporation of group
counselling in the wards by peer educators once weekly as part of the inpatient programme has
both increased VCT uptake and VCT services offered by nursing staff.
HIV testing is also encouraged in the paediatric ward. See para 15.2 ниже on HIV testing in
children below.
10.6.2
Scale up of VCT in wards
Infrastructure –
 clear posters in the appropriate language indicating that VCT testing is available in this
department, the patient need only ask any member of staff in the ward.
Additional staffing –
 peer educators are allocated to work in the wards on a Monday (see para 8.4 выше) and
any other time that they may have available.
Role of peer educators in the wards –
 peer educators provide group counselling on testing for HIV to all ward patients in their
allocated ward as part of their inpatient programme work on a Monday. Where a patient
requests HIV testing, the peer educator will carry out the pre-test counselling and request the
ward nurse to attend to the rapid test and the post-test counselling (see inpatient programme
in section 16 ниже).
10.7
HIV department at hospital
In the past, most patients who requested an HIV test were referred to the HIV department where
there is a permanent nurse on duty who can perform this task. As part of the general scale up of
VCT services at the hospital, this approach was discouraged as patients often lose interest in
having an HIV test if they are referred elsewhere and need to join a further queue. Instead, focus
was placed on offering VCT at each possible point where patients may be coming for other hospital
84
South African national policy only allows nursing staff to carry out the HIV rapid test. Due to the shortage of nursing staff and
the increasing use of task shifting strategies to increase service delivery and HIV testing take up, stakeholders such as MSF are
lobbying for allowing trained lay staff to conduct the rapid HIV testing.
46
services. This meant that the take up of HIV testing in the HIV department decreased, allowing use
of the HIV department staff for VCT community outreach outside of the hospital85.
The majority of patients attending the HIV department have already been diagnosed with HIV with
the exception of caregivers of children who bring a child to the HIV department and other patient
escorts (usually family members). These people are routinely encouraged by the community health
worker or peer educator on duty in the reception area to test for HIV.
10.8
10.8.1
Primary healthcare clinics (PHCs)
Background
Ideally community members should be tested for HIV at primary healthcare level rather than at
the hospital where patients are already ill or in the case of pregnant women, in labour. VCT
needs to be routinely offered to all PHC attendees, especially pregnant women attending their
clinics for ante-natal care.
Historically at Madwaleni this was not the case. Certain of the PHCs were not providing VCT
testing services at all and those that were, were not offering VCT routinely to all patients that
attended the clinic. This meant that pregnant women often presented at Madwaleni hospital in
labour without an HIV diagnosis86.
10.8.2
Scale up of VCT at PHCs
Infrastructure –
 clear posters in the appropriate language indicating that VCT testing is available in this
department, the patient need only ask any member of staff at the PHC.
Additional staffing –
 no additional staffing required. However at least two community health workers need to be
VCT trained at each PHC87 ; and
 at least one community health worker needs to be on duty daily at the PHC for purposes of
HIV pre- and post-test counselling88.
VCT is offered to the following clients –
 all community members who attend their PHC are offered VCT as part of group counselling
undertaken by the community health worker on duty at the PHC in the waiting area;
 all pregnant women are encouraged to take up VCT both as part of group counselling and on
an individual basis by the nurse conducting their first ante-natal visit (see para 14.3.1 ниже).
Experience in the Xora sub district PHCs has shown that counselling a group of pregnant
women at their first ante-natal visit on all the tests that need to be conducted including an
HIV rapid test (including an explanation of PMTCT services available) assists with this being
85
Prior to obtaining funding for a nurse and VCT counsellors (in 2008) which form part of the VCT outreach time, the VCT
outreach team was made up of one of the HIV department nurses and two of the HIV department CHWs.
86
The number of people tested at PHC level at the beginning of 2005 between all 7 clinics was on average less than 100 and the
numbers tested in the maternity ward at Madwaleni ranged between 60 to 100 women a month (where VCT was likely to have
been conducted during labour).
87
PHC CHWs trained together with peer educators and VCT counsellors by Aurum.
88
Difficulties have been experienced in the past with both the ECDOH and Small Projects Foundation (SPF) who from time to
time issue directives regarding where community health workers should be allocated. At one point, all community health
workers had to work in the community and not at the PHC. This resulted in reduced HIV testing at PHCs due to nursing staff
shortages. Currently, 2 community health workers designated as ‘lay counsellors’ may be allocated full-time at the PHC for
purposes of conducting pre- and post-test counselling.
47
regarded as a routine test rather than a “special” test. Pregnant women have the right to
refuse to have an HIV test but in our experience this has not been the case89; and
 all patients diagnosed with TB are individually counselled about the co-infection rate with HIV
and are encouraged to take up VCT.
10.8.3
Strategies that have been successful in increasing VCT at PHCs
Emergency provision of HIV rapid testing kits –
 A recurrent obstacle to PHCs providing daily VCT services is running out of HIV rapid testing
kits. In the rural Eastern Cape, PHCs are burdened with lack of pharmaceuticals and surgical
consumables. HIV testing kits are ordered by PHCs together with pharmaceuticals and
surgical consumables from the district pharmacy. The district pharmacy in turn orders from
the closest central medical stores90 and then delivers to the PHCs. The unavailability of HIV
testing kits is attributable to a breakdown at various different points in this procurement line.
 A system was put in place whereby the nurses at each PHC know to contact the HIV/OVC
S&D manager or the HIV/ARV co-ordinator at Madwaleni’s HIV department as soon as the
PHC runs out of rapid HIV tests (having followed up with the PHC supervisor at sub district
level regarding delivery of their stock). An emergency rapid testing kit it immediately
dispatched with the driver. This ensures that at no time is the PHC unable to carry out an
HIV rapid test91.
 This emergency provision of HIV testing kits to the PHCs needs to be agreed with the
pharmacy department of the hospital. As the pharmacy department of the hospital is not
responsible (nor does its funding allow for) the provision of pharmaceuticals/surgical
consumables/testing kits to PHCs which fall under the district pharmacy management and
funding. Alternatively, outside funding will be required to procure a stock of emergency rapid
testing kits for provision to PHCs.
Monthly review and discussion of PHC’s VCT statistics  Madwaleni HIV programme requires PHCs to submit the statistics which they are already
required to send to the district on VCT for the month to it. These statistics include a
breakdown of number of ante-natal women tested and number of PCR tests done on infants
(see appendix 18.16 for an example).
 Once these statistics are received, the HIV/OVC S&D manager reviews the statistics to:
o determine low testing numbers (considering PHC average monthly number of attendees);
o determine any decreases in HIV testing for the month; and
o compare each PHC’s numbers tested.
 HIV/OVC S&D manager calls each PHC’s head nurse to:
o discuss any reasons for low numbers of patients tested or any decreases in testing
numbers; and
o congratulate the PHC staff on increases in testing numbers and discuss any
changes/new strategies which the PHC put in place the previous month which may have
increased numbers (for discussion with other PHCs).
 Madwaleni HIV programme data capturer prepares a report comparing each of the PHCs’
testing numbers for the month. This report congratulates the PHC with the highest numbers
for the month and is circulated to each PHC head nurse (see appendix 18.17 for an
example).
Ante-natal HIV testing for pregnant women reviewed in monthly peri-natal mortality meeting
89
On average over the last 2 years (2008/2009), approx. 155 pregnant women are tested at the 7 PHCs each month (with less
than 2% refusing an HIV test as part of their ante-natal care). This has also meant that on average less than 5 women a month
arrive at Madwaleni’s maternity ward without an HIV diagnosis.
90
Mbashe sub district orders from Mthatha central pharmaceutical depot.
91
The HIV/OVC S&D manager also follows up with the clinic supervisor regarding the stock out.
48
 See PMTCT para 14.3.2 ниже for further detail.
10.9
10.9.1
VCT Community Outreach
Introduction
Various factors limit a rural communities’ ability and will to access HIV testing services at health
facilities (both at the hospital and PHCs). These include:
Topography – the area around Madwaleni hospital is mountainous and rivers cut through the
valleys making walking to facilities both difficult and extremely time consuming especially in the
rainy season. All roads are dirt and in most cases in very poor condition. The roads often
become impassable when bridges have washed away.
Transport issues: lack of taxi routes and exploitative taxi fares – most of the community either
walk or rely on local taxis to provide transport to health facilities. These taxis do not run on all
routes (due to road conditions) and charge exploitative taxi fares (often exceeding R50 return).
Impoverished community – the Xora community is poor92, the vast majority of people are
unemployed and they do not have funds for taxi fare.
No time – due to the poverty and unemployment, most community members use their days to
subsistence farm, collect woods and water and care for their families. This does not leave time
to spend the whole day accessing a health facility.
Hospitals are intimidating environments – for many community members walking into the
hospital OPD and asking a nurse for an HIV test is intimidating.
Nurses are often busy with other duties in health facility setting – due to understaffing, nurses
are busy with their many duties and a person requesting an HIV test may be made to wait for
considerable time.
10.9.2
Social welfare grant points
The greatest access to large numbers of community members is through the social welfare
grant points. As previously stated the majority of the community are unemployed and rely on
92
Refer to Footnote 3
49
the social welfare grants to survive, chiefly the child support grants and old age pension
grants93.
Consequently, the majority of the community attend these social welfare grant days, not only to
access their grants, but also to shop in the informal market place that is set up around the pay
station for the day.
Therefore, where limited staff are available to run VCT community outreach, these two days a
month (depending on the extent of area), can be used to optimise access to the community.
In summary utilising the social welfare grant points for HIV testing have the following
advantages for the community and the HIV programme:
 no long queues for community members;
 closer to their homes thereby saving on transport and money;
 a person is not taking additional time out of their day to access an HIV test;
 VCT services are easily accessible as community member is already present (tacked onto
another community activity);
 friendly and social environment (its pay day!); and
 minimises use of nurse resource by using VCT counsellors.
Staff requirements –
 one professional nurse/enrolled nurse (nurse); and
 at least two but preferably three/four VCT counsellors (per VCT outreach team).
Organisation prior to setting up testing site –
 at first Madwaleni HIV programme obtained permission from each headman/sub-headman in
the area in which the pay point was stationed to allow the programme to provide HIV testing
at the pay point station. This was time consuming as it was often difficult to locate the
headman timeously.
 later on, we arranged with the chief of the entire area to speak at the traditional leaders
meeting to discuss blanket permission for setting up HIV testing at social welfare grant points
and any other community events taking place within their jurisdiction. This permission was
obtained94.
Marketing the HIV testing service –
 community leaders were encouraged to attend such social welfare grant points and test
themselves. Some had tested previously but agreed to do so again in front of their
communities.
Moving with SASSA95 –
 initially we set up VCT community outreach at one pay point and remained there for the day.
However as SASSA moved in and out within a few hours, the crowd dispersed and minimal
93
On 1 August 2009, child support grant = R240 per month and pension and disability grants = R1010 per month
(www.sassa.gov.za)
94
The same meeting was used to set up a working relationship with chiefs regarding HIV awareness in their communities. This
included putting up billboards on each headman’s property advertising Madwaleni HIV programme’s services specifically the HIV
support group run at each PHC. Each headman took responsibility for the security of these billboards.
95
South African Social Security Agency
50
testing took place after SASSA left. We then started to move from one pay point to another
just ahead of SASSA.
Equipment –
 see appendix 18.18.
Set up plan at pay point –
 see appendix 18.19 for a diagram of the floor plan.
 the nurse works in a ‘quick to set up’ tent (or in some cases an allocated empty room/hut at
the local store where such agreement has been reached with the storekeeper/headman);
 she/he remains in her/his tent while the VCT counsellors encourage community members to
test and manage the people that have requested testing;
 2 VCT counsellors (pre-test VCT counsellors) either also work from ‘quick to set up’ tents or
out in the open area (where they will take their client away from the crowds and sit with the
client and conduct pre-test counselling). This often depends on weather conditions for the
day; and
 1 VCT counsellor (control VCT counsellor) is always stationed outside the nurse’s tent to
ensure that the queue is appropriately managed. Experience has shown without close
management at this point, the crowd and queue can easily become chaotic and impinge on
privacy in testing tent.
System and flow of clients  while the VCT counsellors quickly set up the HIV testing site (see appendix 18.19), the nurse
will address the community either as a group or walk around encouraging community
members to test;
 once the HIV testing site it set up, the VCT counsellors will continue to encourage
community members to test. Where a community member is in the queue for their social
welfare grant, a counsellor will either keep their place in the queue or gain the agreement of
others that the person will not lose their place in the queue while they go to test;
 as soon as a person agrees to test, 1 VCT counsellor will take such client for pre-test
counselling;
 after completion of the pre-test counselling, the VCT counsellor will ask the client to sign the
VCT testing consent form (see appendix 18.20);
 the client will go with their consent form to the nurse’s ‘pre-test counselled queue’.
 the control VCT counsellor will then place a number on the consent form and ensure that the
client goes into the tent when the nurse is ready for such client;
51
 the nurse will briefly summarise how the test is done again, then will mark the rapid test with
the same number as the number on the consent form and will conduct the HIV rapid test;
 once the blood has been placed on the rapid test kit, the client will leave the tent and wait in
the HIV test results queue;
 the nurse places the consent form + the rapid test on a separate table in 1 of 3 trays (behind
him/her and out of vision of person sitting in front of him/her) and then attends to next client’s
HIV test. This allows for increased patient load as each rapid test takes ten – fifteen minutes
before the rapid test result can be read (see ‘consideration section’ below);
 once three clients have tested, the control VCT counsellor will stop the queue for testing and
will arrange that each tested client goes into the tent to receive his/her HIV test result;
 the nurse will check the name of the client against the name on the consent form. She/he
will then check the number on the consent form and the rapid test to ensure she is handing
out the HIV test result to the correct client;
 where the HIV test result is negative, the nurse will conduct post-test counselling (see
appendix 18.15) and the client will leave the tent;
 where the person tests HIV positive, the nurse will :
o conduct the confirmatory rapid test to confirm HIV positive test result;
o give the client his/her result and conduct post-test counselling;
o encourage the client to speak with one of the VCT counsellors immediately after
leaving the tent. As all the VCT counsellors are HIV positive, this has been shown to
be very beneficial in increasing the likelihood of such client attending HIV support
group at their PHC. This will be arranged by the nurse with the control VCT counsellor
who will take such client to one of the pre-test VCT counsellors;
o the nurse will also ask permission to contact the client telephonically in a week or two
to find out how the client is feeling, answer any further questions which the client may
have and discuss the way forward again. The nurse will note down the client’s contact
details on the consent form;
o if the client is not from the Madwaleni – Xora area, the nurse will determine the closest
clinic/district hospital to the client’s home and complete a referral form (see appendix
18.22); and
o if the client is an adolescent, the nurse will give the teenager an invitation to join the
adolescent HIV support group (see appendix 18.23).
 the nurse will note the HIV test result on the client’s consent form;
 once the nurse’s queue has cleared and SASSA has left, the nurse will make sure she/he
has all the consent forms in a folder for collation when back at the HIV department (see VCT
data collection, monitoring and follow up procedure below); and
 the VCT counsellors will pack up the HIV testing site and the VCT outreach team will move
on to next site.
10.9.3
Other VCT outreach sites
Schools High schools are good opportunities to test but more importantly use VCT as a prevention tool.
Running HIV testing days at high schools needs to be run in conjunction with an HIV awareness
campaign/peer education teaching programme/life skills curriculum.
Madwaleni’s HIV programme ran a peer education programme at 6 local high schools (JSS and
SSS) in terms of which:
 each of the schools identified 2-3 of their learners, who have shown strong leadership skills,
to attend training at Madwaleni Hospital;
 the learners were equipped with training on activity based lesson plans;
52





the learners then returned to their schools with the relevant resources to educate their peers
within the structure of their life skills programme;
the lesson topics address basic body functions, the immune system, HIV/AIDS, prevention
and testing, HIV adolescent support group & ARV treatment;
the aim of these lessons was to empower the learners with knowledge as well as to prepare
them for the HIV awareness/VCT outreach day;
after completion of the teaching, these learners then organised the HIV awareness/VCT
outreach day at their school with their teachers and peers; and
the HIV testing was conducted by the Madwaleni’s VCT outreach team (this was often done
in conjunction with an event which the school organised96).
OVC Clinic The majority of the orphans enrolled on the OVC programme have lost one or both parents to
AIDS. Consequently, this group of children, especially the younger ones, were potentially
exposed to HIV during pregnancy, birth and/or breastfeeding and should be regarded as a high
risk group for HIV. Unfortunately, due to these children’s vulnerability97, they often don’t access
healthcare services.
The OVC programme includes pre-test counselling for each caregiver and child who is enrolled
in the programme as part of the health assessment and check up. Our experience has been
that the vast majority of caregivers (including mothers of disabled and HIV positive children)
agree to have their children tested.
Other community gatherings It is important to work together with the chiefs, churches and other government departments to
determine when community gatherings will take place in order that VCT services can be made
available at such gatherings. Examples of places where we have set up VCT outreach sites in
the past:
 local ‘spaza’ stores on social welfare grant pay out days – some of the community who hold
bank accounts or post office accounts do not go to the social welfare pay points to receive
their grants in cash but have their grants paid into their accounts electronically. These are
transferred into their accounts at the end of the month. VCT outreach is set up at the main
stores where the community go to draw their grants;
 outside in the large parking lot of the local ‘Boxer’ store which is the largest and cheapest
supermarket in Xora/Elliotdale (and is always busy). We work together with Boxer who
announces testing in their store and supply free give aways/food in the parking lot to the
encourage HIV testing;
 big church meetings specially around the Easter period;
 Department of Agriculture’s interventions in the community98;
 Headman community meetings (although the dates of these are often difficult to ascertain
with certainty); and
 at the local prison in conjunction with correctional services99.
10.9.4
VCT outreach sites that have been less successful
96
For example, at 2 different schools, one arranged this day on the sports day run at the same time while another arranged it on
parents day at the school.
97
Grandparents and other elderly caregivers do not often have the means, understanding or ability to bring children to health
facilities to check their HIV status.
98
Examples of interventions are 1) a mobile mill is brought into villages to mill maize 2) the department hands out chicks 3)
community education on fencing and ploughing etc.
99
Correctional services allows the VCT outreach team to provide VCT in the prison and any HIV positive prisoners are allowed to
attend either Xora or Madwaleni HIV wellness and ARV clinics.
53
Door to door HIV awareness and scheduled day in the community for testing Initially Madwaleni’s HIV programme tried dropping VCT counsellors in a village to conduct
door-to-door HIV awareness for a week. The VCT counsellor informed the community of a
specific date on which HIV testing would be made available in their village by the VCT outreach
team.
This strategy was resource intense as it required many counsellors and transport and we found
that not many of the community came to test on the scheduled day. The reason given was often
that the community member was away for the day or needed to attend to his/her vegetable
garden or had to fetch wood etc.
This further supported tacking VCT onto other community activities for which the community
were willing or in the habit of taking time out of their daily activities to attend.
Department of Agriculture: cattle dipping days –
It has always been a concern that through operating VCT outreach predominantly at the social
welfare grant points, the programme was accessing limited numbers of men who are less likely
to attend as they do not qualify for child support grants100. We tried to identify community
gatherings that would focus on male participation. The most common such gatherings are the
cattle dipping days run by the Department of Agriculture, where all the cattle are taken for
dipping at certain designated places in the community. However due to the intense
management of cattle required on this day, this did not prove to be a feasible VCT outreach site.
10.9.5
VCT outreach data collection, follow up and monitoring system
Data collection and recording Once back at the HIV department, the VCT outreach nurse will enter the information contained
on the consent form on the ECDOH VCT stats form (see example in appendix 18.21)101. The
nurse does not complete this form at the VCT community outreach testing station in the
interests of time.
The completed VCT stats form (with the attached consent forms) is given to the data capturer
for monthly VCT statistics record purposes. The data capturer stores the confidential consent
forms while the VCT outreach stat forms are filed with those from all hospital departments
together with summary for the month (see example in appendix 18.24).
HIV positive clients follow up system –
Number of people tested in 2006 at different locations
80
70
60
50
40
30
20
10
locations
101
The ECDOH form has been slightly amended to provide more useful statistics to the HIV programme.
54
Mbanyana 09/02
Babane 20/03
females tested
males tested
100
Rebetshane 08/02
Qirgana 16/03
Hobeni 09/03
Ntlonyana 15/03
Cwebe 10/05
Mpakama 06/04
Ntlonyana 13/04
Madwaleni Location 12/04
Mazi 08/05
Hobeni 07/04
Kasa 22/06
Mbanyana 09/06
Mt Pleasant 19/07
Nkanaya 13/07
Ngqatyana 17/07
Mpakama 10/07
Mbanyana 12/07
Babane 17/08
Melithaya 21/08
Ntlonyana 14/08
Hobeni 07/08
Nkanya 10/08
Meltata 24/07
Tafalehashe 02/08
Cwebe 08/09
Hobeni 07/09
Nkanya 11/09
Cuntsula 20/09
Nlonyana 13/09
Babane 16/10
Mndwaka 02/10
Mt Pleasant 13/10
Ntlonyana 08/11
Ngquatyana 08/11
Cwebe 03/11
Nkanya 06/11
Hobeni 02/11
Hobeni 08/12
Cwebe 21/01
Hobeni 11/01
0
Before giving the VCT consent forms and VCT stats sheet to the data capturer, the nurse will
enter the information pertaining to clients who tested HIV positive in her/his “VCT follow up
register”. This “VCT follow up register” notes the following:
 client’s HIV testing date;
 client’s HIV testing location;
 client’s name and surname;
 whether client consented to being followed up;
 client’s telephone number;
 client’s address;
 dates on which client followed up telephonically or by home visit; and
 date on which client joined HIV wellness programme102.
(see appendix 18.25)
The nurse will then follow up the HIV positive clients on days that she is not conducting VCT
outreach in the field, preferably telephonically but if the client does not have a telephone or
cannot be reached then by means of a home visit (provided client gave permission for a home
visit)103.
Once a month the nurse will check the HIV programme database to determine whether these
clients have enrolled in the HIV wellness programme. Once a client has joined, she/he will stop
following up the client.
Monitoring and evaluating VCT outreach outcomes The nurse completes a VCT outreach evaluation tool to assist the Madwaleni HIV programme
in determining the success of such follow up initiatives and the conversion of HIV testing in the
community to enrolment on the HIV wellness programme (see appendix 18.26). The HIV/OVC
S&D manager meets with the nurse every three months to:
 consider the completed evaluation tool i.e. the outcomes of the VCT outreach programme;
and
 discuss initiatives/strategies which may improve such outcomes and achievement of set
targets.
10.9.6
Considerations when conducting VCT community outreach
Staffing Initially, the programme had no additional staff to work full time on VCT outreach. The nursing
staff in the HIV department rotated to run VCT outreach on social welfare grant days with 2
community health workers from the ARV site. On these two days a month, the remaining staff
handled additional patient load in the HIV department.
However as funding increased, a permanent VCT outreach team was formed which included:
 a full time professional nurse;
 a team of VCT counsellors. Optimally a group of 10-12 should be trained and included in
this team. On busy VCT outreach days (such as social welfare grant days and school
testing, all VCT counsellors are used), while on days where there is no VCT outreach, often
only 2-4 are working between OPD and following up HIV positive clients tested at VCT
community outreach.
102
The nurse has been trained on how to obtain this information from the HIV database.
In 2006, we identified that while increasing HIV testing in the area, the number of HIV positive clients identified during VCT
outreach in the year joining the HIV wellness programme in the same year was low (approx. 14%). This follow up strategy has
significantly increased take up to between 30-40% within 3 months of HIV testing date.
103
55
Having a permanent VCT outreach team means that there are resources available for:
 working with the community and other departments to determine other community
opportunities to carry out VCT outreach;
 running a number of VCT outreach days monthly;
 organising district and hospital teams for social welfare grant points (see below);
 spending time following up clients who have tested HIV positive to facilitate their joining the
HIV wellness programme; and
 staffing other VCT initiatives, such as hospital staff testing.
District and hospital buy-in –
Working closely with the district and hospital health team has meant that the Madwaleni HIV
programme was able to increase the number of VCT outreach teams that are able to go out on
social welfare grants days. On social welfare grant days, we now run 3 VCT outreach teams,
made up as follows:
 permanent VCT outreach team = 1 nurse, 3 VCT counsellors
 district VCT outreach team = 1 PHC nurse, 2 community health workers from PHC, 1 VCT
counsellor
 hospital VCT outreach team = 1 HIV dept/hospital nurse, 3 VCT counsellors
This means we can cover most of the SASSA pay points on 2/3 days on which social welfare
grants are paid out in the Madwaleni – Xora area (depending on transport availability for the
day).
10.9.7
VCT outreach lessons learnt
Excessive demand for HIV testing service –
We have experienced VCT outreach days where there are too many community members
seeking HIV testing from 1 outreach team. This can often lead to:
 the privacy of the nurse and client being compromised;
 short and ineffectual post test counselling; and
 inaccuracy with marking rapid tests correctly.
Strategies we have used to combat these include:
 putting a control VCT counsellor in place whose role is to control the ‘no man zone’ outside
the HIV testing tent. As the nurse is inside the tent with the client, she/he is unable to
effectively manage queue and crowds outside the tent. The control VCT counsellor must
have the capacity to control of the community who are seeking testing and keep the queues
in order.
 number system on consent forms. The nurse must decide the number of client’s she can
reasonably test without compromising standards (this may differ from nurse to nurse but in
our experience cannot exceed 50 in any given day). The control VCT counsellor marks
consent forms until the stated number is reached. Thereafter the community is informed that
no more people can be tested on that specific day and that the following testing options are
available to them:
o
testing at their local PHC – inform them which is their closest PHC; and
o
testing at the same place at the following month’ social grant point.
 the community members who are not allocated a number must be requested to disperse by
the control VCT counsellor as continued patient load pressure puts the entire system at risk.
56
 the nurse tests 3 clients in a row without giving the clients’ their results104 (each consent form
with corresponding rapid test is placed in separate in tray). Once 3 clients have been tested,
they return one by one for their results (optimising time which rapid test takes for accurate
reading)
Age of consent to an HIV test Nurses are often not aware that the age of consent to an HIV test without parental consent has
been changed in South Africa. Section 130 of the new Children’s Act no. 38 of 2005 allows
children of 12 years of age and older to consent to HIV testing. They do not require their
parents consent for them to have an HIV test.
It is important that nurses and the community members (such as school teachers and parent
when testing at a school) are made aware of this as children are often turned away from testing
stations despite being allowed to test without parental consent.
10.9.8
Long term outcomes of increased VCT outreach in the community
People now expect the VCT outreach team at social welfare grant points and arrive for testing
even if not accessing a grant –
The Madwaleni HIV programme now receives complaints when we are not available for testing
as social welfare grant points. We also get telephoned by community members to confirm that
we will be at the grant point in order that they can bring another community member for HIV
testing.
Staff motivation by field work and not downstream health facility –
Input from hospital and PHC staff has indicated that they enjoy working in the community
accessing people who are not already ill. The staff gain community respect for working within
the community.
Direct link from testing to HIV support groups: patient advocacy –
The VCT outreach team all wear uniforms which market the PHC HIV support groups. The VCT
counsellors are HIV positive members of the community who speak openly about their status
and are working on the ground with large number of community members whom they know.
The community is exposed to their own community members talking about their status and the
HIV support group which they joined when they became aware and accepted their HIV status.
Promotes community awareness of decentralised nature of the HIV programme –
Both pre-and post-test counseling emphasise the PHC HIV support group as the next step after
finding out that you are HIV positive. HIV positive clients are referred to their closest HIV
support group at which they will be looked after and prepared for ARVs. This continued
exposure to the HIV programme at PHC level has helped market its decentralized services.
Interaction with community in neutral venue –
Historically the hospital and clinics have been the domain of the nurses. At VCT outreach the
team is operating on the community’s terms.
104
Previous experience has shown that nurses when under patient load pressure will often test a number of clients in a row
without providing them with results. Later on, the nurse will call them back for their results, without an effective system and a
limit on the number that can be done in a row, this can often lead to compromised testing and counselling practices.
57
11. HIV support group
If HIV+
WK2
SG Visit 3
WK1
Join HIV Support Group (SG)
SG Visit 2
WK 2
Receive education in group counselling sessions and referral to nurse if unwell
11.1
Entry point into HIV wellness programme
Madwaleni HIV programme uses the HIV support group as the entry point into the HIV wellness
programme.
What does this mean? In most HIV programmes, a support group for people living with HIV is an
ancillary service which a person can choose to utilise or not. At Madwaleni, with certain exceptions
(see below), all community members are required to attend one of the eight HIV support group run
weekly at Madwaleni hospital and its seven primary healthcare clinics to access the HIV wellness
programme (including being initiated on ART).
11.1.1
Purpose of HIV support group
Peer education Use of peer education as a technique for group education has been widely recognised as
effective in crossing barriers to health education. A professional healthcare worker is often
assumed not to understand the circumstances of the patient and her/his input is often not
regarded to have application. In addition, the Xhosa community is recognised to be
paternalistic and education provided by females is often disregarded by male members of the
community105.
Reduction of community stigma Attending an HIV support group which is made up of other community members with HIV has
been instrumental in sub-Saharan Africa from dispelling a person’s concern that he/she is alone
with their burden of being HIV positive. People immediately feel that there are many people
with the same concerns and challenges as they are experiencing. Many community members
attend HIV support group before accepting their HIV status. Were the support group voluntary,
certain community members would choose not to attend the support group and consequently
loose the opportunity to see for themselves that they are not alone in their communities.
Patient advocacy and activism –
The support group can also be used to create a patient advocacy group in the community that
advocates for the rights of those living in the community with HIV. The pictures below reflect
how belonging to a Madwaleni HIV support group is not only about gaining psychosocial support
and HIV related information but belonging to a group with a recognised voice in the community.
105
Men taking an active role in their support group by educating their peers has had good outcomes for the programme.
58
Social network of community members who can assist and support Patients who attend the same HIV support group form a network in the community. They will
often inform a staff member that a person is very ill and is unable to come to the hospital in
which case the programme can send a vehicle to fetch the patient. They also provide support
and assistance to others when healthcare facilities cannot be accessed106. They form a team
who rely on each other’s assistance when circumstances make it difficult for a person to attend
their PHC for clinical monitoring or to collect his/her ART supply107.
Follow up through community networkThis social network discussed above has also proved extremely useful to the HIV programme in
following up patients. When patients do not come on their return appointment dates either for
clinical follow up or to fetch their ART, other support group members from the same village can
often provide information on where the person is or can find out on return to the village. Support
group members also send messages with other support group members when they have a
problem to keep us informed.
Continual adherence education after starting ART The format of the HIV support group session as discussed below provides continued ongoing
reinforcement of ART adherence counselling.
106
For example when a patient went into labour in a heavy storm at night and there was no transport, she went to another
support group members house who assisted with the delivery while on the phone to one of the doctors.
107
For example, near Melitafa PHC, many programme patients need to cross a river to get to the PHC. When it rains heavily, it is
impossible to cross. One person will phone a support group member on the other side of the river that will report the problem
to the PHC nurse who will ensure she keeps their ART supply for collection as soon as the river subsides.
59
11.1.2
Why mandatory attendance?
The reasons for attendance at an HIV support group being made mandatory for entry into the
HIV programme were and to a large extent remain as follows:
Optimising limited resources by determining commitment to HIV wellness108 –
Rural health programmes are hindered by understaffing and limited funding. While the HIV
programme’s intention is to provide HIV wellness services to all community members, feasibly
resources do not to allow for this and priority needs to be given to those community members
who are committed to their healthcare and maintaining HIV wellness. This means that time
spent on opening patient files, taking blood investigations and counselling people who do not
intend returning can be allocated to those that do109. It also reduces the number of people that
need to be followed up after failing to return for HIV wellness services including the collection of
their ART. Requiring a community member to attend an HIV support group three times before
being allowed to join the programme provides the staff with a mechanism for selecting this
“committed group” of HIV positive community members.
Creating community awareness of commitment required to maintain HIV wellness –
By explaining the requirement of attending your closest HIV support group to access HIV
services to a community member, the HIV programme has created an awareness of the
personal commitment required to maintain HIV wellness.
Optimising limited resources by creating a forum for group education –
Limited staffing requires strategies whereby counselling and education can take place in a
group rather than individual forum to ensure reaching a larger target group.
Compel male inclusion in support group environment –
Rural men are less likely to access healthcare services timeously and have a negative influence
on the women in their families access thereto. Where the HIV support group is purely
voluntary, the majority of participants are likely to be women and potentially unmarried women.
By the forced inclusion of men in the HIV support group, they take a role in the group and HIV
awareness is increased generally in the male portion of the community.
Making use of time spent waiting for clinical or pharmaceutical services At Madwaleni hospital, patients are required to sit in the waiting room in queues to see
counsellors, nurses and doctors for clinical care. The HIV support group attempts to make
efficient use of this time. Patients do not lose their place in the queue while they attend support
group as the services continue to be rendered during the time of the support group110.
A different strategy to failed TB treatment adherence –
The Madwaleni-Xora area like many rural South African settings has had a history of patients
failing to fetch their supply of TB treatment and failing to complete 6 months of TB treatment (in
comparison to a lifetime of ART). Once patients become resistant to TB drugs and are
108
Also referred to as rationing a system to restrict demand for a scarce resource so that it matches supply. See Rosen S, Sanne
I, Collier A, Simon JL (2005) Hard choices: Rationing antiretroviral therapy for HIV/AIDS in Africa. Lancet 365: 354–356 and
Rationing Antiretroviral Therapy for HIV/AIDS in Africa: Choices and Consequences, Sydney Rosen*, Ian Sanne, Alizanne Collier,
Jonathon L. Simon.
109
In early 2005, the professional nurse allocated to HIV at Madwaleni had hundreds of CD4 counts results for patients who had
never returned to Madwaleni to collect them and she did not have the time or resources to follow them up.
110
At the PHCs due to lower patient volumes, HIV support group is held prior to the commencement of the HIV wellness and
ARV clinic.
60
diagnosed with multi-drug resistant TB, they pose an infection risk to their families and
communities. In addition, they are sent to specialised TB hospitals for up to eighteen months
away from their families. We wanted to try a different approach further upstream.
The fact that mandatory attendance may be barrier to accessing the HIV wellness programme
for certain community members is understood and continually being evaluated and considered
against the benefits set out above111.
11.2
Definition of HIV support group in the Madwaleni sense
The use of the term ‘support group’ within the Madwaleni HIV programme can be misleading as it is
not a traditional small group of patients aimed at psychosocial therapy alone. The HIV support
groups are made up of all patients attending the HIV wellness programme. While used for
community support of peers infected with HIV, focus is also placed on group education and
community network systems.
Many of the lay staff and patients regard HIV support group as being synonymous with attending
the HIV wellness clinic112.
11.3
Exceptions to attending HIV support group to join the HIV wellness programme
While attendance at the HIV support group is a generally mandatory for enrolment on the HIV
wellness programme there are a number of exceptions to this rule. These are as follows:
Inpatients –
Inpatients have in the past not been required but rather encouraged to attend HIV support group at
Madwaleni if they are able. However more recently due to higher defaulter and lost to follow up
rates amongst patients initiated on ART in hospital, the inpatient programme has been changed to
include a group of inpatients who are treated as outpatients for purposes of enrolment in the HIV
wellness programme (see para 16.3.3 ниже).
Children and their caregivers –
Children and their caregivers (including mothers) are not required to attend HIV support group to
join the HIV wellness programme. Immediately on attending at Madwaleni paediatric HIV clinic
(which also provides HIV services to the caregivers of the children), the child and caregiver are
enrolled. A caregiver HIV support group is held in the waiting area as part of the paediatric HIV
clinic to provide group education to caregivers on issues relating to HIV wellness and ART for
children (see 15.3.4 ниже).
Health facility staff –
Initially the HIV programme required staff to attend HIV support group like all community members.
However due to the low staff enrolment on the programme, a staff programme was developed which
focused on confidentiality113.
Pregnant women attending PMTCT clinic –
Due to pregnant women in the Madwaleni – Xora area presenting for ante-natal care late in
pregnancy, there is limited time available to initiate prophylactic or lifelong ART. Pregnant women
111
See Dr Richard Cooke masters research on this issue.
A person will say they are going to the Bomvana HIV support group to see the doctor or they are attending the Nkanya HIV
support group to fetch their supply of ART.
113
This model did not require HIV support group attendance. Interestingly this has not increased staff uptake of the
programme.
112
61
are therefore enrolled on their first visit to Madwaleni’s PMTCT clinic114 or at their first visit to their
PHC HIV support group (see para 14.4.1 ниже). A HIV support group is also run for pregnant
women as part of the Madwaleni High risk PMTCT clinic (see para 14.7.1 ниже).
Professional healthcare staff discretion –
While HIV support group attendance is the rule, professional healthcare staff retain the discretion to
reduce the number of HIV support groups the person needs to attend or exempt a person from this
requirement completely. As the majority of staff on the programme are lay, it is not possible for
them to assess each person’s circumstances individually. However the lay staff are aware that they
can bring a person’s circumstances forward for consideration by nurse/doctor/management for
exemption. Examples of cases considered for exemption are set out below but are not limited to
these categories:
 a person who is unwell and needs to be fast tracked; and
 a person who is in full time employment and cannot attend the Xora HIV support group held on
Sundays for working people115.
11.4
HIV support group attendance requirements to enrol on HIV wellness programme
A person is required to attend HIV support at any of the operational sites 3 times. On the date of
the person’s third attendance, the person will be enrolled on the HIV wellness programme. If a
person diligently attends HIV support group, this will take a total period of 2 weeks.
11.5
Continued attendance of the HIV support group not mandatory
While continued HIV support group attendance is encouraged and the format of the support group
focuses on teaching old members new information to keep them attending, once a person is a
member of the HIV wellness programme (i.e. the person has a file), he/she is not required to
continue attending the HIV support group. A person can arrive at the HIV department or PHC for
individual counselling, clinical monitoring and ART supply before or after support group (usually
11am-1pm).
114
115
PMTCT patients have a higher defaulter and lost to follow up rate than other outpatients.
Such as teachers who work in the area but go home outside of the area on weekends .
62
11.6
HIV support group model
The HIV support group is facilitated by one or more peer educators. These peer educators are
recruited from the HIV support groups and usually facilitate the HIV support group of whom they
were a member (see appendix 18.9).
The peer educator relies heavily on the involvement of the ‘active support group members’ who
have been members of the support group for some time to assist him/her in guiding the support
group.
11.6.1
HIV support group membership
Each HIV support group has established it own set of rules as to who may and who may not
attend support group. Across the board the HIV support groups require a person to have tested
and to have been diagnosed with HIV prior to him/her being allowed by fellow support group
members to join the support group. Certain of the support groups do allow family patient
escorts or carers to also attend the HIV support group (often with the caveat that the person
must have undergone an HIV test themselves irrespective of the result).
11.6.2
Confidentiality within HIV support group
Active support group members always explain the purpose of HIV support group to new
members and while doing so emphasise the confidentiality of the identity of fellow members.
While every person attending HIV support group knows that other people in HIV support group
are HIV positive, this is to be kept to themselves once they leave the hospital/PHC. It is
emphasised that each person retains the right to disclose his/her status in the community and
that no other community member may do so on his/her behalf.
63
11.6.3
Format of HIV support group session
The 2 hour session is broken up into three sections as set out above. The purpose is for the
session to provide useful psychosocial support and education to a broad range of patients from
those who are attending for the first time to those who have been attending for years and are on
ART.
11.6.4
Splitting the HIV support group
There have been many discussions over the past few years as to whether to spit the HIV
support groups into 2 separate support groups, one for new and one for experienced support
group members in order that the two group’s different needs cab be focused on. However the
support groups themselves have voted against such a split for the following reasons:
 the experienced members felt that the new members are more likely to see the benefits of
the HIV programme if they see and hear the experienced members speaking in the support
group;
 the experienced members felt that they could provide understanding and input to new
members on situations or challenges which the new member may be experiencing such as
disclosure at home; and
 the experienced members felt that they enjoy passing on their knowledge to new attendees.
11.6.5
Strategies to keep experienced support group members coming back
Due to the HIV support groups not wanting to split, the format of the support group had to be
considered with a focus to keeping experienced support group members interested. This is why
the support group is divided into 2 one hour parts. The first part focuses on newcomers being
64
offered support, basic HIV wellness and ARV education by experienced support group
members. While the second part focuses on providing new information every 2 weeks so that
experienced support group members will continue to learn and have the opportunity to ask
more complex questions.
11.6.6
Training peer educator to provide group education on new topics
Determination of topics for HIV support group throughout the year Every 6 months, the HIV team meet to provide input on discussion topics for HIV support group.
As many of the HIV team are members of a support group and facilitate these groups, their
input on topics for discussion is essential. Once everyone has had an opportunity to suggest at
least one topic, the schedule is drawn up with the professional responsible for providing the
training in the Monday morning HIV team meeting. See example appendix 18.27.
2 week cycle –
The group education topics follow a 2 week cycle as reflected in the diagram below.
A short training session is held for fifteen – twenty minutes at the end of every second HIV team
meeting held on a Monday in the HIV department. A simple and easy to understand fact sheet
or facilitation note is provided to each peer educator. See examples in appendix 18.28.
Professional staff assistance or input at HIV support group The peer educators do request professional healthcare members of staff such as
nurse/doctor/social worker/pharmacy/management to sit in for 15-30 minutes of support group
to explain a complex concept or to answer support group questions116.
11.6.7
Clinical referral from HIV support group
Where a patient arrives at the HIV support group and either complains of being unwell or is
unwell, he/she will immediately be referred to see a professional nurse117.
116
The professional staff, especially doctor, enjoy this opportunity to hold a group discussion with patients.
At the HIV department and Xora CHC, the person will be placed in the nurse queue while at the other PHCs, the patient will
be referred into the main clinic where the nurse is stationed (separate building). It is common for very sick patients to arrive at
Xora CHC for the first time as they often do no come from our feeder area but from Mthatha’s feeder areas and have not
117
65
11.7
11.7.1
Setting up an HIV support group
Background
Setting up an HIV support group and gaining sufficient participation therein can be very difficult.
Due to stigma associated with HIV, there is often a resistance among patients to attend an HIV
support group when it first starts. In addition, it was our experience that nursing staff further
entrenched this attitude in patients by believing that patients would be unlikely to attend an HIV
support group and would definitely not attend an HIV support group that was marketed and
known about in the community.
11.7.2
Strategy used to set up HIV support groups
First phase: set up/build hospital based HIV support group Initially, we built on the small HIV support group that already existed at Madwaleni hospital. It is
often easier to set up such a group in the hospital setting as patients have to travel away from
home and their direct communities to attend the group. They therefore feel that it is less likely
that they will be known to be attending support group as they could be going to the hospital for
any one of a number of reasons. We also chose a venue that was away from the OPD setting.
This form of HIV support group is likely to only attract your more committed community
members who are often slightly better educated, have less responsibilities at home118 and have
the financial resources to attend119.
All patients, who attended Madwaleni hospital or any of the PHCs for VCT testing and who
tested HIV positive, were encouraged to join the Madwaleni HIV support group which ran
weekly.
Second phase: split the hospital based HIV support group and allocate to PHCsAfter approximately 6 months, the Madwaleni HIV support group had increased its membership
to over a hundred patients from a wide range of feeder villages. These patients had mostly
become active HIV support group members who had adopted a form of patient activism and
were less fearful of being stigmatised in the community. Some of these HIV support group
members now spoke freely about their status and felt a responsibility towards educating their
communities and fellow HIV positive community members.
We focused on a creating an identity for the Madwaleni HIV support group. Each new support
group member was given a choice to take or not to take a t-shirt which stated in large bold print
on the back (see above) that he/she belonged to the Madwaleni HIV support group.
We then marketed the set up the HIV support groups at each of the PHCs120 to the existing HIV
support group base at the hospital and encouraged them to assist us in replicating the
Madwaleni HIV support group at each of their PHCs.
obtained assistance in Mthatha. They are unable to attend HIV support group and usually require doctor intervention and
immediate admission to Madwaleni hospital.
118
Such as children and partner to take care of.
119
In our experience a group of patients between 25-35 years of age and predominantly unmarried women.
120
Started with 6 sites (1 CHC and 5 PHCs). Later 2 further PHCs were added.
66
These new HIV support groups would be closer to the patients’ homes and many of the HIV
support group members were now less concerned with perceived community stigma and felt
that they could openly attend their PHC to attend their local HIV support group.
Once we had this commitment, we transferred the Madwaleni HIV support group members (with
their HIV wellness files – see para 13.3.3 ниже121) to the 6 newly formed HIV support groups.
This meant that the each HIV support group started with a relatively strong membership base of
5 – 10 members and a peer educator that could be built on.
Due to limited space at the different PHCs, these groups met in any space that was available for
the day122.
Third phase: building the PHC HIV support groups The fact that these HIV support groups had small but relatively stable membership bases,
helped to dispel the PHC health professionals’ belief that no one would attend such HIV support
groups and such staff started actively encouraging patients to join the group.
The PHC nursing staff were encouraged to facilitate a portion of the HIV support group if they
had the time. These HIV support groups ran weekly whether there was 1 member or 10
members in attendance.
Continued marketing of these HIV support groups was done at the Madwaleni HIV support
group and within the communities through the traditional leadership. In addition, billboards
advertising their existence and the times of the various HIV support groups were put up on the
properties of the various village headman/sub-headman in the Madwaleni – Xora area123.
The HIV/OVC S&D manager (then the HIV/ARV site co-ordinator), attended the majority of
these HIV support groups in their early stages. Where the group started to dwindle, active steps
were taken to encourage specific individuals to attend. Different PHCs’ HIV support groups
grew at different rates, some more quickly than others124 but they were self sustaining and
continually growing 6 months after set up.
We also started printing t-shirts which specifically stated the PHC HIV support group to which
the patient belonged (see photos above).
Fourth phase: maintaining membership at the HIV support groups The HIV/OVC S&D manager continued to work together with the PHC peer educators to identify
any factors which may be discouraging patients from first attending or continuing to attend their
HIV support groups. The attendance numbers (including new membership) are reviewed
121
At this point ART was only available a Madwaleni, so those patients who were on ART stayed at Madwaleni but were
encouraged to also attend their PHC HIV support group which many did.
122
At Bomvana clinic, the HIV support group met in the old dilapidated nurse accommodation room used for storage (amongst
the boxes and cupboards). At Xora CHC, the HIV support group met in the room built as a rescusitation room which was not
being used at the time. In the Mqhele PHC, the HIV support group met in labour room as there was infrequently a woman in
labour and if this happened they moved outside under a tree. At Nkanya PHC, the HIV support group met in the church across
the way from the PHC. Lack of space for this group did not stop these groups being set up at the PHCs.
123
The HIV/OVC S & D manager worked with the traditional leaders regarding where to erect these billboards. The
headman/sub headman asked that they be put up on their properties facing the road in order that they may ensure that they
were not vandalised. This assisted with demonstrating the traditional leaders’ support of the HIV support groups.
124
Directly linked to PHC nursing staff buy in and marketing to patients and peer educator’s repoire with her HIV support group
members.
67
weekly at the HIV team meeting. These factors are often PHC and community specific
dependant and need to be dealt with quickly to avoid disintegration of the membership base125.
With time, the community in general has become aware of the day on which the HIV support
group runs at their local PHC. As explained above, the community uses the term ‘HIV support
group’ to also refer to the HIV wellness and ARV clinic run at the PHC. Newly diagnosed
community members are less hesitant to attend these support groups as they usually already
know a number of their community that attend. This has made a significant impact on HIV
related stigma in the Madwaleni – Xora area.
These HIV support groups have continued to grow and in 2009 all have membership in excess
of 250 patients126.
125
By way of example, the church at Nkanya where the HIV support group met required the members to pass in front of the
shebeen where a specific group of old ladies hurled insults at them as they passed by. We arranged for a different gate to be
opened so that passing in front of the shebeen was not necessary and the professional nurse at the PHC met with the old ladies
who frequented the shebeen daily.
126
Other than Hobeni PHC which is a newly built PHC and which only started it splinter group HIV support group in April 2009.
68
12. Adult HIV wellness and ARV programme
12.1
Enrolling in the HIV wellness programme
WK 2
Join HIV wellness programme
 Open file
 Initial individual counselling
session
 Nurse clinical consultation
incl. TB screening
(referral to Dr if necessary)
 Take ELISA, CD4, FBC, ALT,
RPR, Cr, HBV, Urine dipstick
 Dispense prophylactic
treatment
 Conduct or refer for pap
smear
 Provide nutrition if necessary
 Refer to social worker if
necessary
On the date of the patient’s third HIV support group attendance (see exceptions in para 11.3 выше),
he/she will be enrolled in the HIV wellness programme which involves the following steps for that
particular day:
12.1.1
Opening HIV wellness adult paper file – peer educator
A peer educator will open a file for a patient by completing the first section of page 1 of the adult
HIV wellness form see appendix 18.29 which notes the patient’s pertinent background
information.
12.1.2
Conducting individual counselling session: HIV wellness visit no.1 - peer educator
Once the peer educator has opened the patient’s file, the peer educator conducts the first
individual counselling session or ‘HIV wellness visit’ as it is termed. This session has a number
of purposes including:
First instance screening for patient danger signs –
As discussed above, the programme uses task shifting mechanisms to allow it to operate with
limited professional staff resources. The peer educators therefore conduct the first clinical
screening each time a patient attends the HIV wellness clinic. The peer educators’ screening is
very broad in order that no clinical skills are necessary to determine whether a patient should be
on-referred to a nurse for further assessment. The peer educators’ screening includes the
following checks:
o has the patient lost more than 3kg since their last visit;
o does the patient have any TB symptoms from patient self report (coughing, night sweats or
weight loss);
o has the patient been admitted at any health facility since his/her last visit;
o is the patient pregnant; or
o does the patient have any health complaints.
If a patient answers any of these in the affirmative, the peer educator refers the patient to a
nurse for assessment and records the referral on the HIV wellness visit form.
69
In addition, each patient’s vital signs are taken by the nursing assistant in the HIV department
and if abnormal, the nursing assistant refers the patient to see the nurse.
One-on-one counselling on issues associated with living with HIV –
The format of this counselling session is informal and the peer educators have been trained in
counselling skills. The peer educator completes an HIV wellness visit on page 2 of the adult
HIV wellness form (see appendix 18.30). The form which they complete is only a guide to the
issues that should be covered. Emphasis has been placed in training and mentoring on peer
educators focusing on the counselling session rather than completing the form. Many of the
issues discussed are ones which the peer educators themselves experienced and can therefore
provide useful input such as:
 disclosure to family;
 importance of safe sex;
 importance of psychosocial support and nutrition to HIV wellness; and
 information about the HIV wellness programme and ARV treatment
Provision and monitoring of prophylaxis –
Peer educators will start all new HIV wellness patients on prophylaxis which includes
Cotrimoxazole (trade name Bactrim), folic acid and vitamin Bco. They will teach the patient the
importance of getting into a routine of taking their prophylactic treatment once daily. They will
also explain the Cotrimoxazole pill count which they will be conducting at every HIV wellness
visit to help prepare the patient for taking ARV treatment later on. (See training sheet in
appendix 18.32 and pill count form in appendix 18.33).
Once the CD4 count result is known, the peer educators will apply the protocol regarding which
patients should continue on Cotrimoxazole (see appendix 18.34) and explain to those who were
unnecessarily started that they do not need it at this time. Where the peer educator is unsure,
for instance where the patient has a high CD4 count but is unwell, he/she will refer to the
nurse/doctor for advice on the way forward.
CD4 monitoring The peer educator will refer the patient to have his blood investigations taken including his/her
CD4 count. The peer educator will explain the meaning of the patient’s CD4 count to the
patient.
Some patients may already have had a CD4 taken when they open their file. The peer
educators are trained to check this result and complete it on the HIV wellness visit form. Where
the CD4 count is less than 210, they will start ARV preparation (see para 12.4 ниже).
12.1.3
Nurse consultation – professional nurse
Each new patient will see a professional nurse for a clinical visit upon joining the HIV wellness
programme where he/she will assess the patient and complete both the medical history portion
of page 1 of the HIV wellness form (appendix 18.29) and the HIV wellness visit 1 on page 3
(appendix 18.31). For the nurse’s guideline for this clinical visit see appendix 18.35.
70
The nurses have been trained to focus on screening for danger signs (appendix 18.36) and red
flag symptoms (appendix 18.37) each time they see a patient127. Any danger signs or red flag
symptoms need to be completed on the HIV wellness form prior to referral to a doctor128. Most
importantly, nurses have been mentored to focus on screening for TB symptoms at this visit129.
Nurses have over time been mentored130 to manage common clinical issues with reference to
simple protocols such as TB diagnosis and STI management (See appendices 18.39 and
18.38)131.
The nurse will also either conduct a pap smear on all female HIV wellness patients or refer
them to a day on which they have a booking list for conducting such pap smears132.
The nurse will determine which of the patients require a consultation with the doctor who will
see the patient on the same day.
12.1.4
Blood investigations – community health worker + enrolled nurse
The community health worker (CHW) has been trained (as have all the peer educators at the
PHCs) in the standard blood investigations to be taken on joining the programme. In addition,
the CHW will check the front of the file to check if the professional nurse/doctor has requested
any further blood investigations. The CHW will complete the necessary NHLS133 forms and
blood tubes and send the patient to the enrolled nurse, who will check forms and tubes and will
take the necessary bloods. See appendix 18.40 for routine blood investigations.
These blood specimens are taken to the hospital laboratory every hour to ensure that there is
not a large submission at the end of the day. This ensures that the laboratory is able to start
some of the blood investigations during the day and can submit a portion to the courier from
Mthatha laboratory on the same day.
12.1.5
Nutritional support – peer educator
The ECDOH through the district provides nutritional support in the form of fortified porridge and
a high energy formulation134. A peer educator is on duty each adult HIV wellness clinic to
127
The monthly mortality meeting has been used to identify where care could have been improved upon to identify illness
earlier on. Our experience has shown that the rural community (especially men) often do not report ill health easily and
therefore systems need to be put in place for screening for these even if the patient reports that he/she is well.
128
Advanced professional nurses will have the ability to provide further clinical input to doctors regarding their reasons for
referral. However the danger signs and red flag symptoms were identified by HIV clinicians as the minimum requirement to be
considered for each patient’s clinical assessment.
129
Due to high co-infection rate between HIV and TB.
130
This mentoring process has taken place over a number of years. Where a patient is referred that could have been managed
by the referring nurse, the doctor will see the patient together with such nurse instead of managing the patient on his/her own.
This usually takes more doctor time but is imperative in capacitating nurse HIV management skills and in the long run saves
time. At the PHCs, the doctor will sit with the nurse and guide her in conducting this nurse consultation. The doctor will then
see the patients that the nurse (with his/her guidance) has referred.
131
It is important to note that the nurse protocols attached hereto have purposefully been over simplified. In the head
clinician’s experience, more complex clinical protocols are not routinely followed. Where a nurse requests or demonstrates
their interest in a more detailed understanding or protocol, they are provided with those set out in PALSA plus 2007
edition. Western Cape DoH (produced in conjunction with UCT and UCT lung institute by Lara Fairall, Rene English and Eric
Bateman).
132
All PHCs and the HIV department conduct pap smears. Some of the PHCs will conduct the pap smears on the same day as
the HIV wellness clinic while the HIV department refers these patients to the closest Friday.
133
National Health Laboratory Service
134
This is not always in stock and cannot as a result always be provided. In Madwaleni history, we have managed to obtain
nutrition most of the time although since April 2009 this has no longer been possible due to tender issues between ECDOH and
71
determine whether a patient qualifies for nutrition (according to NDOH nutrition guidelines for
patients with HIV&AIDS 18.42) and to supply this nutrition. This guideline requires the peer
educator to be able to calculate the patient’s BMI which they have been trained to do.
12.1.6
Social welfare support – social worker
Nurses and doctors refer patients who require social support to the hospital social worker for
assistance135. The social worker also makes herself/himself available at scheduled HIV support
groups to answer questions and book appointments with patients who require
assistance/support.
In addition, peer educators also consult with the social worker regularly for the referral of
patients which they are concerned about.
Madwaleni HIV programme staff are very strict in following the Department of Social
Development guidelines that reflect who qualifies for a disability grant. We do not submit
disability grant applications on the basis of a CD4 count alone. Only patients who are disabled
by their HIV will be considered in an attempt to break the link between low CD4 counts and
qualifying for disability grants which negatively impacts HIV wellness and adherence to ART.
12.1.7
Return date – peer educator
The peer educator will encourage the patient to return to the HIV wellness clinic in two weeks
time to check his/her blood results specifically the CD4 count and continue individual
counselling136 unless a nurse/doctor has requested the patient to come back sooner for clinical
follow up reasons.
12.2
Return HIV wellness visit to ascertain CD4 count
If CD4>200
WK3/4
If CD4<200
(if CD4< 50 further
nurse consultation)
WK3/4
12.2.1
Conducting individual counselling session: HIV wellness visit no.2 - peer educator
Upon return two weeks later, the patient will see the peer educator again who will check the
patient’s CD4 count and counsel the patient regarding his/her CD4 count. The peer educator
will also explain that there is another blood investigation called a ‘viral load’ which is also very
important which shows how much HIV is in the patient’s blood but that the programme only
takes this six months after the patient has started ART to see that the ART is working137 .
supplier. However accessing nutritional supplements from the district has involved ordering it and arranging transport to fetch
from the district offices.
135
Madwaleni Hospital has been without social worker services on site for more than 1 year since mid 2008 and this has
hampered holistic assistance.
136
Ideally the programme would want this return date to be 1 week later but as CD4 count results usually have a longer than 6
day turnaround time from date of taking and submitting to the laboratory at Madwaleni, this is not feasible. There have been
brief periods where the turnaround time has improved but these have not been sustained by NHLS.
137
The programme found that as NDOH guidelines do not allow for taking a viral load before starting ART, patients are only
counselled on the meaning of a CD4 count. This means that later when viral load is a better indicator of success on ART, patients
still focus and worry about their CD4 counts. Both HIV support group sessions and HIV wellness individual counselling sessions
72
CD4 count above 210  where the patient’s CD4 count is above 210, the peer educator will explain to the patient that
he/she does not need ART yet and that this is a good thing as it will give him/her proper time
to prepare for this lifelong commitment;
 the peer educator will explain that the patient should, if possible, continue attending the HIV
wellness clinic (including the HIV support group) two weekly for continued HIV wellness
counselling and ART preparation. Every 6 months, the patient will have his/her CD4 count
taken again to monitor it so that he/she can be started on ART as soon as he/she needs it;
 the peer educator will then continue to conduct the individual counselling session and
complete the HIV wellness visit 2 on the page 2 of adult HIV wellness form (appendix 18.30);
 the peer educator will also ask the patient for his/her Cotrimoxazole and conduct a pill count.
The results of which he/she will record on the pill count form (see appendix 18.33). Where
the patient is not taking the correct number of pills, the peer educator will explain the
importance of taking it correctly in preparation for starting ART in the future; and
 the peer educator will refer the patient to a nurse for an INH prophylaxis138 assessment
provided the patient is not currently on ART (from a different programme) and has not been
on TB treatment in the last 2 years.
CD4 count below 210  where the patient’s CD4 count is below 210139, the peer educator will explain to the patient
that they need to start ART as quickly as possible and will therefore need to focus on their
preparation for starting ART, this will include:
o the patient will need to attend the HIV wellness clinic weekly until the patient is ready to
be initiated on ART;
o disclosing the patient’s status to someone at the person’s home who will be able to
provide support and assistance (called a treatment partner). In certain instances the
patient will choose a different person to the person to whom they have disclosed at home
to take on the role of treatment partner (often when family member does not have the
capacity to assist such as in the case of the very old);
o get the Cotrimoxazole pill counts correct for 3 weeks in a row (unless the patient’s CD4
count is below 100 then 2 pill counts in a row will suffice); and
o understanding the implications of taking ART every day for the rest of the patient’s life.
 the peer educator will then continue to conduct the individual counselling session focusing
on the above ART preparation issues and complete the HIV wellness visit 2 on the adult HIV
wellness form (appendix 18.30).
 the peer educator will also ask the patient for his/her Cotrimoxazole and conduct a pill count,
the results of which he/she will record on the pill count form (appendix 18.33). Where the
patient is not taking the correct number of pills, the peer educator will explain the importance
of taking it correctly in preparation for starting ART and support mechanisms to assist the
patient.
12.2.2
INH prophylaxis assessment – nurse
now focus on both CD4 count and viral load. In addition in mid 2009, NDOH also did away with baseline viral loads to save costs.
The first time a patient will now have a viral load taken is at 6 months on ART.
138
For TB.
139
Madwaleni HIV programme is focused on strategies in the community to encourage the community to join the HIV
programme upon diagnosis and not waiting to fall ill. There are still a large proportion of patients that require ART immediately
upon enrolment.
73
The peer educator will refer the patients not on ART and with no history of TB treatment in the
last two years to the nurse. The nurse will follow the guideline to either initiate INH prophylaxis
or refer to the doctor for further assessment. See appendix 18.41
12.3
Return HIV wellness visits thereafter
2 weekly HIV wellness visits:

Attend HIV support group

Individual counselling
session relating to living
with HIV and readying for
ARVs

Basic clinical screening
incl. for TB symptoms

Referral for and treatment
of opportunistic infections

Cotrimoxazole pill counts to
prepare for ART

Provide nutrition if
necessary
(after 6 months – once monthly)
6 months
Take CD4 again
12.3.1
Conducting individual counselling sessions: HIV wellness visit no.3 onwards – peer educator
Each visit –
The peer educator will:
 conduct a further individual counselling session;
 complete an HIV wellness visit on the HIV wellness form;
 refer the patient to the nurse should the patient have any health complaints or should any
clinical screening question (focused on TB related symptoms) be answered in the
affirmative;
 book the patient for a pap smear (if still not done or needs to be repeated);
 refer the patient for nutrition should he/she request it or should it look necessary; and
 refer the patient to the social worker should issues come out in the counselling session
which require further intervention or assistance.
Every 6 months  refer the patient to have his/her blood investigations taken every 6 months;
 after 6 months and provided the patient’s CD4 count remains above 210, the peer educator
will explain that the patient need only try to attend the HIV wellness clinic once monthly from
then on;
 every time the patient attends the HIV wellness clinic thereafter, the peer educator will
conduct a further individual counselling session, complete the HIV wellness form and
conduct a Cotrimoxazole pill count; and
 where the patient’s CD4 count has fallen below 210, the peer educator will immediately
assess whether ART preparation has been completed (which should be the case if the
patient attended regularly) and immediately conduct ART adherence counselling (see para
12.5.1 ниже), schedule a home visit (see 12.5.2 ниже) in the following 7 days and schedule
the patient to start ART the following week140.
140
This is the one of the principal benefits of patients joining the HIV wellness programme early, while they have time to prepare
themselves and their families at their own pace. They will then be ready to start ART immediately when their CD4 drops within
the range determined by the NDOH for ART initiation.
74
12.4
ART preparation visits
WK3/4
Determine if patient has met individual
commitment issues prepared for in HIV
wellness programme specifically including:

has identified a treatment partner

disclosing HIV status to a
partner/family member

Cotrimoxazole pill count is correct
Once the patient has ascertained that they need to start ART and he/she needs to attend weekly to
prepare for ART (assuming they have not been on the HIV wellness programme in the past and are
already prepared), a peer educator will see the patient weekly to facilitate ART preparation.
Various strategies have been employed by peer educators to assist patients who experience
barriers to meeting the ART preparation requirements. Examples of these are set out below:
Disclosure issues the peer educator will work together with the patient to understand their reluctance in disclosing
and provide input from his/her own experiences. The peer educators understand that for a
number of patients this process takes time141;
 in certain cases, the patient will ask the peer educator to come to his/her home to explain to
his/her family what HIV is and what it means for the patient to be HIV positive. Certain of the
peer educators are experienced with assisting in this manner; and
 however in certain circumstances, a patient’s home situation does not allow for disclosure to be
made to any person in the home such as where there are no adults in the home or any adults
that do share the home abuse alcohol and cannot be trusted with this confidential information.
In such cases the peer educator will firstly encourage the patient to involve and disclose to a
neighbour or close friend who is seen regularly. Where there is no such person142, the peer
educators will try to link the patient to another HIV support group member from the same area
that can provide some support143.
Pill count incorrect and/or failing to understand implications of taking ART for life  in our experience, continued failure to take Cotrimoxazole correctly and pass the requisite pill
counts is predominantly due to 2 reasons namely:
1) incapacity (due to mental incapacity, illness or old age)
2) failure to accept of HIV status and the resultant path forward.
In both instances, the peer educators will attempt to involve the following family member:
o mental incapacity – principal caregiver which is usually the mother
o illness – either mother/wife/husband
o old age – child of patient144
o non acceptance – preferably wife/husband (if none than parent); and
141
Despite the clinical urgency to start ART. Where ART preparation is unlikely to be completed quickly and the patient requires
urgent ART, the preparation process can be continued after the patient has been initiated (usually with the assistance of a family
member).
142
This is more commonly experienced with older men in the programme who have become ill, whose younger partners have
left them and who now live a very isolated unsupported life with HIV.
143
There are a few cases where a patient will be initiated on ART without disclosure to any person and without a treatment
partner as there is no person suitable for this role.
144
We have often had cases where a child in high school is able to support and assist their grandmother with ART adherence.
75

the patient will be encouraged to bring the family member with to the next HIV wellness clinic
and both the patient and his/her treatment partner will be taught together so that there is support
in the home environment.
Once the peer educator is satisfied that the patient has met the requirements for starting ART as set
out in para 12.2.1 выше, the peer educator will immediately conduct ART adherence counselling,
schedule a home visit in the following 7 days and schedule the patient to start ART the following
week.
12.5
ART adherence counselling and home visit


1st individual adherence counselling (by
counsellor)
Home visit to prepare family for starting ART
WK4/5
12.5.1
ART adherence counselling
The peer educators conduct individual ART adherence counselling which each patient who is
ready to initiate ART. This session is conducted on the same day that the person is evaluated
to have completed ART preparation. For a 12 point guideline to such adherence counselling
see appendix 18.43.
The peer educator will teach the patient how reminders will help him/her to remember to take
his/her ARVs. Most patients only need to use certain of the reminders for the first few months
until taking ART becomes an established habit.
Reminders:
Treatment partner – discussed above.
Alarm clock – most patients now have a mobile/cell phone which can be used to set an alarm
clock. Most patients do not know how to use this function and need to be taught. Where
patients do not have a mobile phone, many have a wall clock in their homes. Where a patient
has no access to the time, the HIV programme provides the patient with a simple alarm clock
and battery and teaches him/her how to use it.
Pill box – pill boxes are provided to each literate patient who starts ART. Illiterate patients are
given a choice as to whether they will find the pill box useful145. The pill boxes are not provided
by ECDOH and are procured with private funding146.
ART patient treatment file (see appendix 18.44) provided to each literate patient who starts
ART. This file is made up of information relating to ARVs and side effects in Xhosa. It includes:
 a drug diary – in which the patient completes the ARVs he/she is taking and marks off when
he/she has taken such drug;
 a side effect diary – in which the patient records when he/she is not feeling well and
describes the complaint and the grade of the complaint;
 ARV clinic appointment diary – in which the pharmacy assistant records when the patient is
to come back to the ARV clinic for his/her next supply of ART.
145
Our experience has shown that pill boxes confuse illiterate patients and that taking the pills from the containers (which are
clearly marked to show the difference between each ARV drug) has better adherence outcomes.
146
It is not possible to procure pill boxes labelled in Xhosa and so new labelling needs to be pasted onto the pill box with Xhosa
days of the week.
76
Once the ART adherence counselling has been completed, the peer educator will:
1. schedule a home visit with the patient prior to ART initiation the following week;
2. write the patient’s name on the board in the HIV department office recording the date147 on
which the patient will be start ART and his/her name; and
3. put the patient’s file in the tray for patient’s scheduled to start ART.
12.5.2
Home visit to prepare family for patient starting ART
Many ARV programmes advocate a home visit to prepare the family for the patient starting ART
but it is our experience that very few carry these out. Madwaleni’s HIV programme, despite
limited transport resources, ensures that these home visits are carried out and do not delay the
patient starting ART.
Once the peer educator has completed the adherence counselling, he/she will schedule the
home visit with the patient. This allows the patient to select a day and time where family
members whom the patient wants present during the home visit are there. This home visit is
used for the following:
 to gain an understanding of the extent to which the patient has explained his/her ART with
the family;
 to answer the family member’s questions;
 to ascertain where the patient will keep his/her treatment at home; and
 to facilitate a family discussion on who will:
o
help remind the patient that is time to take his/her ART and when they will do so;
o
take the patient to the clinic/hospital if he/she is unwell; and
o
contact the HIV programme if the patient needs urgent help.
12.6
ART initiation
WK4/5



12.6.1
Clinical assessment for ART initiation by doctor
2nd individual adherence counselling by
pharmacy assistant (PA) – ARVs dispensed
Baseline bloods taken if DTT blood results
more than 3 months old
Why still centrally
All patients are still initiated on ART centrally at Madwaleni hospital. This is for a number of
reasons:
 the Madwaleni HIV adult wellness clinic is set up as a ‘one stop shop’ at which all processes
are conducted on the day of ART initiation so that provided the patient is clinically well,
he/she will go home with his/her ART on the same day148;
 Madwaleni hospital has X-ray facilities which are not available at the PHCs. All patients
initiating ART have a chest X-ray reviewed by the doctor as part of ART initiation process149;
147
Should always be the following Tuesday unless the patient has a problem with this date.
There is no delay between a doctor signing a prescription for a patient and the patient receiving his/her first ART supply as is
the case in many other government ARV sites.
148
77
 the Madwaleni HIV adult clinic is set up in an efficient streamlined way in order that 20
patients can be started on ART on single Tuesday (see process below);
 all professional staff and required resources are available at Madwaleni hospital on a
Tuesday and are focused on initiating patients on ART; and
 initiating ART at a PHC would delay a patient as the doctor only attends once monthly (CHC
twice monthly). While initiating centrally means that a patients can be starting on ART within
7 days of completing ARV readiness.
While replicating processes for ART initiation at the PHCs weekly may be possible, the risk to
long term sustainability thereof due to reliance on doctor presence at PHCs and the additional
costs involved in funding the additional resources required, so that a patient does not need to
come to Madwaleni for a single day, is arguable.
In addition, the programme staff have consulted with the HIV support group patients regarding
how they feel about ART initiation at Madwaleni. While it may be easier to be initiated at the
PHC, many patients see it as a sign of their success with their ART preparation to be referred
elsewhere for the day on which they start ART. The programme covers the cost of transport for
patients who cannot afford to come to the hospital for ART initiation.
However with the acceptance of the importance of nurse-initiated ART by NDOH and an
increased likelihood that it may be implemented150, Madwaleni HIV programme is now phasing
in ART initiation at the PHCs through the doctor-led ARV clinics (see section 13 ниже). Those
patients who would have come to Madwaleni in the same week as the doctor-led ARV clinic
date at their PHC will be initiated at their PHC. This will be used as an opportunity to
appropriately mentor the PHC nurses in ART initiation.
12.6.2
Preparation for patients scheduled for ART initiation
The following preparation steps are taken by the following staff members for patients scheduled
to start ART. These steps are all prepared for on the Friday/Monday preceding the ART
initiation days being Tuesday/Wednesday and Thursday:
Typed list for doctors –
The administrator types a list of patients scheduled to start ART for the week (Tuesday –
Thursday) from the whiteboard on which the peer educators have reflected scheduled ART
starts (where a patient is not reflected on whiteboard, their file will not be prepared). This list
also reflects whether this is a new patient for ART start or whether it is a patient who has been
previously delayed or failed to come for previously scheduled ART start. See as an example
appendix 18.46.
Files collected –
The administrator collects the files from:
 tray for patients scheduled to start ART;
 tray for patients whose ART start was delayed;
 tray for patients who failed to come on scheduled appointment date; and
 from filing drawers (in event not in proper place)
Files prepared –
The administrator prepares each file by including the following forms:
149
Referring patients for a chest X-ray at hospital from PHC was trialed but most patients failed to get chest Xray for doctor
review at PHC. The cost and difficulty of coming to Madwaleni for ART initiation was viewed as important enough but not
merely for a chest X-ray.
150
Dr Thobile Mbengashe, Chief Director HIV, AIDS and STI – Dec 2009
78
 check all patients’ blood results are in their file (if not, contact laboratory for outstanding
results);
 ART start initiation tag stapled to front of file (see appendix 18.47);
 check home visit form completed – staple into back of file;
 patient ART initiation consent (English stapled into file on top of home visit form and Xhosa
goes version loose to be included in patient treatment file once signed – see appendix 18.48)
 ART prescription – (stapled on top of consent - see appendix 18.50)
 ART clinical monitoring form (stapled on top of prescription form – see appendix 18.50); and
 ART investigation monitoring form (stapled on top – no form should ever be placed on top –
see appendix 18.50).
Files placed in Tuesday/Wednesday/Thursday ART start box –
The administrator places all files in applicable tray so that CHW in charge of reception for the
day can fetch these in preparation.
12.6.3
Process on ART initiation date
When a patient arrives with his/her treatment partner at Madwaleni hospital to initiate ART,
he/she will be assisted to follow these steps:
Report to reception –
Patient reports to reception on day of ART initiation. The patient will be given his/her HIV
wellness file which has now been prepared for ART initiation and continued monitoring. See
para 12.6.2 выше.
X-ray –
Peer educator provides patient with pre-prepared X-ray form to go for chest X-ray immediately.
Once the chest X-ray is completed151, the patient returns to the HIV department.
Nurse review –
Nurse reviews patient clinically and completes the first ARV visit block on the ARV clinical
mentoring form (see appendix 18.52) before referring to the doctor for final assessment for ART
initiation, including checking that patient has chest X-ray and blood results in file.
Doctor assessment –
Doctor assesses each patient for ART initiation. Where the doctor is satisfied with the patient’s
clinical picture and has briefly established the patient’s understanding of his/her treatment and
adherence thereto, he/she will:
 sign the ART initiation consent forms (appendices 18.48 and 18.49);
 prescribe ART and sign the ART prescription form (appendix 18.50);
 tick the ART start tag (appendix18.47); and
 tick on the ART start list that the patient started ART an whether the patient is currently in TB
treatment152;
Where the doctor is not satisfied with the patient’s understanding of ART and adherence
thereto, he/she will refer the patient back to the counsellor. Where the doctor is not satisfied
with the patient’s clinical picture and intends delaying the ART start for treatment of
opportunistic infections, he/she will indicate that the patient has been delayed and the estimated
period of the delay.
151
It is advisable to set up this arrangement with the X-ray department so that it is aware that on Tuesday mornings, the HIV
department will send 10 -20 patients for chest X-rays.
152
For HIV database purposes.
79
Blood investigations –
Patient then goes to the community health worker for determination of which routine bloods
need to be taken (baseline bloods are only retaken if ‘decision to treat’ blood investigations
were taken more than 3 months old (see routine blood investigations protocol in appendix
18.40). The community health worker will complete the requisite NHLS forms together with the
correct tubes and send the patient to the enrolled nurse who will check the routine bloods
ordered and take the blood.
Pharmacy adherence counselling and dispensing of ART –
Lastly the patient will see the pharmacy assistant who is based in a counselling room in the HIV
department153 for further adherence counselling session and dispensing the patient’s ART for
the first time. The pharmacy assistant will counsel and dispense to two patients who are
starting the same ART regimen at the same time. This strategy ensures more patients can be
initiated and also allows patients to learn from each other during this group process.
The pharmacy assistant sits around the table with the 2 patients and their 2 treatment partners.
He/she will follow the ART initiation guidelines for pharmacy assistants set out in appendix
18.53154. This counselling session is interactive and requires each patient to demonstrate their
ART adherence related knowledge which they have already been taught by peer educators. In
the interests of time, where a patient does not have an adequate understanding, the pharmacy
assistant will refer the patient back to the peer educators for further counselling.
The pharmacy assistant needs to complete the following processes after completing the
adherence counselling session:
 dispense the patient’s ART, including completing the medication labels (see example in
18.63) and the TCB date thereon;
 sign the ART initiation consent forms and ask the patient to sign the ART initiation consent
form (put the Xhosa version in the patient’s treatment file) (appendices 18.48 and 18.49);
 reflect ART dispensed on the ART prescription and dispensing form (see appendix 18.50);
 tick the ART start tag; and
 reflect the ART start on the dispensing sheet for the day (see appendix 18.61 and pharmacy
dispensing process in para 12.7.2 ниже).
153
Pharmacy is based in the OPD setting and does not allow for appropriate counselling space. It also ensures that HIV
programme staff can manage patient flow to pharmacy assistants and answer any questions which pharmacy staff may have
(specifically doctor prescription related queries). At Madwaleni this also works as the ARV store room is attached to the HIV
department and does not require the drugs to be brought from the OPD pharmacy storeroom.
154
This guideline was created during a 2 day workshop in 2006 between the pharmacist, HIV/ARV site co-ordinator and the
pharmacy assistants taking into consideration all team members’ adherence related experience over the previous year.
80
12.7
Continued management of adult patients on ART
2 weekly
adherence
visit
ART
adherence
checked by
PA and
referral to
PHC
1 + 2 + 3 month
clinical visits
 Nurse clinical visit
 adherence
checked (incl. pill
count (PC)) and 1
month repeat ART
dispensed by PA
 blood
investigations if on
NVP, TDF, AZT
Thereafter
 Attend monthly/three monthly
for ART supply
 Nurse check up 6 monthly at
18/24/30/36 months when
blood investigations taken
 Nurse clinical visit one month
later at 19/25/31/37 months
incl. review of blood
investigations
12.7.1
4 + 5 month check
up visit
 Nurse check up
visit
 Adherence
checked (4
month last PC if
correct) and 1
month repeat
ART dispensed
by PA
13 month clinical visit
 Nurse clinical visit incl.
review of 12 month
blood investigations
 adherence checked,
nurse and PA
considered for 3 month
supply of ART
 1 or 3 month repeat
ART dispensed by PA
6 check up month
visit
 Nurse check up
 adherence
checked and 1
month repeat ART
dispensed by PA
 6 month blood
investigations
taken incl. CD4,
viral load
12 month visit
 adherence checked
and 1 month repeat
ARVs dispensed by
PA
 6 month blood
investigations incl.
CD4, viral load
7 month clinical
visit
 Nurse clinical visit
incl. review of 6
month blood
investigations
 adherence
checked and 1
month repeat
ART dispensed
by PA
8 +9+10 + 11
month visit
 adherence
checked and 1
month repeat
ARVs
dispensed by
PA
Preparation for patients scheduled for repeat ART supply
The following preparation steps are taken by the following staff members in preparation for
patients scheduled to return for their ART repeats. These steps are all prepared for on the
Friday/Monday preceding the ART repeat days being Tuesday/Wednesday and Thursday:
Print ART repeat file list for each day of the week –
The administrator prints the ART repeat file list for each day of the week for Madwaleni HIV
department and each PHC from the HIV programme database (for example see appendix
18.60).
Pull files of patients on ART repeat file list –
The nursing assistant and community healthworkers then pull these files.
Print ART medication labels –
The administrator prints the ART medication labels from the HIV programme database on the
label printer (see appendix 18.63)
Prepare ART repeat files –
The nursing assistant and community healthworkers then prepares the files which involve:
 attaching appropriate file tag to the front of the file. The file list reflects the appropriate tag
i.e. month 12 on ART means the tag for month 12 (see appendix 18.65); and
 inserting patient’s ART medication labels in file155.
Place ART repeat files in ART repeat box for each day of the weekThe nursing assistant and community healthworkers group files according to each day in
the appropriate box to be placed at reception for that day.
Print ART stock requisition and ART repeat dispensing list per day per clinic for pharmacy
assistantThe administrator prints these 2 reports off the HIV programme database and places in the
pharmacy tray in the HIV department office (see examples in appendices 18.61 and 18.64).
The pharmacy assistant on duty for the specific clinic will collect the ART stock requisition
155
The peer educators do this for each of their PHC ARV clinics.
81
report first thing in the morning and go to the ARV drug stock room to pack a box156 with the
required stock. He/she will place the dispensing list in the top of the box for use when he/she
starts dispensing (see dispensing procedure below).
12.7.2
Process on ART repeat visit date
Reception – community health worker/peer educator The patient collects his/her file at reception from the community health worker/peer educators
on duty.
Nurse consultation – professional nurseRoutinely: 1 – 7 months and 6 monthly thereafter
Each patient will see a professional nurse each month for the first 7 months. Thereafter the
patient will see a professional nurse every 6 months and at anytime that the patient is unwell.157
The nurses understand the patient journey as set out in appendix 18.55 and also use the file tag
system to ensure that the patient receives the correct clinical care for the length of time on ART.
These nurse consultations take 2 different forms –
Clinical visit (month 1, 2, 3, 7 and 6 monthly thereafter)
A clinical visit is a more in depth clinical consultation with the patient which includes a review of
all his/her blood results taken the previous month with a focus on CD4 count and viral load after
6 months on ART. See appendix 18.56 for a nurse guideline to a clinical visit. Blood results are
completed on page 1 of ART clinical monitoring forms (see appendix 18.51).
Check up visit (month 4, 5, 6)
A check up visit is intended to be a briefer clinical consultation where the nurse quickly
assesses the patient’s health (see appendix 18.56 for a nurse guideline for these visits). Due to
the increased risks associated with undiagnosed opportunistic infections and immune
reconstitution syndrome, close clinical monitoring of the 6 month period after started ART
irrespective of whether the patient has health complaints or not is essential158.
Nurses have been mentored to refer to clinical protocols for managing certain recurring clinical
issues such as high viral loads, side effects, peripheral neuropathy and concerns regarding
possible lactic acidosis – see appendices 18.57, 18.58, 18.59)159.
Similarly to HIV wellness visits, nurses are trained to identify danger signs and red flag
symptoms (with a focus on TB). These are noted in the applicable section on page 2 of the ART
clinical monitoring forms (see appendix 18.52) and the patient is referred to the doctor
accordingly.
156
The HIV programme makes use of hardy big black plastic boxes for transport ARV drug stock to various clinics including the
pharmacy assistant counselling room in the HIV department.
157
At first ART patients were required to be seen by a professional nurse monthly (for a nurse check up each month that wasn’t
a stipulated clinical visit) throughout their treatment. However experience demonstrated that patients failed to go to see the
nurse unless they were unwell. It was decided that time was being wasted trying to get all patients to see a professional nurse
each month and focus was better placed on ensuring that patients honoured their nurse consultations for the first 7 months of
treatment and 6 monthly thereafter.
158
Monthly mortality meetings have identified this 7 month period as having increased risk of mortality (especially in patients
who have not routinely attended their nurse consultations).
159
It is important to note that the nurse protocols attached hereto have purposefully been over simplified. In the head
clinician’s experience, the more complex the clinical protocols are the less likely they are to be followed. Where a nurse
requests or demonstrates their interest in a more detailed understanding or protocol, they are provided with those set out in
PALSA plus 2007 edition. Western Cape DoH (produced in conjunction with UCT and UCT lung institute by Lara Fairall, Rene
English and Eric Bateman).
82
The nurse will tick the tag on the front of the patient’s file that he/she was seen by a nurse and if
Cotrimoxazole (Bactrim) was dispensed.
ART dispensing – pharmacy assistant Each patient will see the pharmacy assistant for his/her repeat ART supply for the month. The
pharmacy assistant will attend to the following:
Conduct a short adherence counselling session –
The pharmacy assistant will conduct a short adherence counselling session each time before
dispensing the patient’s next month’s ART supply . See appendix 18.54 for detail regarding the
form of each counselling session from the first to the thirteenth month on ART. In summary the
adherence counselling sessions include the following:
 Month 1 – 4: more in depth adherence counselling session and a pill count (which is
recorded on the dispensing sheet)160.
 Month 5 – 12: shorter adherence counselling session with no pill count (provided the patient
was adherent to ART for the first 4 months).
 Month 13: review of patient’s adherence over the last 12 months and discussion regarding 3
month supply of ART going forward161.
Dispenses ART –
The pharmacy assistant will check the dispensing list against the patient’s ART prescription and
will dispense the appropriate ART supply to the patient by doing the following:
 attaching the medication label onto the correct bottle/pack of ART and including the date on
which the patient is to return for further supply of ART (TCB date) (appendix 18.63);
 completing the dispensing form in the patient’s file (appendix 18.50) including:
o the date you issued the ART;
o the ART drugs and quantities issued to the patient; and
o the TCB date given to the patient
 tick the file tag to reflect that he/she has supplied the patient with ART; and
 complete the dispensing list (appendix 18.61) including:
o complete weight;
o sign that you issued ART;
o complete date you issued ART;
o state if person other than patient collected ART;
o complete TCB date
(This will be handed to the data capturer at the end of each day).
Down referring patients to their PHC (see section 13.4.5 ниже on transferring for ART
monitoring and supply to PHCs) –
At the two week adherence visit162, the pharmacy assistant will refer the patient back to his/her
PHC for continued ART monitoring and supply. Where the patient joined the HIV wellness
160
Experience has shown that it is not feasible to conduct a pill count every time the patient fetches his/her ART supply.
However merit was recognised in conducting pill counts in the early stages of ART. Therefore patients only receive pull counts
for the first 4 months. Where these pill counts are correct and the patient is understood to be generally adherent, the pill
counts will stop. This is regarded by patients as a sign of success on ART. However due to patients receiving an ART supply for
30 days when ART is supplied on a 28 days cycle results in patients’ collecting surplus ART. The Madwaleni pharmacy assistants
therefore also run pill count campaigns where all patients are encouraged to bring all excess ART at home in and the pharmacy
assistant then only dispenses the difference required.
161
Due both high patient load for pharmacy assistants and to reduce the return visit burden for patients who are often well
enough to work and who have found employment outside of the Madwaleni area, provided the patient’s clinical outcomes are
good (virological suppression and immunological success) and the patient is adherent, the patient may choose to be supplied
with ART on a 3 monthly basis (except for month period in which the 6 monthly blood investigations need to be taken and
reviewed).
162
Where a patient is unable to return to Madwaleni for his adherence visit, the pharmacy assistant will refer him/her
immediately to his PHC for his/her next 1 month ART supply.
83
programme at Madwaleni but there is a closer PHC to his/her home, the pharmacy assistant will
offer the patient the option of continuing his/her treatment at the PHC. Where the patient
agrees to be referred, the pharmacy assistant will
 ascertain the date of the next doctor-led ARV clinic at the PHC (see para 13.4 ниже);
 complete a down referral consent form (appendix 18.62); and
 note on the dispensing list (see appendix 18.61) the PHC and date to which the patient has
been referred.
Blood investigations – community health worker and enrolled nurse The CHW has been trained (as have all the peer educators at the PHCs) in the routine blood
investigations to be taken every 6 months of the patient being on ART. In addition, the CHW
will check the front of the file to check if the professional nurse/doctor has requested any further
blood investigations. The CHW will complete the necessary NHLS forms and blood tubes and
send the patient to the enrolled nurse, who will check forms and tubes and will take the
necessary bloods. See appendix 18.40.
Patient repeat visit monitoring – community health worker/peer educator
Many patients do not know who all they need to see on their repeat visit. The file tag system
was introduced so that any member of staff can quickly assess whether the patient has
completed all necessary stations. The file tag below demonstrates that this patient has
completed each station and the CHW/peer educator at reception can accept the patient’s file
when he/she leaves the HIV wellness and ARV clinic to go home.
84
13. Decentralisation to PHCs
13.1
Background
It has always been central to the Madwaleni HIV programme model that the programme and all its
services are made available to the community at the PHCs. Due to the barriers to care outlined in
the VCT outreach (section 10.9.1 выше), unless the programme could do so, many of the
community would not be able to initially or continue to access the HIV wellness and ARV services
for the financial, topographical and social reasons set out above.
However at the same time, set up and implementation of the programme at one site in a poorly
resourced rural area is a sufficiently onerous task, never mind at nine sites simultaneously. In
addition to barriers in experienced within the hospital setting there were added barriers to consider
at the PHCs. These included:



no additional staff at the PHCs to carry out these services. At least at Madwaleni hospital there
was a small additional organogram created by ECDOH for the ARV site which included certain
additional staff to supplement existing hospital staff. Many of the PHCs were operating on
skeleton staff already163;
there was no existing referral and support system between the hospital and the PHC regarding
any health services offered to the community; and
there was no working relationship between hospital management and the sub-district
management due to the hospital falling into a separate district (and sub district)164 to the PHCs.
The decentralisation (also commonly known as “down referral” when relating to ART) of the HIV
wellness and ARV programme to the PHCs was implemented slowly in phased approach.
This section will detail the steps to phasing in such services. Many of these steps were learnt along
the way and have now been incorporated into this guideline set out below.
13.2
13.2.1
Preparation steps prior to phasing in decentralised HIV wellness and ARV services at PHCs
Buy-in required
Local Service Area/Sub district team –
It was important early on to establish a working partnership between:
 HIV/OVC S & D manager
 the Middle Manager for the Health Centre
 the Clinic Supervisor (responsible for PHCs)
 the sub-district HIV Comprehensive Care and Treatment (CCMT) Manager
 the sub-district HIV Prevention Manager
 the sub-district Mother and Child Women’s Health (MCWH) Manager
 the sub-district Nutrition Manager
163
Many PHCs only had a single professional nurse. This is still the case at 1 of the PHCs at which the programme operates.
Madwaleni hospital fell in OR Tambo district, KSD sub district while the CHC and PHCs fell in Amathole district, Mbashe sub
district until April 2009. This demarcation consequent reporting line caused major obstacles for the implementation of a
decentralised HIV programme and relied heavily on the commitment of the staff at ground level to work together for the benefit
of the community.
164
85
This team met quarterly to discuss ongoing implementation issues165 and are essential in
obtaining tacit approval from sub-district management regarding the implementation of the
decentralised programme.
PHC staff –
It was necessary to meet with each team of PHC staff including all nursing staff and CHWs
outlining the HIV programme, discussing the phased approach and expected challenges along
the way. Most importantly, it was at this point, that we committed to working together as a team
to establish a single decentralised programme in which the HIV programme staff would work
with the PHC staff at the PHC (see joint team in para13.4.3 ниже)166.
Hospital pharmacy department –
The ART drug supply to the PHCs comes from the hospital which is the accredited ECDOH ARV
site. It is therefore essential to obtain the buy-in and commitment from the pharmacy
department as a whole. In addition, the HIV programme is reliant on the hospital pharmacy to
provide pharmacy assistants to work both in the HIV department and as part of the ARV
outreach team (see para13.4.3 ниже) in conducting adherence counselling and dispensing ART.
This means that the pharmacy department will lose staff in the hospital pharmacy when
allocated to the HIV programme duties167.
13.2.2
Peer educators selection and allocation
The roll out of the HIV programme at the PHCs requires additional peer educators. We
identified active, impassioned and committed members of the Madwaleni HIV support group
based at the hospital and selected these new peer educators focusing on support group
members that lived in close proximity to the various PHCs (see for detailed explanation of
selection process appendix 18.14).
As these peer educators only work at each PHC once a week, it is possible for each peer
educator to cover two PHCs (one on Wednesday and one on Thursday). Initially each PHC
only had one peer educator but this was increased to two or three over the next few years as
the patient loads increased at each PHC.
13.2.3
Training of staff
Peer educators –
The new peer educators require the following training:
165
This meeting was set up and followed up each time by the HIV/OVC S & D Manager and was unlikely to have happened if not.
The meeting convened whether or not all parties attended (provided a number of follow ups were done in this regard). The first
three parties were predominantly involved in resolving issues and actual implementation. It was however very important to
actively involve the sub-district managers and ensure that minutes of these meetings were circulated (including to the sub
district manager). From 2005 – 2009, sub district managers from Madwaleni Hospital’s sub district (KSD) were also invited and
in fact often attended. This allowed the platform for encouraging the two teams to work together as a partnership to resolve a
problem that may only have been experienced by one sub district such as a nutrition stock out. The team was motivated by
being responsible for the same patients. It also allowed for a sharing of systems and experiences between the two groups.
166
Historically additional health services are added to PHC staff work load in the interests of decentralisation/down referral with
little to no ongoing resource or technical support from the referral hospital. This has often led to a lack of commitment to the
service and negative outcomes for the patients.
167
The HIV Directorate of the ECDOH recognised this extra burden on the pharmacy departments of accredited hospitals and
therefore worked with the Pharmaceutical Directorate to create additional pharmacy worker posts funded by the conditional
grant allocated by the NDOH for HIV. This allowed Madwaleni HIV department to work with the pharmacy department to
appoint 3 additional pharmacy workers/assistants to increase their staffing component and capacity. In Nov 2009, a donor
funded a further 2 pharmacy assistants to increase the capacity of the pharmacy at the PHCs.
86
 formal VCT, HIV and ARV related training168;
 mentoring by nursing staff and experienced peer educators (if any at this time) based at
Madwaleni HIV department. The peer educators need to be capacitated to:
o facilitate and run HIV support groups;
o counsel HIV wellness patients on living with HIV – including disclosure, safe sex, healthy
living, encouraging other member’s of family to test for HIV etc;
o weighing patients and other basic clinical screening mechanisms – asking about health
complaints, TB symptoms and STIs – for purposes of referring to nursing staff at clinic;
and
o prepare appropriate patients for starting ART – identifying patients with CD4 counts under
210169, conduct ART adherence counselling and the necessary home visit to the prepare
family.
PHC nursing staff –
Where professional nurses at PHCs have no HIV management training, it will be necessary to
either arrange for external170 and/or provide in-service training171 on HIV and ARV
management172.
13.2.4
Equipping ARV outreach team and PHCs
ARV outreach team –
Instead of replicating the equipment list at each PHC, the ARV outreach team from Madwaleni
hospital is equipped with the following simple and inexpensive items:
 2 large plastic boxes/trunks that can lock (1 for ART and 1 for doctor’s drugs)
 Small cooler box for blood specimens (if no daily NHLS courier service to PHC)
PHC –
Each PHC will only require a reliable scale for weighing (if it does not already have one) and a
lockable cabinet and filing cabinet that will be allocated solely to the HIV programme.
13.3
13.3.1
First phase: Set up HIV wellness and ARV readiness clinics at PHC
Select a day once a week to run the HIV programme at each PHC
Due to limited staffing at PHC it is necessary to select a day that does not coincide with antenatal clinic or immunisation clinic. We also ensured that that it is was not the same day as the
adult HIV wellness and ARV clinic at the hospital.
13.3.2
Set up a HIV support group at PHC
Market the new HIV support group at the PHC to the members of the hospital HIV support
group on the above selected day which will be facilitated by the trained peer educator (with
clinic nurse supervision). For more detail on HIV support group set up see para 11.7 выше).
168
Provided by a number of service providers such as TAC, ATTIC, ARK. After 2006, this training has been provided to the
Madwaleni HIV programme by one of its donors – Aurum Institute for Health Research (PEPFAR funded).
169
PHC nurses will identify WHO stage 4 illness that requires patient to start ART.
170
Regional Training Centre (RTC) in Eastern Cape if government site or Foundation for Professional Development
171
The HIV clinician on the programme has provided this training both in formal sessions for group of PHC nurses and through
continual mentoring of skills at the PHC.
172
Where formal training is arranged through external service provider, it will still be necessary to arrange one or two sessions
with the professional nurses on the Madwaleni HIV programme specific model, its applications and the tools used.
87
13.3.3
Set up HIV wellness and ARV readiness clinic
A minimum of 2 peer educators are allocated per PHC to facilitate the running of the HIV
wellness and ARV preparation clinic at the PHC. These peer educators essentially replicate the
HIV wellness services as run at the HIV department at the hospital under the supervision of the
PHC nurse (as detailed in section 12 выше). Their tasks include:
Enrolling new patients in HIV wellness programme at the PHC Including:
 opening HIV wellness file (para 12.1.1 выше);
 conducting individual counselling session: HIV wellness visit no. 1 (para 12.1.2 выше);
 referring for nurse consultation (para 12.1.3 выше);
 referring for blood investigations (para 12.1.4 выше) - the peer educator completes the
NHLS forms and blood tubes as per the attached guideline;
 provide nutritional support (para 12.1.5 выше); and
 provide a return date (para 12.1.7 выше)
Identifying patients with CD4 counts under 210 (see para 12.2 выше)  both from ART readiness list and from patient’s CD4 count results in patient file and patients
whom the PHC professional nurse has identified with WHO stage 4 illness;
 conducting individual counselling sessions: HIV wellness visit no. 2 (para 12.2.1 выше); and
 conducting ARV adherence counselling and scheduling home visits (para 12.5 выше)
Conducting return HIV wellness visits thereafter (para 12.3.1 выше) –
for those patients who do not require ART as yet in terms of national guidelines.
Scheduling the patients for ART start at Madwaleni Hospital the following TuesdayIncluding:
 writing patient’s name on board with date of start, and
 putting the patient’s file from PHC in tray for patients scheduled to start ART.
Bringing cooler box of blood specimens back to hospital At the end of the day at PHC, the peer educator will complete “the blood investigations
submitted from the PHC form” (see appendix 18.68) and register the blood investigations with
hospital laboratory (if no NHLS courier to that PHC on the day173). The following week the peer
educators will take all the blood results from these specimens back to the PHC and file in the
patients’ files.
See appendix 18.66 for detailed guidelines for peer educators to run HIV wellness and ARV
readiness programme procedure at clinics.
13.3.4
By completion of first phase
By the end of this phase, patients will receive all HIV wellness and ARV preparation services at
their PHC. They will only be required to start attending Madwaleni HIV department from their
scheduled ART start date. Ensuring that patients attend their PHC for the delivery of HIV
173
For the first 3 years of the HIV programme, there was no reliable courier service to the PHCs. Since 2008 this has improved.
However the courier still does not come daily to all the PHCs and when it does come it is often early in the morning prior to the
arrival of the patients. Where some blood investigations have been taken already by the time the courier comes, these are sent
and the remainder come back with peer educators at the end of the day.
88
services from the beginning largely eliminates patient reluctance to be down referred to PHCs
from the hospital after ART inititiation174.
13.4
13.4.1
Second phase: Set up doctor-led ARV clinic
Period of second phase
The second phase is scheduled to run for 3 months.
13.4.2
Prior preparation at PHC
It is important for the HIV/OVC S&D manager to meet with Clinic Supervisor and the all nurses
and CHWs from the PHC to confirm previous buy-in to the HIV programme, specifically focusing
on running the ARV programme at PHC. This will be more demanding of their time and input.
Use the meeting or set up a further training session to brief the PHC team on the system for
running the ARV clinic including blood taking, nurse monitoring of patients, referral of patients to
doctor etc (see section 12.7 выше).
13.4.3
Set up ARV outreach team
The ARV outreach team is made up of the following members:




1 hospital/clinic doctor – HIV programme HIV clinician (head of team)
1 professional nurse (from hospital HIV dept)
1 pharmacy assistant (from hospital unless clinic has its own)
2 peer educators (same as already running HIV wellness and ARV readiness programme)
This team will be required to be at the PHC for 1 afternoon per ARV clinic other than the peer
educators who will start running the HIV wellness and ARV readiness service from the morning.
13.4.4
Schedule ARV clinic days
The ARV clinic is started monthly at each PHC. This means that all patients on ART will attend
on the single day per month.
It is necessary that the ARV clinic day coincides with the day of the week that HIV wellness and
ARV readiness programme is run at the particular PHC. The monthly ARV clinic dates need to
be scheduled a year in advance and both the hospital and PHCs need to be provided with this
schedule. The hospital requires the schedule both in the HIV department and in the OPD
setting to facilitate the referral of patients to the correct date. While the PHC staff require the
schedule in order to prepare appropriately, with a focus on optimal staffing for the scheduled
date175.
13.4.5
Transfer existing ART patients to PHC
All ART patients who come from a specific area are consulted about being seen at their PHC
rather than at the hospital. In our experience hesitancy to transfer is associated with a belief
174
A common issue in the implementation of down referral to PHC from centralised services is patient reluctance to transfer.
Despite only requiring 1 day of commitment per month, the ARV outreach team has arrived at the PHCs to find that there is
only one of three professional nurses as the other two are on leave and on training on the specific day. This has been the most
frustrating barrier to the smooth functioning of these days. In the beginning of the ARV clinic roll out at the PHC, it is useful to
phone a week ahead and remind PHC staff.
175
89
that the quality of the service provided at the PHC will be inferior to that provided at the
hospital176. By explaining that the same doctor, nurse and pharmacy assistant will be present,
helps to manage these concerns.
It is important that the each patient consents to transfer to their PHC (see appendix 18.62).
This process needs to be started a month prior to the scheduled ART clinic date in order that
the patient can be supplied with sufficient ARVs until such ‘TCB date’ at their PHC. The
pharmacy assistant will supply only enough ARVs until the ARV clinic date e.g. if patient attends
Madwaleni 3 weeks before the ARV clinic date at his/her PHC, he/she will only be supplied with
three weeks of ARVs177.
13.4.6
ARV outreach team preparation prior to leaving for PHC
File preparation –
The peer educators for the PHC will pull the patient files as per the file list of patients due for
ART at the PHC and attach the file tags178.
Doctor’s essential drugs –
The doctor will stock a “doctors box” of essential drugs (especially those which the PHCs are
known to often not have in stock179) from the hospital pharmacy. These drugs will be under the
doctor’s control at all times and will be brought back at the end of the ARV clinic.
Pre-pack ART –
The pharmacy assistant on duty for the PHC will pre-pack the ARVs for the PHC patients at the
hospital. He/she will use the same tools as when pre-packing for Madwaleni ARV repeats i.e.
using the ART stock requisition (see appendix 18.64)and ART repeat dispensing list (see
appendix 18.61) for the PHC (as printed by the administrator and placed in the pharmacy tray in
the HIV department).
Arranged transport –
The HIV department will organise transport for the ARV outreach team which will be ready to
leave at 11am (after the doctor’s ward round in the hospital). The doctor’s essential drug box
and the ARV drug boxes will be loaded into the vehicle.
13.4.7
System at PHC doctor-led ARV clinic
Peer educators – have already weighed all ART patients, given each patient their file and
dispensed prophylactic treatment to those still qualifying in terms of protocol;
Enrolled nurse – has started taking the necessary blood investigations for the ART patients as
set out on their file tag;
HIV dept (hospital) professional nurse – sits with one of the PHC’s professional nurses and
sees the ART patients together thereby facilitating the following:
 clinically monitoring the ARV patients including reviewing blood results, identifying danger
signs and red flag symptoms;
176
This patient issue is also elimated when patients start accessing HIV wellness and ARV preparation at their PHC.
This requires co-ordination by the HIV/OVC S&D manager together with the pharmacy staff.
178
It is possible to keep the ART patient files at the PHCs. However we find that follow up of patients overdue for ART is more
difficult and blood result filing is not always up to standard.
179
This has changed over time at Madwaleni’s feeder PHCs where work with the district has improved drug supply to the PHCs
and the doctor now takes far fewer drugs.
177
90
 diagnosing and treating all minor health ailments or opportunistic infections in terms of nurse
protocols; and
 obtaining doctors input with regard to nurse’s clinical decisions (where necessary) and/or
refer patients with complicated clinical problems to the doctor.
ARV outreach doctor – sits with the other PHC’s professional nurse180 and see referred patients
together thereby teaching the following:
 determining which patients should be referred to the doctor and which can be managed in
terms of nurse protocols by the PHC nurse;
 clinical examination of a patient with HIV;
 diagnosing and treating of opportunistic infections; and
 identifying and managing side effects of ARVs/other drugs.
Pharmacy assistant – sees each ART patient for the following:
 counselling each patient with regard to ongoing adherence; and
 dispensing pre-packed monthly ART supply (see above dispensing procedure in para 12.7.2
выше)181.
It is preferable that each professional nurse and where possible enrolled nurse take a turn to sit
with the pharmacy assistant to determine the processes for when patients come after the ARV
down referral date. Where the PHC has its own pharmacy assistant, this person will work with
the hospital pharmacy assistant.
13.4.8
Procedure at the end of ARV clinic at PHC
Pharmacy function –
The pharmacy assistant will:
 determine which patients were due but did not come from their repeat dispensing list;
 leave pre-packed ART for these patients together with their files (supplied by peer
educators) and the “PHC nurse dispensing list” on which the pharmacy assistant ticks which
patients ARV drug supply has been left at the PHC (see appendix 18.70);
 these ARV drugs stay at the PHC for 7 days for the patient to collect from the professional
nurse. The professional nurse will dispense in terms of the procedure set out in nurse
guidelines to issuing ART at PHC for overdue patient in appendix 18.72; and
 after 7 days, at the following weekly HIV wellness clinic, the professional nurse will send the
uncollected ARVs with the “PHC nurse dispensing list” back to the hospital pharmacy with
the peer educators. The peer educator will submit the “PHC nurse dispensing list” to the data
capturer to capture the patients that collected their ART late.
Meeting –
Between hospital ARV outreach team and PHC staff to discuss the following:
 review the functioning of the clinic for the day specifically patient flow and appropriate doctor
referrals;
 discuss clinical issues arising from any patient seen during the day;
 which patients that did not arrive for their scheduled ART repeat182 and the professional
nurse will check the ARV drugs left behind by the pharmacy assistant;
 patients with high viral loads at that PHC and the action to be taken
180
Where there is more than 1, otherwise these roles are combined.
Where the pharmacy does not have enough staff, it is possible to use the 3 months period for the pharmacy assistant to train
a nursing assistant at the PHC to perform this function.
182
If any staff member knows why the patient did not come. In many instances a staff member will know that the patient was
admitted or fetched his/her ART supply at Madwaleni or is away in Johannesburg/Cape Town but expected back (patients often
phone peer educators with this information).
181
91
 patients that require follow up for:
o being previously overdue for ART repeats; or
o to continue ART preparation; or
o with red flag blood results or pap smears; or
o requiring repeat CD4 counts (longer than 6 months since previous CD4)
13.4.9
Procedure at the end of ARV clinic by ARV outreach team at hospital
Pharmacy assistant – submits the dispensing list to data capturer for capturing and packs away
any additional ARVs in pharmacy store room.
Peer educator – submits blood investigations to the hospital laboratory after completing “the
blood investigations submitted from the PHC form” (appendix 18.68).
13.5
Third phase: Remove hospital HIV dept nurse from ARV outreach team
This phase is the same as second phase except that the hospital HIV dept nurse no longer forms
part of ARV outreach team. The PHC’s professional nurses are now fully trained by hospital nurse
and doctor to see patients, manage minor health ailments, opportunistic infections, side effects in
terms of nurse protocols. They should only refer complicated clinical problems to the doctor. The
doctor will continue to mentor the PHC professional nurses to ensure that the correct referrals are
coming through to the doctor.
In addition, where the PHC has its own pharmacy assistant (or a nursing assistant has taken this
role), the hospital pharmacy assistant will no longer form part of the ARV outreach team183.
13.6
13.6.1
Fourth phase: Introduction of nurse-led ARV clinic
Introduction
Once the patient load increases at the PHCs, it will not be possible to manage all ART patients
on one day a month. In our experience, a maximum of fifty ART patients can be managed
effectively by a PHC in one day.
Introducing a nurse-led ARV clinic on a second day a month furthers the sustainable
decentralisation model. Thereafter as the patient load further increases, nurse-led ARV clinics
can be introduced each week until each PHC runs an HIV wellness and ARV clinic weekly.
No ARV outreach team will go from the hospital to the PHC on the nurse-led ARV clinic. The
second and third phase will ensure that the PHC nursing staff are experienced in HIV and ARV
management and are thus able to run the nurse-led ARV clinic on their own.
13.6.2
Transfer of stable ART patients
Only stable patients who have been on ART for more than 6 months (i.e. who are virologically
suppressed and come every month without requiring follow up) will be seen at the nurse-led
ARV clinic. It is therefore necessary to review the PHC ART patient list on the HIV database
and determine which patients can be transferred to the nurse-led ARV clinic. This transfer will
need to be planned 6 weeks prior to first nurse-led ARV clinic in order that ART patients
183
This is unlikely however as none of the Madwaleni PHCs (other than CHC) has its own pharmacy assistant. In the long term,
ECDOH needs to fill these posts to ensure full decentralisation of services.
92
attending the PHC’s doctor-led ARV clinic can be supplied with 6 weeks of ART and transferred
to the new nurse-led ARV clinic.
All patients newly initiated on ART at the hospital will be transferred to the doctor-led ARV clinic.
13.6.3
Pharmacy preparation for nurse-led ARV clinic
A pharmacy assistant will pre-pack the ARVs for the ART patients due on the nurse-led ARV
clinic on the same date as pre-packing for the doctor-led ARV clinic. The pharmacy assistant
will take the ARVs in a box clearly labelled “Nurse-led ARV clinic” with the dispensing list and
‘PHC nurse dispensing list” when he/she goes to the PHC as part of the ARV outreach team on
the doctor-led ARV clinic day.
The process between the pharmacy department at the hospital and the PHC staff is set out in
the guideline to doctor and nurse-led ARV clinic at PHC from a pharmacy perspective (see
appendix 18.71).
13.6.4
System at PHC nurse-led ARV clinic
Peer educators - has already weighed all ART patients, given each patient their file and
dispense prophylactic treatment to those still qualifying in terms of protocol;
Enrolled nurse – has taken the necessary blood investigations for the ART patients as set out
on their file tag;
PHC professional nurse – sees each the ART patient to:
 clinically monitor, including reviewing blood results and identifying danger signs and red flag
symptoms;
 diagnose and treat minor health ailments;
 diagnose and treat opportunistic infections in terms of nurse protocols;
 identify and manage ARV side effects; and
 determine whether the patient requires referral to a doctor and either refer the patient to
hospital (if urgent) or to next doctor-led ARV clinic date (if less urgent).
The second professional nurse/enrolled nurse184 - sees each ART patient to:
 counsel each patient with regard to ongoing adherence; and
 dispense pre-packed monthly ART supply in accordance with guideline (see appendix
18.72).
13.7
13.7.1
Last phase: Fully decentralised HIV wellness and ARV clinic at each PHC
ART initiation at the PHCs
As set out above, patients are currently initiated on ART at Madwaleni HIV department due to
human resource constraints and sustainability issues. However with the acceptance of the
importance of nurse-initiated ART by NDOH and an increased likelihood that it may be
implemented185, Madwaleni HIV programme is now phasing in ART initiation at the PHCs
through the doctor-led ARV clinics. Those patients who would have come to Madwaleni in the
same week as the doctor-led ARV clinic date at their PHC will be initiated at their PHC.
This will be used to mentor the PHC nurses to initiate ART in asymptomatic patients. Once
NDOH policy and nursing council practice change, most patients will be able to be initiated on
184
Where there are no other nursing staff, the same nurse will also need to dispense ART
185
Dr Thobile Mbengashe, Chief Director HIV, AIDS and STI – Dec 2009
93
ART at the PHC by the nurses. This should first be done on the doctor-led ARV clinic under
doctor supervision and mentorship and can then later on nurse-led ARV clinics.
13.7.2
Further introduction of nurse-led ARV clinics
As the patient load continues to increase, further nurse-led ARV clinics will be introduced on the
same day as the weekly run HIV wellness and ARV readiness clinics. This will need to be
discussed and implemented together with the PHC nursing staff186.
13.7.3
Continued monitoring of patient load at each PHC
To ensure that the ART patient load at each clinic is managed appropriately, it is necessary to
continue to manage the transfer of stable ART patients from the doctor-led ARV clinic to the
nurse-led ARV clinics allowing space on the doctor-led ARV clinic for patients newly initiated on
ART or not yet stable on ART. The HIV programme administration based at the hospital need
to follow this following process in doing so187:
 review all ART patients scheduled to attend the following doctor-led ARV clinic from the
pharmacy dispensing list for that date;
 where a patient is stable (suppressed viral load and collecting ART supply monthly), transfer
the patient to a nurse-led ARV clinic with less than 50 patients by noting on the pharmacy
dispensing list that the patients needs to be transferred. It is important to include the date to
which the patient should be transferred and the appropriate ART supply to ensure the patient
has sufficient ART until such date. The pharmacy assistant will then affect the transfer at the
following doctor-led ARV clinic.
13.7.4
Completion of final phase to decentralisation of ARV services
By the completion of the last phase of decentralisation each PHC will be operating:
 an HIV wellness clinic weekly (including HIV support group and ARV readiness programme);
 a ARV clinic weekly including ART initiation at the PHC:
o 1x monthly by doctor (for new and clinically complicated patients) with pharmacy
assistant; and
o 3 x monthly by PHC professional nurses.
186
It is important that the ARV clinics not detract from the HIV wellness and ARV readiness clinic which is being run by the peer
educators weekly. Historically the doctor-led ARV clinic has done so but this has been acceptable as the HIV wellness and ARV
readiness clinic functioned optimally on the other 3 weeks a month. With introduction of ARV clinics every week, this needs to
be more closely monitored.
187
It may be possible for each PHC to manage this process by the professional nurse who sees each patient noting on the patient
file, after checking that the patient is stable, that such patient can be transferred to a nurse-led ARV clinic. The pharmacy
assistant who will be present will then affect this transfer when dispensing the patient’s ART supply.
94
14. Prevention of mother to child (PMTCT) services
14.1
PMTCT patient flow chart
P
Pregnant woman
presents at PHC
(ideally before 20
weeks)
H
If not already
tested, tested for
HIV at first visit
C
Already a member/encouraged
to join HIV wellness
programme:
-
Child
attends weekly HIV
support group
receives individual and
-
group counselling
Continues antenatal care at PHC
If she is HIV+
If qualifies for triple therapy:
referred at 26 weeks
H
O
S
P
I
T
A
L
Mother
If qualifies for dual therapy:
provided by PHC at 28 weeks
Attends hospital PMTCT (High risk) clinic
(HIV/ARV DEPT):
-
Infant follow up
done at PHC – PCR
testing
attends pregnant HIV women SG
continued individual counselling
continued ante-natal care
Obstetric consultation and follow
up by maternity doctor
HAART evaluation, preparation
and start by HIV team
95
Delivery at hospital or CHC
(MATERNITY DEPT):
-
-
NVP + 3hr AZT hourly
NVP syrup
administered+ AZT
syrup dispensed
PHC f/u date given
Mother and child
14.2
Background
The Madwaleni model for PMTCT services has changed considerably over the last five year period
with the incorporation of prophylactic dual ARV therapy in January 2008 in the national PMTCT
guidelines188 and the more recently focus on the PHCs initiating this therapy189.
In terms of implementation by ECDOH of PHC initiated dual therapy, there still remain a number of
concerns for which strategies are currently being explored. These concerns include:
 retaining the benefit of using the need for prophylactic PMTCT treatment to expose pregnant
women to the benefits of the HIV programme and thereby encourage early enrolment;
 pro-active follow up of CD4 count results by PHC staff to ensure women who require lifelong
triple ARV therapy are initiated on this therapy timeously; and
 follow up systems for both the women and their newborn infants who have followed the PMTCT
services only at their PHC independently of HIV programme at PHC or hospital.
14.3
HIV testing of pregnant women
Initially there were poor rates of HIV testing amongst pregnant women at their first ante-natal visit at
the PHCs. This was evidenced by the large number of women arriving at Madwaleni hospital’s
maternity ward in labour but untested. Now more than 95% of ante-natal pregnant women are or
have been previously tested for HIV.
Where women test HIV negative, they are encouraged to re-test at 34 weeks of pregnancy as part
of their ante-natal care.
Where a woman tests HIV positive, the nurse immediately takes an ELISA and CD4 count together
with other necessary ante-natal blood investigations.
The following two initiatives have increased the rate of testing across the CHC and PHCs:
14.3.1
Determining strategies with PHC staff to increase VCT uptake
The Madwaleni HIV programme worked with the PHC staff to determine strategies which would
increase VCT uptake amongst pregnant women. These included:
 group counselling of pregnant women on ‘first ante-natal visit’ day at the PHC by community
health worker on the importance of testing for HIV and the PHC nurse knowing the woman’s
HIV status so that prevention of transmission to their unborn child could be facilitated;
 fostering peer discussion amongst the women in such an environment surrounded by others
in the same position with the same decision to make;
 community health workers forming a queue of the pregnant women who want to attend the
individual pre-test counselling and conduct such pre-test counselling so the women are less
likely to feel alone making the decision to have the test;
 in the unlikely event that the pregnant woman arrives at the nurse for her ante-natal visit not
having consented to testing for HIV, the nurse will speak to her again about the risks
associated with failing to test;
188
For implementation on 1 April 2008 (2008/2009 financial year).
Madwaleni HIV programme has raised concerns that the pressure from ECDOH has interfered with the effective
implementation of PHC initiated dual therapy which could have been achieved if implementation had been done in conjunction
with the programme which was already managing PMTCT services in the area.
189
96
 any pregnant woman who chooses not to have an HIV test is earmarked for ongoing
counselling at her second ante-natal visit by the nurse.
In addition, each month the PHCs reported on the number of first ante-natal visits to their PHCs
and the number of these that consented to being tested for HIV. This made it possible to
determine the testing rates possible in certain PHCs. It also highlighted PHCs that were not
achieving the same results for further input and facilitation.
14.3.2
HIV testing reporting forming part of monthly peri-natal mortality meeting
Secondly, the first initiative was strengthened in 2007 by the introduction of the monthly pernatal mortality meeting as part of Saving Mothers Saving Babies Programme (SMSB)190.
Madwaleni hospital and the Mbashe-Xora sub district were identified by the SMSB ECDOH
programme for facilitation of maternal and child outcomes. The peri-natal mortality meeting
includes the maternity ward at the hospital, the PHCs, the clinic supervisor, the HIV/OVC S&D
manager from the hospital and the MCWH manager from the sub-district.
At the instigation of the HIV/OVC S&D Manager, a portion of the meeting was allocated to HIV,
including but not limited to PMTCT, as it is the one opportunity to meet with the clinic staff
together in this regard191.
This meeting provided a platform for group to:
 review the HIV testing rates of ante-natal women in the area both at the PHCs and Xora
CHC; and
 discuss each pregnant women who arrived at either the Madwaleni or Xora CHC maternity
ward with an unknown HIV status, specifically which PHC had conducted her ante-natal care
(the maternity wards recorded in their register which PHC these women came from so that
this report can be generated see para 14.8.2 ниже).
14.4
HIV management prior to initiation of prophylactic ART
Already a member/encouraged
to join HIV wellness
programme:
attends weekly HIV
support group
receives individual
and group counselling
Pregnant woman
presents at PHC
(ideally before 20
weeks)
If not already
tested, tested for
HIV at first visit
If she is HIV+
Continues antenatal care at PHC
190
Started at Madwaleni and the Mbashe-Xora clinics in mid 2007.
Due to significant transport problems and short staffing, holding meetings with all the clinic staff is difficult. Therefore where
such a meeting is taking place (usually through pressure from ECDOH), using this opportunity to discuss HIV management
strategies and the achievement thereof is optimal.
191
97
In terms of the Basic Ante-natal Care guidelines (BANC), women are encouraged to attend their
first ante-natal visit before 20 weeks of pregnancy. However in deep rural areas, women still
present late in pregnancy, often only at 28 – 32 weeks of pregnancy192. This complicates the
ability to timeously manage their HIV care. The PMTCT model of care is based on early
presentation but provides a system for late presenters.
14.4.1
Fitting into HIV wellness programme at PHC
Pregnant women who test HIV positive at their first ante-natal visit prior to 26 weeks of
pregnancy are encouraged by the nurse to join the HIV wellness programme at their PHC.
They are therefore referred to the next weekly HIV support group.
On their first visit to the HIV support group, the pregnant woman is enrolled on the programme
(see para 12.1 выше). She does not need to attend 3 support groups due to the time
constraints imposed by her pregnancy.
As her ELISA and CD4 count investigations will already have been taken by the nurse during
her first ante-natal visit, this will not be repeated.
On enrolment in the HIV wellness programme, receive ART preparation counselling (see para
12.4 выше) and ART adherence counselling (see 12.5 выше) by the peer educators in time for
commencement of prophylactic dual ART therapy or lifelong triple ART therapy.
The nature of the ART adherence counselling will differ depending on whether the woman is to
be initiated on prophylactic dual ART therapy or lifelong triple ART therapy. A guideline to
PMTCT counselling for counsellors is set out in appendix 18.73 which includes information for
peer educators on ARV treatment regimens for pregnant women and a framework for both
prophylactic dual ART and lifelong triple ART adherence counselling.
Unfortunately, in the Madwaleni experience, pregnant women are less likely to join the HIV
support group at their PHC than other patients193. It is for this reason that an HIV support group
was started at Madwaleni’s High risk PMTCT clinic (see below)194.
14.4.2
Continued ante-natal care at PHC
The pregnant woman continues her ante-natal care at her PHC in terms of BANC guidelines.
The nurse is then able to continue monitoring the progression of the pregnancy and the time
that prophylactic dual ART therapy or lifelong triple ART therapy needs to be initiated.
192
SMSB programme is working on community awareness strategies to increase early presentation for ante-natal care.
193
The principle reason for this being that the pregnant woman has just been tested and has not had sufficient time to accept her HIV+ status.
194
Prior to the roll out of dual therapy at the PHCs, all pregnant women whether being initiated on dual or triple therapy ART
were coming to Madwaleni’s High Risk PMTCT clinic. This meant that they were all exposed to the pregnant women HIV support
group. This helped deal with issues relating to newly diagnosed HIV status and acceptance thereof in a group of many women in
the same position. This has been important in retaining them in the HIV programme after delivery. Initiating dual therapy at the
PHCs mean that many of these women are not exposed to the HIV support group setting and therefore different strategies need
to be considered to encourage attendance of PHC HIV support group or setting up PMTCT HIV support groups at each PHC.
98
14.5
Referral system for low CD4 count or high risk pregnancy
Continues antenatal care at PHC
If qualifies for triple therapy:
referred at 26 weeks
The nurse at the PHC should receive the pregnant woman’s CD4 count prior to 26 weeks of
pregnancy.
Where she her CD4 count is low195 or at any point during ante-natal care she is classified as a high
risk pregnancy in terms of BANC196, the nurse will counsel the woman about the importance of
referring her to the Madwaleni high risk PMTCT clinic at the HIV department.
She will explain that at Madwaleni, she will receive an obstetric consultation with a doctor and
where if necessary, she will be prepared and initiated on lifelong triple ARV therapy for both her own
health and also to protect her child from the transmission of HIV197.
However, the pregnant woman must consent to accepting such referral. If she does not want to be
referred, there is risk that she will not go to Madwaleni and also not go back to her PHC as she has
not followed the nurse’s instructions. She will therefore not receive any form of prophylactic PMTCT
treatment and more importantly, receive no further ante-natal care198.
Although discouraged, she can choose to continue her ante-natal care at her PHC and be started
on prophylactic dual ARV therapy for the remainder of her pregnancy.
The nurse completes a PMTCT consent form (see appendix 18.74). She completes the date on
which she has completed the consent form and the date for the referral. Where the woman is
referred for a low CD4 count, she should be referred at 26 weeks of pregnancy. Otherwise if for any
other high risk factors, the next PMTCT clinic date.
195
In terms of NDOH guidelines, pregnant women with a CD4 count of less than 200 should be started on lifelong triple therapy.
President Zuma announced on 1 December 2009 that this would change to 350 from the beginning of the next financial year i.e.
1 April 2010.
196
High risk not in relation to her HIV which it can be argued automatically makes a pregnancy high risk.
197
Transport is provided from Madwaleni to fetch these women each Thursday from the PHCs.
198
It has been our experience that the PHC nurses were referring pregnant women and they were not seen again either at
Madwaleni or the PHC. This consent system was introduced to ensure a choice was given to the woman and that elected choice
could later be tracked (see para 15.8 below)
99
14.6
Dual ARV therapy initiated and monitored at PHC
Continues antenatal care at PHC
If qualifies for dual therapy:
provided by PHC at 28 weeks
14.6.1
CD4 count above guideline threshold and no high risk factors
Where the pregnant woman has a CD4 count above the guideline threshold199 for triple ARV
therapy and has no high risk factors, she will be initiated on prophylactic dual therapy at the
PHC and continue her ante-natal care at the PHC.
14.6.2
No CD4 count and no high risk factors
All women who present late for ante-natal care and therefore have not had a CD4 count taken
or a result received by 28 weeks of pregnancy will be initiated on prophylactic dual ARV therapy
by the PHC immediately199. The pregnant woman will still be referred if necessary for
assessment for lifelong triple ART when her CD4 count is received.
14.7
High Risk PMTCT clinic at Madwaleni
If qualifies for triple therapy:
referred at 26 weeks
Attends hospital PMTCT (High risk) clinic
(HIV/ARV DEPT):
-
199
attends pregnant HIV women SG
continued individual counselling
continued ante-natal care
obstetric consultation and follow
up by maternity doctor
HAART evaluation, preparation
and start by HIV team
In terms of Policy and Guidelines for implementation of the PMTCT programme – 11 February 2008
100
For a flowchart setting out the PMTCT visit by a patient to the PMTCT clinic at the HIV department
at the hospital see appendix 18.75. This will be explained in further detail below.
14.7.1
PMTCT HIV support group
At every Thursday PMTCT clinic a support group is held for the HIV positive pregnant women
attending the clinic. This support group forms part of her clinic visit i.e. she does not need to
leave the queue waiting for the nurse or counsellor to attend the support group. The support
group is held with the women while they queue for the services rendered by the HIV
department.
This support group is facilitated by a peer educator who is has received additional training in
PMTCT related issues.
In addition, two women have been identified who:
 live in the village surrounding the hospital;
 attended the PMTCT programme during their pregnancies;
 each chose a different feeding option (exclusive formula feeding and exclusive breast
feeding) based on her circumstances;
 both have healthy HIV negative infants; and
 both are enrolled on the HIV programme for their own health.
These women sit in the support group and explain their experience and answer questions in
Xhosa200.
As the support group forms part of the PMTCT clinic, pregnant women become acquainted with
the role of the support group and importantly realise there are many other women in their
communities experiencing the same psychosocial difficulties in the early stages of their HIV
diagnosis. Once receptive to the concept of a support group, it is easier to encourage these
women to join the support groups at their PHCs after delivery.
14.7.2
First visit at 26 weeks
Where the pregnant woman has been attending the HIV wellness programme at her PHC, she
will already have a file, blood results and will already have received both HIV wellness and ART
adherence counselling. These women are simple to manage and initiate on ART timeously.
The following steps will be followed:
 an HIV wellness visit (para 12.1.2 выше)- peer educator
 a PMTCT first visit tag will be attached to the front of the file which sets out all the necessary
steps for the visit (see appendix 18.76) – peer educator
 a nurse consultation (para 12.1.3 выше) and ante-natal visit. The nurse will also note the
ART regimen for ART adherence counselling – professional nurse
 ART adherence counselling (para 12.5.1 выше, also see guidelines for PMTCT adherence
counselling in appendix 18.73)– peer educator
 an obstetric consultation – PMTCT doctor.
200
These women have not been employed as full time peer educators as they do not have the capacity to take on the wider role
and responsibilities of a peer educator. They often know the other women and are able to communicate their own experience
in their own language.
101
During this obstetric check, the doctor will designate each patient as “high risk – doctor”, or
“high risk – nurse”. The former are the patients whose pregnancies require continued
monitoring by a doctor due to high risk factors while the latter are patients initiated on lifelong
triple ART that can continue to be managed by the HIV department nurses.
 a return date for ART start date 2 weeks later at 28 weeks of pregnancy – peer educator +
doctor
All pregnant women who have not attended the HIV wellness programmes at their PHCs now
have to be fast tracked through the ARV preparation and readiness in order that they can start
ART two weeks later. Differences to the process for pregnant women who joined the
programme at their PHCs are highlighted in grey).
 opening HIV wellness adult paper file (para 12.1.1 выше)and conducting an HIV wellness
visit (see para 12.1.2 выше)201 - peer educator
 a PMTCT first visit tag will be attached to the front of the file which sets out all the necessary
steps for the visit (appendix 18.76) – peer educator
 a nurse consultation (para 12.1.3 выше) and ante-natal visit – professional nurse
 blood investigations (para 12.1.4 выше - other than ELISA and CD4 provided these were
taken by PHC) – community health worker + enrolled nurse
 an obstetric consultation – PMTCT doctor
 a return date for the following week – peer educator
14.7.3
Second visit at 27 weeks (not necessary if previously part of HIV wellness programme)
Pregnant women who joined the HIV wellness programme the previous week need to attend the
PMTCT clinic again at 27 weeks for the following:
 conducting a second HIV wellness visit (see para 12.2.1 выше)202 - peer educator
 a repeat PMTCT first visit tag will be attached to the front of the file which sets out all the
necessary steps for the visit (see appendix 18.77) – peer educator
 check ELISA and CD4 count results in file – peer educator
 a nurse consultation - determine ART regimen – professional nurse
 ART adherence counselling (para 12.5.1 выше, also see guidelines for PMTCT adherence
counselling in appendix 18.73) – peer educator
 A return date for ART start date the following week at 28 weeks of pregnancy – peer
educator
14.7.4
ART initiation
The pregnant woman will return for ART initiation at 28 weeks which will follow the same
procedure as adult ART initiation set out in para 12.6 выше other than that the woman will not
be sent for an X-ray.
14.7.5
Continued management – ART repeats
201
No prophylactic treatment will be issued by peer educator or CD4 count monitored by peer educator. In addition, all these
patients will see the nurse whether or not the patient has been complaining about her health.
202
No prophylactic treatment will be issued by peer educator or CD4 count monitored by peer educator. In addition, all these
patients will see the nurse whether or not the patient has been complaining about her health.
102
A pregnant woman will continue to return to Madwaleni’s PMTCT clinic for her repeat ART
supply until after delivery at which point she will be referred to the ARV programme at her PHC.
This should only include two further visits which will fit in with her continued ante-natal care
review dates at the high risk PMTCT clinic.
The repeat ART visit will follow the same form as the adult ART repeat visit (see para 12.7
выше). However the counsellors will continue to conduct an HIV wellness visit for these two
ARV repeat visits if the patient was not already part of the HIV wellness programme at the PHC.
Due to fast tracking these patients, continued attention is required on preparing them for taking
ART for the rest of their lives203.
Unless the patient has been designated as ‘high risk – doctor” (see para 14.7.2 выше), she will
continue to be managed by the nurses in the HIV department. Those patients who have been
marked “high risk – doctor” will continue to be referred by the nurse to the doctor after each
ante-natal visit and repeat ART supply.
14.8
Delivery at hospital or CHC
If qualifies for dual therapy:
provided by PHC at 28 weeks
Delivery at hospital or CHC
(MATERNITY DEPT):
Attends hospital PMTCT (High
risk) clinic (HIV/ARV DEPT)
-
-
14.8.1
NVP + 3hr AZT hourly
NVP syrup
administered+ AZT
syrup dispensed
PHC f/u date given
Background
In deep rural areas of the Eastern Cape, home deliveries continue to be common place204. The
circumstances of the community often make getting to the hospital or CHC difficult and
sometimes impossible205. Both the ART adherence counselling for pregnant women and the
ante-natal care provided by the PHCs emphasise the importance of delivering at the hospital or
CHC.
203
This is evidenced by the higher lost to follow up rate amongst pregnant women – see outcomes above.
In the Madwaleni-Xora statistics, home deliveries are estimated at approx. 30% of births in the area. This statistic is obtained
from mothers who bring children for immunisation after birth who were not born at one of the health facilities. There may be
more who are also never brought for immunisations.
205
Where a woman goes into labour at night and has to hire a taxi to take her to the hospital, the taxis charge between R300 –
R800 for the trip depending on where the woman lives.
204
103
Besides the obvious importance for appropriate obstetric care, the correct implementation of the
dual therapy regimen206 is unlikely where a woman delivers at home as:
 the women is required to take a stat dose of nevirapine when she starts labour and to take
AZT 3 hourly during labour; and
 the infant is to be given a stat dose of NVP and AZT issued to the mother so that she can
administer it twice daily doses of AZT for 7 or 28 days207.
14.8.2
Maternity system
In a number of hospitals in the Eastern Cape, the maternity department manages PMTCT
services in their entirety. In the Madwaleni model, PMTCT services are predominantly
managed by the HIV programme with the PHCs. However, there is close team work with the
maternity ward to ensure the continuum of PMTCT related services.
The following useful systems have been implemented within the maternity wards at the hospital
and CHC to assist with the appropriate provision of PMTCT services:
 the maternity data capturer/ward clerk ensures that all HIV positive pregnant women get a
brightly coloured tag stapled to the inside of their maternity file on admission (see appendix
18.78);
 the doctor/nurse reflects which lines on this tag apply to this pregnant woman during her time
in the maternity ward. This means that every member of staff in the maternity ward is aware
thereof;
 The maternity data capturer/ward clerk reflects the following in ECDOH maternity register in
the following places:
o in HIV column - whether the woman was started on triple or dual therapy on
admission
o in NVP column - reflect whether infant was given stat dose of NVP
o in complications column - whether AZT syrup given to mother to administer for 7 or
28 days;
 the maternity data capturer/ward clerk reflects the details of mother in a register provided by
HIV department for ‘HIV exposed Infants’ with the following information:
o mothers name
o child’s name
o date of birth
o address + telephone number (if any)
o PCR follow up date in 6 weeks time
o name of PHC referred to for PCR; and
 the nurse on discharge will reflect on the newly issued road to health card (RTHC) for the
infant that the infant was “HIV exposed”. This assists the PHC staff for identifying infants for
PCR testing (see para 15.2.2 ниже)208.
206
This is one of principle reasons for advocating for a change to a triple therapy regimen of Zidovudine, Lamivudine and Kaletra
for pregnant women in deep rural areas. Not only are the drugs more efficacious in preventing transmission to the infant, and
better for the resistance profile of the woman but are more likely to be followed correctly and easily as it only requires the
pregnant women to take all the three drugs from 28 weeks of pregnancy until delivery with no further requirements during
labour or for the infant after delivery.
207
Depending on whether the mother was started on dual therapy more than 4 weeks before delivery or not.
208
In 2009 a stamp was introduced by ECDOH for this purpose.
104
14.9
HIV exposed infant follow up (IFC)
Infant follow up
done at PHC – PCR
testing
Delivery at hospital or CHC
(MATERNITY DEPT):
-
-
14.9.1
NVP + 3hr AZT hourly
NVP syrup
administered+ AZT
syrup dispensed
PHC f/u date given
Birth recording system
The information from the register of HIV exposed infants in the maternity wards is provided to
the data capturer to update the information relating to the birth and testing of the infants on the
HIV database.
In addition, to assist with tracking of the birth of the infants, all women enrolled in the
programme have PMTCT tracking tags attached to the front of their HIV programme file by the
data capturer (see appendix 18.79). When the woman comes back to the hospital or her PHC
for either continued HIV wellness or an ARV repeat supply, any member of staff who interacts
with her is required to complete the tag. Once the tag is complete, the tag will be given to the
data capturer to update the information on the HIV database.
See appendix 18.80 for page of the database that is completed.
14.9.2
PCR testing at PHC
A pregnant woman’s ART adherence counselling and her counselling upon leaving the
maternity ward, focus on the importance of her taking her baby for HIV testing (PCR testing) at
her closest PHC, six weeks after birth. All the PHCs provide PCR testing using the dried blood
spot technique which the nurses have all been trained to use.
Despite PCR testing being conducted by each of the PHCs, these HIV testing rates were still
low. On investigation, it seemed that the main reason was that PCR testing was grouped with
VCT i.e. the mother and infant were sent to the nurse responsible for VCT209.
209
The mother may not go especially if she has already queued the whole day for immunisations. Often there is not another
nurse available for VCT and therefore PCR testing was delayed to another day.
105
The HIV programme has worked with the PHCs to include PCR testing in the PHCs’
immunisation clinic to increase the testing of HIV exposed infants. This can be difficult as the
patient load requires the nurse running the immunisation clinic to see a number of mothers and
infants at the same time (giving the infants the same set of immunisations in a row).
By reflecting that the infant has been exposed to HIV on the RTHC meant that the nurse could
quickly identify which mothers and infants who were required to be seen separately for this
testing. The testing is then does at the same time as the infant’s six week immunisations.
The nurse completes the IFC form at the time of taking the PCR. These forms are kept in a file
and the results are later attached (see appendix 18.81)
14.9.3
PCR recording and follow up system
All PCR results, irrespective of whether the PCR was taken at the hospital’s HIV or paediatric
department or at the PHCs, come to the HIV department’s data capturer for capturing. The
data capturer captures the result in two places:
 the IFC database which is an excel spreadsheet recording every PCR result coming though
the HIV department; and
 the HIV programme database (pregnancy related sheet) if the mother is enrolled on the HIV
programme.
After capturing, he/she sends a copy to the PHC or paediatric department210.
Where the mother of the child is enrolled on the HIV programme and has a file, the result is filed
in the mothers file (attached to the IFC form). Where the mother is not enrolled in the
programme, the PCR result is attached to the IFC form filed in the IFC files.
Where the child is HIV positive, the file/result (if no file) is sent to the paediatric HIV doctor for
review. The doctor will liase with the HIV/ARV co-ordinator regarding contacting the mother to
bring the child to the next paediatric HIV clinic (see below) either through the PHC or directly.
14.9.4
Giving the result to the mother
When the PCR is taken, the mother is given a review date of 2 weeks later for the result211.
When she returns and the result is given to her, she is required to sign the IFC form
acknowledging being told and understanding the result.
14.9.5
Referral into the paediatric HIV (PART) clinic
Where the PHC nurse sees the mother on her review date or after being contacted regarding
the result, and the child is HIV positive, the nurse will complete a PART clinic referral form (see
appendix 18.82) and refer the mother and infant to the following week’s PART clinic at the HIV
department212. If the mother is seen in the paediatric ward or the HIV department at the
210
If the NHLS system were integrated with the HIV database and this information could be sent electronically considerable time
would be saved.
211
Although the turn around time on PCR results from Mthatha NHLS has gone through period of taking upto 6 weeks due to
backlogs.
212
Since June 2009, once monthly PART clinic at Xora. However Xora nurses still refer to Madwaleni where next PART clinic date
at Xora is more than 2 weeks away.
106
hospital, she will be referred to the next PART clinic unless it is on the same day in which case,
she will be referred directly to a peer educator for a paediatric file to be opened (see para 15.3.1
ниже).
14.10 PMTCT patient monitoring and follow up
14.10.1
HIV and IFC database
The HIV and IFC databases provides specific reports for the HIV/OVC S&D manager, the
HIV/ARV site co-ordinator and the head HIV and PMTCT clinicians which assist with monitoring
and evaluating the programme. These include:
 infants testing HIV positive not enrolled on the HIV programme;
 the numbers of pregnant women joining the HIV wellness programme;
 the number of pregnant women starting dual or triple ART through the PMTCT clinic213;
 the number of pregnant women not attending their HIV wellness repeat visits for their own
clinical monitoring once they have completed the dual therapy regimen and delivered;
 the pregnant women who have defaulted on collecting their ART supply;
 the pregnant women with red flag blood results; and
 the pregnant women who have died prior to starting ART or already on ART;
 the deaths of any of the PMTCT patients’ infants in utero, during delivery or after delivery
prior to PCR testing.
14.10.2
Clinical meeting (see also para 17.2 ниже)
The professional staff hold a short clinical meeting at the end of each Thursday PMTCT clinic.
This meeting is facilitated by the PMTCT doctor and is used to:
 review the functioning of the clinic for the day specifically patient flow and appropriate doctor
referrals;
 discuss clinical issues arising from any patient seen during the day;
 comment on any interesting clinical case study observed during the day for purposes of
professional staff development;
 specifically:
o 1st week - review all PMTCT patients and whether there is any information on delivery214
(using the PMTCT follow up spreadsheet – see para 14.10.3 and appendix 18.84);
o 2nd week - review of previous month’s PMTCT related statistics including how many
pregnant women enrolled in the HIV programme, how many started dual or triple therapy
regimens and any deaths;
o 3rd week - review all women who have delivered more than 6 weeks previously who have
not brought their infant to the HIV department or PHC for PCR testing (using the PMTCT
follow up spreadsheet – see para 14.10.3 and appendix 18.84); and
o 4th week - discuss HIV positive PCR results for previous month from PMTCT programme
(using the PMTCT follow up spreadsheet – see para 14.10.3 and appendix 18.84) (if any).
14.10.3
Follow up of PMTCT women and infants
The information completed on the HIV database allows the programme to track all infants born
of HIV positive mothers, whether they survived, whether they were tested and their HIV result.
213
214
System currently not set up to record pregnant women being initiated on dual therapy at PHCs.
This used to include more dual therapy patients but these have reduced due to mostly being managed at the PHCs.
107
This information is used by the data capturer to compile of a list of all women who have formed
part of the PMTCT programme in order that the programme can follow up those for whom their
infant’s survival and HIV results are not known. This is called the PMTCT follow up
spreadsheet.
A nurse from the HIV programme works with the one of the peer educators to contact (either by
telephone or home visit) each of these woman to obtain this information. Where it is found that
the infant has not been tested, she is encouraged to bring her baby immediately for testing to
his/her closest PHC215.
For example of PMTCT follow up spreadsheet (information obtained from HIV database), see
appendix 18.84.216
14.10.4
Communication system between HIV department and PHCs
The success of the PMTCT programme is largely dependent on a continuous system of care
provided between the PHCs, the HIV department at the hospital and the maternity wards. It is
essential that this communication works both ways. The PHC nurses have the personal
relationship with the patient and therefore need to be kept informed of the success of their
referrals for ART initiation.
A system was developed in terms of which the HIV department data capturer keeps a record of
all the referrals made by the PHCs using the referral consent forms received from the PHCs.
He/she then tracks whether the patient:
 arrived on her review date;
 whether and when she was started on ART; and
 dual or triple ART regimen217.
This feedback is given monthly to the PHCs through the peri-natal mortality meeting. This
allows them to track the patients that did not go to Madwaleni’s PMTCT clinic. It also gives
them feedback regarding each of their patients for continuation of their care after the birth of
their child including following up on bringing the infant for his/her PCR test.
For example, see appendix 18.83.
215
During this review process, it has been found that PHCs have not given the mother the results of the PCR test. The
programme copy of the PCR is sent to the PHC again and the mother is requested to go to see the nurse for the result.
216
There is a recent initiative (February 2010) to incorporate this spreadsheet generated from the HIV database into the
communication between the HIV department and PHCs i.e. all the information combined into one document.
217
Patients were also referred for dual therapy prior to the PHCs being capable of initiating dual therapy (training and drug
stock). Certain patients are still initiated on dual therapy at Madwaleni including those from the Madwaleni catchment area and
those who were referred by the PHC and who the doctor decides to initiate on dual not triple ART.
108
15. Paediatric HIV wellness and ARV services
15.1
Paediatric patient flow chart
The flow chart below sets out the patient journey for any paediatric outpatient (and their caregiver)
who tests for HIV. This section will follow the flow chart and explain each block in detail including
the various clinical protocols, staff guidelines and administrative tools that are used.
If HIV+
Refer to Madwaleni
PART clinic
WK 1
Join HIV wellness
programme
 Open file
 Initial individual
counselling session
 Nurse clinical
consultation
 Dispense prophylactic
treatment
 Attend caregiver
support group
 Provide nutrition if
necessary
 Refer to social worker if
necessary
Child has been/likely to
have been exposed to
HIV or is ill
VCT:
<18 months:PCR
>18 month: rapid
(see testing protocols)
Second HIV wellness visit: Doctor clinical
consultation
If CD4 >200
Child > 5yrs
If CD4 < 200
If CD%>20%
Child 3 – 5 yrs
If CD4 <20%
WK 3
If CD% >25%
Child 1- 3yrs
If CD4 < 25%
Child < 12
months



Clinical assessment for ART
initiation by doctor
2nd individual adherence
WK 4
counselling by pharmacy
assistant (PA) – ARVs
dispensed
Yellow blocks = at hospital/CHC
Baseline bloods taken if DTT
White blocks = at PHC
blood results more than 3
months old
2 weekly
adherence
visit
ART
adherence
checked by
PA
Monthly HIV wellness visits:

Attend caregiver support
group

Individual counselling
session relating to living
with HIV and readying for
ARVs

Cotrimoxazole pill counts to
prepare for ART

Nurse check up/clinical visit

Dispense prophylactic
treatment

Referral to doctor for
treatment of opportunistic
infections

Deworming + Vit A

Provide nutrition if
necessary
WK 3
ARV preparation session:

HIV wellness visit

ART adherence counselling

Home visit to prepare familyBlue
for starting
area
ART
Take CD4 again:
<3 yrs: every 3 months
>3yrs: every 6 months
= HIV wellness prior to ART
Orange area = ARV programme
Monthly review – same
as adults
Down refer to PHC when
clinically stable (VL
suppressed)
109
Monthly review – same
as adults at PHC
15.2
HIV testing of children
Child has been/likely to
have been exposed to
HIV or is ill
VCT:
<18 months:PCR
>18 month: rapid
(see testing protocols)
15.2.1
Protocols for HIV testing in children
The protocol which sets out which children should be targeted for testing, at what point and
through which testing method are set out in appendix 18.85 relating to children younger than 18
months and appendix 18.86 relating to children older than 18 months.
15.2.2
Focus areas for HIV testing in children
HIV testing of children is focused on:
 through the PMTCT programme (see para 14.9 выше) – all infants of HIV positive mothers
are tested at six weeks of age at their PHCs;
 in the paediatric ward – where sick children’s caregivers are counselled regarding the
importance of testing (where the mother is present, she is encouraged to test first to
determine whether it is necessary to test her child); and
 through the OVC programme (see para 10.9.3 выше) – the OVC group is regarded as high
risk as many of these childrens’ parents who have died had HIV.
15.3
Enrolling in the HIV wellness programme
If HIV+
Refer to Madwaleni
PART clinic
Join HIV wellness
programme
 Open file
 Initial individual
counselling session
 Nurse clinical
consultation
 Dispense prophylactic
treatment
 Attend caregiver
support group
 Provide nutrition if
necessary
 Refer to social worker if
necessary
The procedure for enrolling a paediatric patient on the programme is very similar to an adult
other than that the caregiver and child are not required to attend an HIV support group before
enrolling in the programme. The child is immediately enrolled on the date he/she arrives at the
110
paediatric HIV clinic (PART clinic). Importantly, a paediatric patient is routinely seen by a nurse
and at least once by a doctor prior to the date on which ART is initiated.
The procedure is set out below to provide a comprehensive picture of a paediatric patient
journey through HIV wellness and ART initiation despite the similarity to an adult patient (albeit
more briefly – for further detail on each step, see adult HIV wellness and ART section above).
15.3.1
Opening HIV wellness paediatric file – peer educator
A peer educator will open a file for a paediatric patient by sitting with the child’s caregiver and
completing the first section of page 1 of the paediatric HIV wellness form (see appendix 18.87)
which notes the patient’s pertinent background information.
15.3.2
Conducting individual counselling session: HIV wellness visit no.1 - peer educator
Once the peer educator has opened the child’s file, the peer educator conducts the first
individual counselling session or ‘HIV wellness visit’ as it is termed with the caregiver. This
session has a number of purposes including:
one-on-one counselling on issues associated with living with HIV The peer educator will discuss issues associated with caring for a child living with HIV and asks
a few preliminary questions regarding the child’s health, documenting the answers in page 2 of
the paediatric HIV wellness form218 (see appendix 18.88).
Teaching and monitoring of prophylaxis The peer educator will teach the patient the importance of getting into a routine of giving the
child his/her prophylactic treatment once daily.
CD4 monitoring The peer educators are trained to ensure that the patient’s CD4 count results are in the file at
their next HIV wellness visit. They will check this result and complete it on the paediatric HIV
wellness visit form.
15.3.3
ARV adherence counselling (only younger than 12 months) – peer educator
Where the infant is younger than 12 months and provided the peer educator is of the opinion
that the caregiver has the capacity to immediately learn about ART and the provision thereof to
the child, the peer educator will follow the HIV wellness visit with the first ARV adherence
counselling session. See para 15.4.1 ниже for detail.
Where the peer educator is concerned about the caregiver’s capacity to take in too much
information in one session, she/he will discuss the plan going forward with the professional
nurse219.
15.3.4
Attend caregiver support group – peer educator
218
Historically in the paediatric programme, the counsellors played a smaller counselling role only conducting ARV adherence
counselling when instructed to do so by a nurse. This changed in 2009 and all caregivers and children receive a preliminary
counselling session by a counsellor (similar to the adult programme). This also helps in ensuring CD4 counts are on file by the
time the patient gets through to the nurse.
219
Keeping in mind the urgency of starting infants under 12 months on ART.
111
A caregiver support group is facilitated by one of the peer educators as part of every PART
clinic. The support group is run in the reception area where the caregivers are queueing to see
the counsellors, nurses and doctor. The support group is used to answer caregiver’s questions
relating to taking care of a child with HIV and addressing any concerns they may have
regarding transmission to others in the family. In addition, ARV adherence is continually
counselled with a focus on dosage changes in children.
15.3.5
Nurse consultation – professional nurse
Each new paediatric patient will see a professional nurse for his/her initial visit upon joining the
HIV wellness programme where he/she will assess the patient and complete:
 the medical history portion on page 1 (appendix 18.87);
 plot weight and height on appropriate growth chart (appendices 18.101)
 the nurse assessment portion of page 2 (appendix 0, including the developmental
assessment (using appendix 18.92 as a guide); and
 the HIV wellness visit 1 on page 3 (same as adults - appendix 18.31).
For a detailed nurse guideline outlining this visit for children:
 younger than 12 month - see appendix 18.93; and
 older than 12 months - see appendix 18.94.
The nurse will start prophylactic Cotrimoxazole and multi-vitamins in terms of the protocol for
children (see appendix 18.89) and will prescribe deworming treatment and vitamin A220.
The professional nurses have been trained to screen for danger signs and red flag symptoms
specific to paediatric patients. Any danger signs or red flag symptoms need to be completed on
the paediatric HIV wellness form prior to referral to a doctor on the same day. See appendix
18.98 for danger signs and red flag symptoms in paediatric patients.
All paediatric patients under 12 months will automatically be referred to the doctor.
15.3.6
Blood investigations – community health worker + professional nurse
The professional nurse will take the necessary blood investigations from the child and the CHW
will complete the necessary NHLS forms. See appendix 18.91 for the routine blood
investigations to be taken for paediatric patients.
15.3.7
Nutritional support – peer educator
All members of staff can refer a child to the peer educator to distribute ECDOH provided
nutritional support for children with HIV (see appendix 18.42)221.
15.3.8
Social welfare support – social worker
The hospital social worker spends 2 hours every Wednesday at the PART clinic providing social
welfare assistance to caregivers who attend the PART clinic. This includes assisting with the
processes involved in applying for and obtaining the necessary social welfare grants (child
220
Unless prescribed in previous 6 months in RTHC.
Donor funding is used to procure emergency food supplements for periods where government provided nutrition cannot be
obtained. In addition, such funding is used for specific elemental/milk formulations required but not provided by government.
221
112
support, foster and disability). She also works closely with the ancillary OVC programme and
refers children from PART to the OVC programme for continued support.
15.3.9
Return date – professional nurse + peer educator
The peer educator and the professional nurse will encourage the caregiver and child to return to
the HIV wellness clinic in two weeks time to check the child’s blood results, specifically the CD4
count or percentage and continue individual counselling unless a nurse/doctor has requested
the patient to come back sooner for clinical follow up reasons.
15.4
Return HIV wellness visit to ascertain CD4 count
Second HIV wellness visit: Doctor clinical
consultation
If CD4 >200
Child > 5yrs
If CD4 < 200
If CD%>20%
Child 3 – 5 yrs
If CD4 <20%
If CD% >25%
Child 1- 3yrs
If CD4 < 25%
Child < 12
months
ARV preparation session:

HIV wellness visit

ART adherence counselling

Home visit to prepare family for starting
ART
15.4.1
Conducting individual counselling session: HIV wellness visit no.2 - peer educator
Upon return two weeks later, the caregiver and child will see the peer educator again who will
ensure that the child’s CD4 count is back. The peer educator will continue with the counselling
involved in a further HIV wellness visit and complete the second wellness visit on page 2 of the
HIV wellness form (appendix 18.88).
15.4.2
ARV adherence counselling - peer educator
The peer educators have also been trained to determine based on the child’s age and CD4
count/percentage whether the child is required to start ART.
CD4 count/% qualifies for ART initiation Where the CD4 count/% falls within the parameters for starting ART, the peer educator will
conduct ART adherence counselling. The peer educators have been trained on the standard
ARVs which will be prescribed by the doctor based on the weight and age of the child. The
peer educators use their guideline on ART counselling for children set out in appendix 18.89
113
and the dosaging table set out in appendix 18.100 to determine the ARV drugs and dosages222.
Where the peer educator is unsure, he/she will wait for the paediatric patient to see the nurse
and consult with the nurse thereafter regarding the specific ARV adherence counselling that
needs to take place.
Where the nurse or doctor decide to initiate a child on ART due to staging or for any other
reason (see below), they will refer the caregiver and child back to the peer educator after their
consultation with clear instructions regarding the specific ARV counselling that needs to take
place.
Once the ART adherence counselling has been completed, the peer educator will:
 schedule a home visit with the caregiver prior to ART initiation the following week;
 write the patient’s name on the board in the HIV department office recording date223 that the
patient will be start ART and his/her name; and
 put the paediatric patient’s file in the tray for patient’s scheduled to start ART.
CD4 count/% does not qualify for ART initiation Where the CD4 count/% does not require the child to start ART, the peer educator will explain
this to the caregiver but also explain the importance of coming back monthly for HIV wellness
review. In addition, the child’s CD count/% will continue to be monitored so that ART can be
started as soon as necessary. Where the child is less than 3 years old, a new CD4% will be
taken every 3 months. Where the child is older than 3 years, a CD4 count/% will be taken every
6 months.
The peer educator will place the appropriate tag on the front of the file relating to HIV wellness
continued visits for children 1-3 year (see appendix 18.95) and for children over 3 years (see
appendix 18.96) to ensure all staff are aware of the continued monitoring of the child.
15.4.3
Nurse clinical visit – nurse
The caregiver and paediatric patient will then see the nurse who will review the CD4 count/%,
determine whether the child needs to be initiated on ART and check the correct adherence
counselling has been done by the peer educator. In addition, the nurse will conduct a clinical
visit similarly to the initial visit as set out in para 15.3.5 выше (also see appendix 18.94).
15.4.4
Doctor initial consultation – doctor
This consultation will happen at the first visit for children under 12 months of age and at the
second visit for children over 12 months of age (unless referred by the nurse at first visit due to
danger signs or red flag symptoms).
The doctor will stage the patient using appendix 18.97224. The doctor will review the peer
educator and nurse’s decision regarding whether it is necessary to initiate ART yet.
222
The peer educators have received a number of in-service training sessions on determining the correct ARV drugs and dosages
for children including written tests on this. There decision is always reviewed by the nurse and doctor. In our experience where
the peer educators had to wait for the nurse or doctor to make to make the decision first, it meant that the adherence
counselling had to happen at the end of the caregiver and child’s visit. The caregiver was less inclined to pay attention to the
important information as she is concerned about transport home. Where this is done earlier in the day, the more receptive the
caregiver is to the counselling session.
223
Should always be the following Wednesday unless the patient has a problem with this date.
114
15.4.5
Home visit to prepare family for patient starting ART – peer educator
Once the peer educator has completed the adherence counselling, he/she will schedule the
home visit with the caregiver and child. For further detail see para 12.5.2 выше.
15.5
Return HIV wellness visits thereafter
Monthly HIV wellness visits:
Attend caregiver support
group

Individual counselling
session relating to living
with HIV and readying for
ARVs

Cotrimoxazole pill counts to
prepare for ART

Nurse check up/clinical visit

Dispense prophylactic
treatment

Referral to doctor for
treatment of opportunistic
infections

Deworming + Vit A

Provide nutrition if
necessary
Take CD4 again:
<3 yrs: every 3 months
>3yrs: every 6 months
15.5.1
Conducting individual counselling sessions: HIV wellness visit no.3 onwards- peer educator
Each visit –
The peer educator will:
 conduct a further individual counselling session; and
 complete an HIV wellness visit on page 2 of the HIV wellness form (appendix 0).
Every 3/6 months  ensure the paediatric patient has had his/her CD4 count/% taken; and
 where the paediatric patient’s CD4 count/% qualifies him/her for ART initiation, the peer
educator will immediately conduct ART adherence counselling (see para 15.4.2 выше),
schedule a home visit (see para 15.4.5 выше) in the following 7 days and schedule the
patient to start ART the following week.
15.5.2
Continued nurse HIV wellness check up or clinical visits – nurse
The caregiver and paediatric patient will see the nurse at each monthly HIV wellness visit for
either a check up visit or a clinical visit (every 3/6 months - see appendix 18.94) which includes
a review the child’s CD4 count/% to determine whether the child needs to be initiated on ART.
224
The doctor is training the nurses to conduct the staging and reviewing the staging at his/her consultation.
115
15.6
ART initiation



Clinical assessment for ART
initiation by doctor
2nd individual adherence
counselling by pharmacy
assistant (PA) – ARVs
dispensed
Baseline bloods taken if DTT
blood results more than 3
months old
The necessary administrative preparation for the children starting ART during the week is included
in the preparation for all patients initiating ART in the week. See para 12.6.2 выше.
The process on the ART initiation date is the same as for adults (see para 12.6.3 выше) other than
that:
 the prescription and dispensing form is different for children as it requires a repeat prescription
from the doctor every 3 months to review weight changes (see appendix 18.99)
 the pharmacy assistant will counsel each caregiver and child on their own and focus on
demonstrating how to give the syrup formulations to children.
15.7
Continued management of paediatric patient on ART
2 weekly
adherence
visit
ART
adherence
checked by
PA
Monthly review – same
as adults
Down refer to PHC when
clinically stable (VL
suppressed)
Monthly review – same
as adults at PHC
The preparation for paediatric patients scheduled for repeat ART supply forms part of the
preparation for adult patient repeats. See para 12.7.1 выше.
The same patient tag system described above for adults is used for children (see para 12.7.1 выше)
to assist all staff to monitor that the caregiver has completed all steps involved in this repeat ARV
visit.
The process on the ART repeat date is the same as for adults (see para 12.7.2 выше) other than
that:
 a paediatric patient is routinely seen by the nurse every month (not only for first 7 months as
with adults unless ill);
 the doctor will see the child every 3 months to review the prescribed ARV dosages and enter a
new prescription on the paediatric prescription form (appendix 18.99);
 a peer educator will see the caregiver and child after each dosage change to repeat ARV
adherence counselling and specifically demonstrate administering the changed dosage.
All the forms for ART clinical monitoring are the same as for adults (see appendix 18.51 and 18.52)
116
The nurse completes the blood investigation results on page 1 of the ART clinical monitoring form
and identifies any concerns in this regard (see appendix 18.51). Similarly to HIV wellness visits,
nurses are trained to identify danger signs and red flag symptoms (see appendix 18.98). These
are noted in the applicable section on page 2 of the ART clinical monitoring form (see appendix
18.52) prior to referral to the doctor.
Nurses are also being trained to manage certain recurring clinical issues in paediatric HIV patients
using the protocols drafted for this purpose. For an example see appendix 18.102 on how to
manage anaemia.
The process for ART dispensing by the pharmacy assistants and blood investigations is the same
as for adults (see para 12.7.2 выше).
15.7.1
Down referral to PHC
Unlike adult patients, children are not referred to their PHC immediately on initiating ART. The
paediatric patients did not attend their local PHC225 for their HIV wellness visits and will
therefore be attending their PHC for the first time upon down referral. A paediatric patient will
only be down referred when stable on ART. The nurse or doctor will inform the pharmacy
assistant by using the tag on the front of the file to refer the caregiver and child to their closest
PHC for their next ART visit226.
The pharmacy assistant will only refer children to the doctor-led ARV clinic at the PHC. These
children will continue to be monitored by a PHC nurse monthly and the ARV outreach doctor
quarterly for a new prescription.
15.8
15.8.1
Monitoring of paediatric HIV programme and its patients
HIV database
The HIV database provides specific reports for the HIV/OVC S&D manager, the HIV/ARV site
co-ordinator and the paediatric HIV clinician which assist with monitoring and evaluating the
programme. These include:
 infants testing HIV positive not enrolled on the HIV programme (see PMTCT programme
para 14.9 выше)
 the numbers of paediatric patients joining the HIV wellness programme;
 the number of paediatric patients starting ART;
 the paediatric patients that qualify for starting ART based on their CD4 count/% but have not
started;
 the paediatric patients on the HIV wellness programme that are not attending their HIV
wellness repeat visits for clinical monitoring;
 the paediatric patients who have defaulted on collecting their ART supply;
 the paediatric patients with high viral loads or other red flag blood results; and
 the paediatric patients who have died prior to starting ART or already on ART.
15.8.2
Clinical meeting (see also para 17.2 ниже)
225
Other than Xora CHC which has its own PART clinic and therefore these children are initiated on ART at the CHC.
The pharmacy assistants have also been trained to consult the nurse/doctor on whether they can down refer when a patient
requests this or the pharmacy assistant is aware that the child is stable and has had a good adherence record.
226
117
The professional staff hold a short clinical meeting at the end of each Wednesday PART
clinic227. This meeting is facilitated by the paediatric doctor and is used to:
 review the functioning of the clinic for the day specifically patient flow and appropriate doctor
referrals;
 discuss clinical issues arising from any patient seen during the day;
 comment on any interesting clinical case study observed during the day for purposes of
professional staff development;
 specifically:
o 1st week - mortality discussion which reviews all paediatric patient deaths that occurred in
previous month;
o 2nd week - review of previous month’s paediatric related statistics including how many
paediatric patients joined the HIV wellness programme and how many started ART in the
month;
o 3rd week - discuss all children with high viral loads and plan of action for each; and
o 4th week - discuss all children who are not attending HIV clinic and need to be actioned.
227
A similar meeting is held monthly at Xora CHC.
118
16. Inpatient programme
16.1
Background
Madwaleni as a rural district hospital and has a number of patients diagnosed with Tuberculosis
(TB) who need to be admitted for up to 44 days for their streptomycin injections as they are unable
to attend their PHC daily for these injections due to the distance or cost of getting to their local PHC
each day. It was initially with these patients in mind that the inpatient programme was implemented.
The inpatient programme now actively recruits any HIV positive inpatient to be enrolled in the HIV
programme and start ART if clinically indicated while in hospital.
16.2
Inpatient flowchart
Out-patient
member of
HIV/ARV
programme
Seen and
treated by
ward doctor
HIV+ patient
admitted to
hospital
Out-patient
GROUP 2
GROUP 1
 patient clinically
eligible to receive
ART
 unable to receive
counselling
 Dr starts ART (see
protocol)
 Nurse administered
ART
GROUP 3 Discharged
from Group 2 while still
an inpatient to attend
HIV dept as an outpatient including
starting ART at HIV dept
(not in ward)
Patient prepared by peer
educators in the wards for
joining HIV programme and
starting ART
ART started in ward
GROUP 3
Discharged from
hospital before ART
start
 through HIV dept
 patient takes own ART
 nurse signs chemotherapy
chart
GROUP 3 Discharged from
hospital after ART start
Join out-patient
programme at either
hospital or 1 of 7 primary
healthcare clinics at
which programme
operates
Group 3
 Patient receives discharge
counselling on how to
continue as an out-patient
 If already started on ART adherence + drug supply
check by pharmacy
assistant
 patient takes own ART
 nurse signs
chemotherapy chart
119
16.3
Brief explanation of group 1, 2 and 3
The inpatient programme developed 3 separate groups of patients that have become known by the
staff as group 1, 2 and 3. These will be briefly explained more fully below:
16.3.1
Group 1 – Palliative step-up group
This group of patients are patients that have been admitted at the hospital that are either:
 unable to be counselled due to their clinical condition but for whom ART is the only treatment
that will potentially improve their chances of survival; or
 require ART extremely urgently and cannot be delayed while preparing for the ARV
readiness.
These patients are initiated on ART by the doctor in charge of their ward in consultation with the
HIV clinician on the HIV programme. The doctors follow the protocol set out in appendix
18.104. These patients are administered their ART by the ward nursing staff together with other
prescribed medication.
These patients have a high mortality rate228. Those that survive are transferred to Group 2 and
follow the ARV readiness preparation and enrolment in the HIV programme discussed in paras
12.1, 12.4, 12.5 выше prior to discharge from the hospital.
16.3.2
Group 2 – Fast track inpatients
This group of patients are patients who have been admitted into the hospital but although
clinically unwell are able to understand and participate in individual counselling about their HIV
positive status, enrolling in the HIV programme and starting ART.
The patients that are admitted for longer periods because of specific treatment regimes are
often prepared and started on ART while in hospital. However many patients that are only in
hospital for a few days are merely counselled and encouraged to enrol in the programme upon
discharge or enrolled in the programme but will on start on ART as an outpatient after
discharge.
Where Group 2 patients are started on ART in the ward, they are responsible for taking their
own treatment i.e. the ART is not administered by the ward nurse but is only recorded in the
patient chart by the ward nurse after having checked that the patient has remembered to take
his/her ART229.
16.3.3
Group 3 – Discharged patients
Group 3 refers to all patients who are discharged from either hospital or from Group 2 (prior to
discharge from hospital).
Initially Group 3 only referred to all patients who were discharged from hospital somewhere
along the continuum of HIV care. In order to ensure that upon discharge, the patient
228
By 30 September 2009 out of 71 patient who started ART as Group 1 patients 53% died.
This strategy has a dual purpose: 1) for the patient to practise adherence before leaving the hospital with monitoring 2)
ensure the patient receives their treatment as the nursing staff often fail to give prescribed medication.
229
120
understands the next step in his/her health care, all inpatients are referred to the HIV
department upon discharge. A peer educator or community health worker counsels the patient
regarding where the patient will continue his/her care as an outpatient and what the next step in
such care is. In addition, where the patient has already started ART, the counsellor will check
that the patient has sufficient ART supply for his return date and if not refers the patient to the
pharmacy department prior to going home.
However after running the inpatient programme for eighteen month, we determined there was a
significantly higher ‘lost to follow up’ rate amongst inpatients than outpatients230. In addition,
both doctors and peer educators reported certain patients in the ward being disinterested in the
counselling generally and despite encouragement, failing to attend the HIV support group run at
the HIV department at the hospital. As a result, a further group of patients were added to Group
3. These were patients that the doctors/nurses/peer educators felt may not have accepted their
HIV status and/or may not be committed to their HIV wellness or starting ART. Instead of
initiating such patients on ART in the hospital ward where it is possible for the patient to
passively partake in the process, such patients are discharged from Group 2 while still
inpatients and encouraged to attend the adult HIV wellness and ARV clinic at the HIV
department at the hospital on a Tuesday. This creates an opportunity for such patients to
interact in the HIV support group context and demonstrate active participation in their health
care prior to starting ART. These inpatients are for all intents and purposes regarded as
outpatients.
16.4
System for delivery for HIV services to inpatients
For a detailed guideline to each step of the inpatient programme system refer to appendix 18.105.
16.5
16.5.1
Staff allocation to inpatient programme
Peer educators work in wards on Mondays
Peer educators and community health workers are allocated to the various hospital wards in
groups of two or three231 on a Monday (see para 8.2 выше). Their role in the wards includes
the following:
 group education on HIV and the benefits of testing for HIV;
 conducting pre-test counselling for HIV (see para 10.6 выше) and arranging for the ward
nurse to conduct HIV test and post test counselling;
 leading a Group 2 patient through the process of enrolling in the HIV programme and
readying for starting ART;
 transferring a Group 1 patient to Group 2 by leading the patient through the process of
enrolling in the HIV programme and understanding their ART and adherence thereto; and
 checking on HIV programme patients that have been admitted and ensuring that they have
their ART supply with them and are able to take it with/without assistance.
16.5.2
Doctor/pharmacy assistant/HIV dept nurse on Thursday
Group 2 inpatients are scheduled to be initiated on ART on a Thursday. Their files prepared
for ART initiation by the administrator are taken by the HIV/ARV site co-ordinator to the
230
In April 2007 approx. 18 months after starting the in- patient programme the lost to follow up rate (including patients still in
area known to have decided to stop ART) was 2.5% in the out-patient group compared to 8.8% amongst the inpatient group.
231
3 are allocated to the Infectious disease wards which have higher number of HIV positive patients.
121
doctors’ meeting on Thursday morning232. The doctors then see the patients in their wards and
where the doctor is satisfied on the day with the patient clinically, he/she will prescribe ART.
The HIV department will then arrange for the pharmacy assistant to dispense ART to the
patient with the appropriate adherence counselling.
16.6
Communication tools used in inpatient programme
A number of different staff members are involved in the inpatient programme in different locations in
the hospital at different times. Three tools are used to promote effective communication regarding
inpatients:
16.6.1
Group 2 counsellor form
This form is placed in the patient’s chart by the peer educator and is used by the peer educator
to reflect counselling progress to assist the doctor/nurse team to determine when the patient
has enrolled on the HIV programme and is ready to start ART. The doctor will also reflect on
this form (top right hand corner) if the peer educator can proceed with ART adherence
counselling based on the patient’s clinical picture.
See appendix 18.106
16.6.2
Inpatient programme list – doctor communication tool
This form is used by the doctors to communicate with the HIV department specifically the
HIV/ARV site co-ordinator. Each doctor will complete such a form weekly reflecting his/her
ward patients who require attention including whether they are placing them in group 1, 2 or 3.
It also reflects discharges from the hospital prior to enrolment (i.e. patient has no file) and
deaths on the ward. The HIV/ARV site co-ordinator then ensures the following:
 this list is distributed to the counsellors allocated to the specific ward for action by the
counsellors and ward nurses;
 at the Monday meeting with the counsellors, a report is given on each patient and noted on
the form;
 the HIV/ARV site co-ordinator then copies the form and returns it to the specific doctor at the
Thursday doctors meeting so that the doctor has an up to date list of actions completed and
he/she can add new instructions or new patients to the list; and
 the deaths on the ward are captured on the database.
See appendix 18.107
16.6.3
Doctors discharge summaries233
232
The HIV/ARV site co-ordinator attends this meeting weekly as Thursday is the doctor’s meeting in the Infectious disease
wards. This allows for communication regarding the inpatient programme specifically the follow up of patients.
233
In ECDOH district hospitals, patients have a patient chart in the ward and a hand held clinical record/booklet in which health
professionals make notes to reflect the history of care for a patient. When a patient come back to the hospital or the PHC as an
outpatient, the patients hospital chart is not drawn and only the notes in the hand held clinical record/booklet are of any use to
provide a history. These are sometimes lost and sometimes replaced when full (although the majority of patients are very good
with their booklets and are more reliable then the hospital system were hospital patient files to be introduced). When a doctor
discharges a patient, he/she is required to write a discharge summary which used to be placed in the patient hospital chart. The
doctor therefore often only wrote a few words in the hand held clinical record/booklet. We introduced carbon copied books for
these discharge summaries, so that when the doctor writes it, 3 copies are made, one remains in the discharge summary book in
the ward (no longer put in patient ward chart as these are filed away and never retrieved), one to be stapled/stuck into the hand
122
When a patient is discharged from the hospital, the doctor writes a discharge summary in a
book which makes 3 carbon copies, one of these is sent to the HIV department if the patient
was part of the inpatient programme irrespective of whether they had enrolled in the programme
and have a file as yet. A nurse in the HIV department is responsible for capturing the admission
date, discharge date and the primary diagnosis. These discharge summaries are then get filed
in the patient’s HIV programme file which assists health professional in accessing the full history
of the patient when seeing the patient again either as an in or outpatient.
One of the copies stays in the discharge summary book on the ward and the last is stapled in to
the patient’s hand held clinical record/booklet so that any healthcare worker managing the
patient outside of the hospital wards or HIV programme has the necessary information.
16.7
16.7.1
Monitoring of inpatient programme
Monday report back meeting
The peer educators and community health workers meet with the professional nurses in the HIV
department on a Monday afternoon to provide feedback on the inpatients progress making use
of the current and previous week’s ‘inpatient programme list’ to determine progress of each
patient (also see the report made to clinical staff in para 17.3.2 ниже).
16.7.2
HIV database
The information from the ‘inpatient programme list’ and discharge summaries is captured on the
database. This means that the following information regarding inpatients is tracked and useful
for continued monitoring and evaluation234:
 patients initiated on ART as Group 1 patients and their survival rate;
 all patients initiated on ART as inpatients (both Group 1 and 2) and their adherence to ART;
 periods of admission in hospital of all patients enrolled in the HIV programme; and
 mortality in hospital of patients enrolled on the HIV programme.
held booklet and the last one to be sent to the HIV dept if the patient was part of the inpatient/HIV programme. This was
introduced in 2009.
234
Only since May 2009 (prior to this only recorded in notes section on database)
123
17. Patient monitoring systems
17.1
17.1.1
HIV programme database
Introduction
The HIV programme database (the database) is central to the effective functioning of the
Madwaleni HIV programme. From its inception, the Madwaleni HIV programme ran a
rudimentary data system in Microsoft Excel. The current database was developed in Microsoft
Access in April 2007 and the data from Excel extracted into it. In 2008, the back end of the
database containing the data tables was moved to SQL which links to an Access interface for
users.
The database was developed235 from within the HIV programme and has undergone continued
development through the years and is therefore tailored to meet the specific needs of the
programme.
17.1.2
Principle elements
The database contains the following principle elements:
Patient specific related  Patient’s demographic information;
 Patient’s HIV wellness history – date of diagnosis, date of joining HIV support group, date of
enrolling on HIV wellness programme;
 Patients ARV initiation related information – date of starting ART, where started ART,
whether pregnant or co-infected with TB at ART start;
 Blood and pap smear results;
 HIV wellness visit dates and dates at which INH prophylaxis collected;
 Pregnancy related information – including DOB of child and PCR result;
 ARV regimen related - ARV drugs and dosages prescribed and changes to ARV regimens;
 Dispensing history including weight;
 Hospital admission related – including diagnosis;
 TB diagnosis;
 Transfer history – including down referral to PHCs; and
 Deregistration related information – death and lost to follow up.
Planning related  List of patients due for ART repeats for each ARV clinic held at Madwaleni or PHCs;
 Dispensing list for pharmacy department setting out each patient due for ART repeat for
each ARV clinic held at Madwaleni or PHCs (including details of their drug regimens); and
 Medication labels for ART drug containers for each patient due for ART repeat for each ARV
clinic held at Madwaleni or PHCs.
Patient specific monitoring  Report of HIV wellness patients who have not been attending the HIV wellness programme;
235
By Lynne Wilkinson when she was the HIV/ARV site co-ordinator together with Tjaart Coetsee (the then community service
pharmacist) who did the majority of programming. It has been continuously developed by Lynne Wilkinson and Tjaart Coetsee
with input from Dr Tom Boyles more recently.
124








Report of patients whose CD4 count requires the person to start ART;
Report on patients overdue for their ART repeat;
Report on patients with detectable viral load after 6 months on ART;
Report on patients on INH prophylaxis;
Report on HIV wellness patients overdue for repeat CD4 count and viral load investigation;
Report on patients with red flagged blood results that require action;
Report on patients to stop Cotrimoxazole prophylaxis; and
Report on patients with pap smear results that require action.
ARV and other pharmaceutical stock requirements  Report to pharmacist of ARV drug requirements for HIV programme for following month
including estimation of increase based on 3 month history of ARV starts236; and
 ARV stock requirements for each ARV clinic held at Madwaleni or PHCs.
Programme monitoring  Report on monthly statistics – per operational site/entire HIV programme;
 Report on all patients enrolled on HIV programme at each operational site (hospital/PHC);
 Report on new files opened/new patients enrolled in HIV programme for the current month;
 Report on patients started on ART in current month;
 Report on patients deceased in current month; and
 Report on CD4 recovery for HIV programme patients over 6 month periods on ART.
See the section above for HIV database reports specific to monitoring the adult, paediatric (para
15.8.1 выше), PMTCT (para 14.10.1 выше) and inpatient (para 16.7.2 выше) programmes.
17.1.3
Ad hoc queries
The manner in which the HIV database is constructed makes it fairly simple to write a query
requesting a report on any data which is captured and can be used to monitor specific patient
related follow up or operational efficiencies. Once these become used regularly, they are
formalised into a formal report. For example a query tracking the birth of infants and their PCR
results of all the PMTCT patients on the programme.
17.1.4
Data capturing requirements
The HIV programme would not be able run using the database without reliable and up to date
data capturing. The programme is heavily reliant on the services of a competent data
capturer237 who needs to be updating the patient specific related information continually to
ensure that the reports generated are current and therefore reliable238.
236
For the first 2 years of the programme, the pharmacy department needed to keep paper registers of ARV drug regimens per
patient to enable the pharmacist to calculate the ARV drug requirements for the programme. This has to be reconciled with HIV
department Excel data system to determine patients deregistered due to death or lost to follow up. This was an onerous and
lengthy process with a big margin for error which directly affected ARV stock levels for future months.
237
Madwaleni HIV programme managed with only 1 data capturer for most of its existence until early 2009 when a further data
capturer was employed to capture for the OVC programme and assist with HIV programme data capturing. He is allocated
approximately 50% between the two programmes. This has also meant that when 1 data capturer is on leave/sick the other data
capturer can take over both programmes for the period of absence. In the past, one of the professional staff had to spend
evenings capturing to ensure that the programme a backlog in capturing didn’t effect operations which immediately results in
most of the reports being out of date.
238
By way of example, should a dispensing list not be captured, all the patients who were due for ART will be reflected as
overdue and their next month’s supply of ART will not be sent to their PHC for collection.
125
We have focused on streamlining the capturing processes as it is not viable for a data capturer
to review each file for changes after the patient has visited especially as many of the patients
are seen at the PHCs.
17.2
Clinical meetings with professional staff
The HIV programme holds a short clinical meeting at the Madwaleni HIV department at the end of
each Tuesday, Wednesday and Thursday239. This meeting is facilitated by the doctor in charge of
the clinic for the day and is intended to:
 review the functioning of the clinic for the day specifically patient flow and appropriate doctor
referrals;
 discuss clinical issues arising from any patient seen during the day;
 comment on any interesting clinical case study observed during the day for purposes of
professional staff development;
 specifically allocated subject for review and discussion (changes weekly):
General HIV wellness and ARV programme
o 1st week – mortality discussion (review all deaths that occurred in previous month)
o 2nd week - review of previous month’s statistics
o 3rd week - discuss all patients from Madwaleni/Vukukhanye clinic with high viral loads and
plan of action for each
o 4th week - discuss professional staff issues
Paediatric HIV wellness and ARV programme (see also para 15.8.2 выше)
o 1st week - mortality discussion (all deaths that occurred in previous month)
o 2nd week - review of previous month’s paediatric related statistics
o 3rd week - discuss all children with high viral loads and plan of action for each
o 4th week - discuss all children who are not attending HIV clinic and need to be actioned
PMTCT programme (see also 14.10.2 выше)
o 1st week - review all PMTCT patients and whether any information on delivery
o 2nd week - review of previous month’s PMTCT related statistics
o 3rd week - review all women who have delivered more than 6 weeks previously who have
not brought infant for PCR testing
o 4th week - discuss HIV positive PCR results for previous month from PMTCT programme (if
any)
Most of the above discussions are aided by database print outs and a review of the relevant
patient’s file.
These meetings have improved doctor-nursing communication regarding specific patients and
have assisted in identifying areas in clinical care that require improvement, additional training
needs or a change in strategy/systems240.
17.3
17.3.1
Report back and follow up meetings with peer educators/CHWs
Introduction
239
Introduced in early 2008 (prior to this ad hoc meetings were held but found to be less effective)
By way of example, in the early monthly mortality meetings, it was determined that a number of the deceased patients had
failed to see a professional nurse when collecting their repeat ART supply in the first 6 months of ART. It was therefore possible
to implement a system in terms of which this could be checked before a patient left the clinic. In addition, a number of the files
had no notes from the professional staff who saw the patient which meant it was not possible to ascertain their medical history
prior to death. Emphasis was placed on professional nurses recording notes both the in the patient’s file and in their OPD card.
240
126
As previously set out, the peer educators are instrumental in running the HIV wellness and ARV
programme at all eight of the operational sites. They are the first point of contact for the
patients and many of the patients are often only seen and followed up by the peer educators. It
is therefore essential that appropriate monitoring and support of the peer educators is routinely
provided.
17.3.2
Report to professional staff
The professional nurses in the HIV department hold a meeting on a Monday afternoon with the
peer educators/CHWs where they provide feedback regarding:
 the progress of inpatients seen during the morning as part of the inpatient programme;
 any programme patient admitted in one of the wards in which they worked in the morning;
 any outpatient that they have seen which they have any clinical or psychosocial concerns
about; and
 any outpatient that they have been told is unwell by other programme patients241.
Professional nurses provide input and guidance in this regard.
17.3.3
ARV readiness follow up meeting
This is a critical meeting held by the administrator with the peer educators weekly on Tuesday
after the adult HIV wellness and ARV clinic. The administrator prints the report from the
database of all patients with CD4 counts lower than 210 not on ART as yet. The peer
educators provide input with regards the progress of the patient in their preparation to start
ART.
Where a patient is not attending an HIV wellness clinic, follow up of the patient is arranged.
Where a patient is having difficulty managing the preparation steps, the peer educators put their
heads together regarding ways in which we can facilitate this process.
The administrator makes notes on the plan or progress of each patient which is updated in the
database for follow up the following week. Each PHC team of peer educators’ goal is to ensure
that the list of such patients from their PHC is short and the progress of each patient clearly
known and understood242.
17.4
End of HIV wellness and ARV clinic meeting at PHCs
Similarly to the clinical meetings held at Madwaleni, one is held at the end of each ARV clinic at the
PHC243. The team meeting includes the doctor, pharmacy assistant, professional nurses, peer
educators and PHC CHWs. This team discusses the following:
 the functioning of the clinic for the day specifically patient flow and appropriate doctor referrals;
 any clinical issues arising from any patient seen during the day;
 patients that did not arrive for their scheduled ART repeat244
241
For the first 3 years of the programme, this report back was done within the HIV department meeting on a Monday morning
but was found to be very time consuming and not requiring all staff members input. It was then shifted to the end of Monday
which also works better after the ward patients had been seen by the peer educators.
242
This feedback meeting has been held since 2005 (where the list was generated manually). It has been instrumental in
ensuring that HIV wellness patients are not lost in the critical stages of ART preparation.
243
Similar meetings have been encouraged at the PHCs on HIV wellness days (i.e. the alternative weeks) between the nurses and
counsellors. Only a few of the PHCs hold these routinely.
244
Whether any staff member knows why the patient did not come? In many instances a staff member will know that the
patient was admitted or fetched his/her ART supply at Madwaleni or is away in Johannesburg/Cape Town but expected back
(patients often phone peer educators with this information).
127


patients with high viral loads at that PHC and the action to be taken
patients that require follow up for:
o being previously overdue for ART repeats; or
o to continue ART preparation;
o red flag blood results or pap smears; or
o repeat CD4 counts (longer than 6 months since previous CD4).
128
18. Appendices
18.1
Map of Madwaleni- Xora area
129
18.2
Xora/Elliotdale location within Eastern Cape
130
18.3
Examples of task shifting used at Madwaleni
Not an exhaustive list
Task
Pre and post HIV testing counselling
Weighing patients
Taking vital signs
Opening patient file
Checking blood results in file (fetching from
lab ifwellness
not)
HIV
counselling
CD4 count monitoring
ARV preparation counselling
Dispensing prophylactic Rx
Screening for patient complaints and
objective
danger
signs
Taking blood
investigations
Completing NHLS blood forms and tubes
Running HIV support group for adults
Running HIV support group for caregivers of
children HIV support group for pregnant
Running
womenfeeding counseling breastfeeding v
Infant
formula formula
feeding feeding counselling
Correct
Various data collection: blood investigations
taken, details
of child
born to files
PMTCT patient,
Fetching
and filing
of patient
HIV
wellness
and
ARV
patient
repeat
visits
Identifying HIV wellness patients
for possible
INH prophylaxis
Starting
INH prophylaxis
Continued INH prophylaxis once initiated
Maintaining records of all patients ART drug
regimens ART for patients at PHCs
Prepacking
Distributing pre-packed ART
Clinical monitoring of adult and paediatric
patients on ART
Task shifted from:
Prof Nurse
Prof Nurse
Prof Nurse
Prof Nurse
Prof Nurse
Prof Nurse
Prof Nurse
Prof Nurse
Prof Nurse
Prof Nurse
Prof Nurse
Prof Nurse/Enrolled nurse
Prof Nurse
Prof Nurse
Prof Nurse
Prof Nurse
Prof Nurse
Prof Nurse/Data capturer
Administrator/Data capturer
Prof Nurse
Doctor
Prof Nurse
Pharmacist
Pharmacist
Pharmacist
Doctor
131
Task shifted to:
Lay worker
Lay worker
Nursing assistant/student nurses
Lay worker
Lay worker
Lay worker
Lay worker/Programme
administration
Lay
worker
Lay worker
Lay worker
Enrolled nurse
Lay worker
Lay worker
Lay worker
Lay worker
Lay worker
Lay worker
Lay worker
Lay worker
Lay worker
Prof Nurse
Enrolled nurse
Data capturer/Programme
administration
Pharmacy
assistants
Pharmacy assistant
Professional nurse
18.4
NDOH accreditation form/tool
Revised May 2006
This is an embedded file if you double click you will get entire 14 page document. Alternatively
download at www.doh.gov.za/docs/faform-f.html
132
18.5
Accreditation criteria
Operational Plan for Comprehensive HIV and AIDS Care, Management
and Treatment for SA
19 November 2003
(Last modified: 23 April 2008 07:46:08)
Chapter 4
1. Presence of a service point project manager, who will supervise programme conduct
and expansion. Where practical and effective, a project manager may supervise
programme conduct and expansion for more than one service point.
2. Availability of a trained care team on-site with representation of all relevant
professions (clinicians, nurses, and counsellors), easy access to trained laboratory,
pharmacy and nutritional staff, and links to NGOs and other service providers. The
care team should consist of sufficient staff in appropriate ratios to manage the
projected number of patients.
3. Implementation and maintenance of current standards of care as provided by the
National Treatment Policy Guidelines.
4. Access to care 24-hours a day at the service point, or in the direct vicinity, with
coverage relationships explicit to both facility staff and patients.
5. A staff recruitment, training and skills development plan in place for health care
workers responsible for HIV and AIDS care and treatment (including volunteers and
lay counsellors) based on initial needs and projected long-term patient numbers.
6. Appropriate numbers of consultation, treatment and counselling rooms should be
available to assure patient confidentiality, based on projected patient numbers.
7. Access to appropriate laboratory services, which have appropriate equipment, trained
operators, and an effective maintenance plan, overseen by the NHLS. Adequate
specimen preparation protocols should be in place for service points accessing
laboratory services outside their own facilities.
8. Secure and adequate pharmacy storage, and sufficient cold-chain capacity,
appropriate to handle Schedule 5 drugs (See Chapter VIII, Drug Distribution).
9. Adherence to drug dispensing Standard Operating Procedures (SOPs) for OI
prophylaxis and treatment, and ARVs.
10. Access to patient nutritional status assessment and nutritional support.
11. Existing links with on-site and/or proximal VCT centres, antenatal clinics, FP
clinics, TB clinics, STI clinics, TB/HIV demonstration districts, and any other
patient referral facilities, to ensure that HIV-positive patients are formally referred to
the accredited service point.
12. A PMTCT programme in place for service points providing antenatal care and a
referral system in place for sites without antenatal care facilities.
133
13. Formal referral systems and links with other operations within the service point (inpatient
wards, other clinics, support units) and outside expertise (secondary/tertiary
care facilities and sub-specialties, including neurology, ENT, ophthalmology,
oncology, pulmonary and infectious diseases).
14. Referral systems and linkages with community resources (NGOs, CBOs, HBC, faith based
organisations, PLWHA groups, traditional health practitioners, community
leaders, industry, and other support organisations) that complete the continuum of
medical care and support services.
15. Linkages in place with support organisations and NGOs to ensure continuous care
and support in the home and community, including support groups, adherence
support, educational activities, bereavement counselling and family support.
16. A system in place to track patients/treatments.
17. A system in place to maintain medical records and to transmit core data to a central
data collection point.
18. A system in place to ensure that durable equipment is appropriately inventoried and
service and maintenance agreements are in place. Where equipment is needed, the
service point shall have a plan for procuring and installing the equipment.
19. 24-hours post-exposure prophylaxis (PEP) access, according to the latest national
guidelines.
20. A plan for channelling into the care system HIV-positive blood donors, patients
treated with PEP, and prison populations identified as HIV-positive.
21. Established links with the provincial HIV and AIDS Unit to coordinate briefing of
local officials and to streamline input from local advisory committees.
22. Identification of technical assistance needs in administrative and various other
technical areas, including medical training.
23. Participation in IEC activities, in particular by enlisting resources to help educate
patients, families and communities about the basics of HIV and AIDS care and
treatment, the role that ARV treatment can play, and the difficulties inherent in
lifelong treatment for affected individuals and their families.
Guide set out in Annex 4 to operational plan
ANNEX IV.2: ACCREDITATION CRITERIA: SERVICE POINTS
Minimum requirements:
1. Adequate number of consultation and treatment rooms for projected number of patients, to
ensure patient confidentiality.
2. Adequate, private counselling space for projected number of patients, to ensure patient
confidentiality.
3. Safe waste disposal throughout the site, with sharps buckets present in all exam rooms and in
the laboratory.
Strengthening recommendations:
- Electricity generator for sites without back-up.
- Early development of an expansion plan, as needed and including laboratory and pharmacy,
based on projected patient numbers.
- Development of an adequate waiting/reception area, if not yet available.
- Creation of on-site flexible space for group training and group counselling sessions.
134
- Improvement of accessibility where needed (access roads, pedestrian pavement, accommodating
patients with disabilities, rerouting of public transport lines).
ANNEX IV.3: ACCREDITATION CRITERIA: MANAGEMENT AND ADMINISTRATION
Minimum requirements:
1. Presence of a dedicated project manager with a health care background, who supervises the
programme and its expansion. Project management skills are advantageous for this position, but
most important is a non-judgmental approach to HIV and AIDS care and treatment, as nonjudgmental site leadership has shown the closest correlation with site success in terms of patient
follow up and retention. Included in the project manager’s tasks are maintaining contact with the
provincial HIV and AIDS Unit and local officials, and streamlining/incorporating input from local
Advisory Committees.
2. Clearly identified management personnel with contact data:
-Clinic Director/Administrator
-Medical Director
-Chief Nurse
In smaller service sites these roles may overlap, but the persons need to be identified.
3. Adequate staff on site to manage, take inventory of, and account for all resources (monetary and
otherwise), including IT equipment, laboratory equipment, reagents and medication.
4. Adequate system in place to account for all resources (monetary and otherwise) in a
real time manner.
5. (Cell) Phone access to each facility that is part of the service site.
6. Fax access.
Strengthening recommendations:
- Establishing computer and internet access, or extending existing services.
- Implementation of computerized administration systems for service points with paper records.
- Participation in fiscal and administrative internal and/or external QC.
- Implementation of systems for tracking patient utilization in the outpatient clinic, daily bed
occupancy rate, average length of stay, and number of referrals.
ANNEX IV.4: ACCREDITATION CRITERIA: CLINICAL SERVICES
Minimum requirements:
1. A confidentiality policy in place for all service site employees.
2. Dedicated HIV care and treatment team available within the service site with representation of
physician(s), nurse(s) and counsellors in appropriate ratios:
-physician to professional nurse ratio range 1:1 to 1:4 (depending on nurse involvement in
counselling and education)
-nurse to counsellor ratio minimally 1:2, unless all counselling is provided by nursing staff; no
maximum ratio
3. Appointment system or other system in place to assure highest obtainable continuity in care with
the above health care workers, and to track patients.
4. Universal precautions in place throughout the site.
5. Dedicated HIV care and treatment service capacity in place, which may be embedded in the
overall care structure of the facility, as long as continuity of care is ensured. This means that
irrespective of the time and place the service site chooses to provide care (e.g. the routine OPD
clinic), continuity between the patient and the care and treatment team must be ensured.
6. On-site or nearby access to adequate laboratory services, pharmacy, and nutritionist(s) or health
care providers with a background in nutritional counselling.
7. Implementation and maintenance of the comprehensive HIV and AIDS care and treatment plan in
alignment with National Treatment Policy Guidelines.
8. Documented integration of the comprehensive HIV and AIDS care and treatment programme with
onsite and/or local VCT, STI, TB, FP, PMTCT, and ANC services. This integration should include
explicit referral systems.
9. Trained physician availability within the service site during the hours that HIV positive patients are
seen in the clinic.
10. 24 hours access to medical care at the service site or at a proximal referral facility, with
coverage (hours and location) explicitly clear to staff and patients.
135
11. 24 hours access to PEP packages (according to the latest national guidelines) at the service site
or proximal referral facility with clear referral lines, including essential timelines.
12. PMTCT programme in place on site, if ANC is provided at the service site; established PMTCT
referral lines to be in place for service sites without ANC services.
13. Adequate opening hours and clinic days when considering the projected patient numbers and
projected duration of interaction with health care workers.
14. Access to, or clear referral systems in place for the following (sub)specialties:
• antenatal care/obstetrics
• gynaecology
• internal medicine
• surgery
• paediatrics
• infectious diseases
• dermatology
• neurology
• ophthalmology
• ENT
• gastroenterology
• pulmonary medicine
• cardiology
• oncology
15. Access at service site or at referral facility to oxymetry, X-ray imaging, ultrasound imaging, PAP
smears, and diagnostic pathology.
16. Written strategy for collaboration with local traditional healers and alternative medicine
providers, preferably including referral lines.
Strengthening recommendations:
- Creation of IV treatment/blood transfusion capacity.
- Creation of short stay/overnight stay availability.
- Resolution of gaps in (sub)specialist expertise within the service area.
- Development of strategies to increase appropriate utilization of referral and consultation services.
- Early identification of correctional facilities in the service site area and identification of their needs.
- Create access to CT and MRI imaging, if not yet available.
- Tracking of immunization data for children and influenza vaccination data for adults.
- Tracking of OI prophylaxis provision data.
- Tracking of patient numbers lost to follow-up
ANNEX IV.5: ACCREDITATION CRITERIA: HUMAN RESOURCES
Minimum requirements:
1. Presence of a dedicated project manager per service site as described under Section B.
2. Sufficient administrative and accounting support staff on site to comply with section B.
3. Dedicated HIV care and treatment team on site with representation of physician(s), nurse(s) and
trained counsellors in appropriate ratios for the projected patient numbers:
-physician to professional nurse ratio range 1:1 to 1:4 (depending on nurse involvement in
counselling and education)
-nurse to counsellor ratio minimally 1:2, unless all counselling is provided by nursing staff; no
maximum ratio.
-maximum physician to patient ratio at onset of programme=1:15 per clinic day
4. Access at service site, or in immediate vicinity, to adequate laboratory staff for projected number
of patients and laboratory tests, both technicians and clerks (NHLS responsibility).
5. Access at service site, or in immediate vicinity, to adequate numbers of pharmacy staff with
representation of at least one pharmacist. Number of pharmacy assistants and clerical staff should
be sufficient to meet the minimum pharmacy certification requirements as described in section G.
6. Access at service site, or in immediate vicinity, to sufficient nutritionist(s) or health care
provider(s) with a background in nutritional counselling, to serve the projected patient numbers. All
projected patients should have a minimum of one nutritional evaluation upon entry into the care
system.
136
7. Where human resource shortages exist, or are predicted based on projected patient numbers for
phases 2 and 3, a recruitment and retention plan should be in place. This plan does not need to be
service site driven, depending on the policies of the province and/or district.
Strengthening recommendations:
- Consider hiring Social Worker(s).
- If implementing hospital supported transportation, ensure adequate driver availability.
ANNEX IV.6: ACCREDITATION CRITERIA: LABORATORY SERVICES
Minimum requirements:
1. Adequate and tidy laboratory space to accommodate the equipment and staff sufficient for the
service site specific procedures and tests to be performed.
2. Sharps containers and other universal precautions in place.
3. Refrigerator capacity on site with ability to cool samples to 2-8 centigrades.
4. Sample centrifuging capacity.
5. Sufficient number of phlebotomists or persons approved to draw blood on site.
6. Protocols in place for sample preparation, storage, and transport, at service sites without on-site
laboratory
7. Adequate laboratory equipment, or access to such equipment at the NHLS referral lab, to perform
the following tests:
- HIV-1 ELISA
- Western Blot
- CD4+ count
- HIV-1 viral load
- genotypic HIV-1 resistance testing
- urinalysis and dipstick
- electrolytes
- LFTs
- Lipase
- Cholesterol
- lipid panel
- FBC with differential
- ESR
- RBC typing and crossing
- India ink stain
- cryptococcal antigen
- CMV serology
- toxoplasmosis serology
- hepatitis A serology
- hepatitis B serology
- hepatitis C serology
- VDRL/RPR
- AFB stain
- aerobic and anaerobic bacterial cultures
- Mycobacterial cultures
- viral cultures
- fungal cultures
- KOH preparation
8. Proven ongoing participation of the laboratory in internal and external QA and QC programs.
9. A system in place to alert health care providers regarding abnormal lab results in a real time
manner.
10. A system in place to report lab results in a timely manner.
11. Maintenance plan in place for current equipment, including IT equipment.
12. A protocol in place for indeterminate HIV serology results, consistent with national guidelines.
Strengthening recommendations:
- Integration of laboratory result reporting with patient records.
- Purchase of a freezer, preferably with the capacity to freeze samples at –70 centigrades.
137
18.6
Optimal HIV programme staffing
Optimal HIV programme staffing levels - Main site + 1 community health centre (CHC) + 7 primary healthcare centres (PHCs)
Number of staff (whether filled or not)
% of their time spent in standard
week on any/all aspects of HIV
programme
Management staff
1 x HIV/OVC strategy and decentralisation
manager
1 x ARV site co-ordinator
All 100%
Doctors at top levels
1 CMO level
Doctors at lower levels
Nurse mentor
Professional nurses
Lower level nurses
Dietician
Senior social worker
3
1
Main site - 4 optimal (3 need to be on site
and there is always 1 on
leave/training/sick)
CHC - 3 optimal (2 need to be on site and
there is always 1 on leave/training/sick)
PHC - 3 optimal (2 need to be on site and
there is always 1 on leave/training/sick)
Main site/CHC - 4 optimal (3 need to be on
site and there is always 1 on
leave/training/sick!)
PHC - 2 optimal (1 always on
leave/sick/training!)
1 - HIV programme
1 - HIV programme
138
Salary level
Level 11
Level 10
100%
Level 12
1 x PMTCT at main site and clinics
(100%)
1 x paediatrics at main site and clinics
(100%)
1 x TB/HIV integration at hospital and
clinics
100%
Level 10/11
Level 11
Main site - 100%
CHC - 2 x 100% 1 x 25% (need 2 at
weekly clinic as min)
PHC - 3 x 25% (need 2 at weekly clinic
as min)
Main site - 100%
CHC - 2 x 50% 1 x 25%
PHC - 2 x 25%
50%
All 100%
New revised nursing levels ito OSD
based on experience and recognised
specialisations
New revised nursing levels ito OSD
Level 8
Level 8
Auxillary social workers
Chief Pharmacist
2 auxillary social workers
1 - HIV programme
All 100%
Auxillary pharmacy workers
5
Data capturers
Administrator
Admin clerks (filing, faxing, phoning)
Transport co-ordinator
Drivers
Defaulter co-ordinator
Head peer educators/counsellor mentors
1 x senior
1x junior
1
1 per site
1
4
1
2
All 100%
All 100%
All 100%
All 100%
All 100%
All 100%
All 100%
Staff on stipends
25 peer educators + 5 community health
workers at main site and 3 per other site
All 100%
Volunteers on expenses
10 VCT counsellors
50%
Level 5
Level 10
100%
Level 4
Level 7
Level 5
Level 8
Level 3
Level 4
Level 3
Level 3
Level 3
50%
139
Equivalent to government stipend
for CHWs
Half of government stipend for
CHWs
18.7
Organogram HIV/OVC/HBC within hospital structure 2009
140
18.8
Role of HIV/OVC S&D Manager within hospital/sub district/district structure 2009
Amathole District
Madwaleni hospital
HIV, OVC and HBC programmes
Mbashe sub district
responsible for hospital provided
healthcare services
responsible for decentralised HIV, OVC
and HBC services within hospital and
sub district
responsible for primary healthcare clinic and
community outreach provided healthcare
services
Hospital
Manager
Sub district
Manager
Nursing
Services
Manager
Out
Patients
Area
Manager
In
Patients
Area
Manager
All
Programmes
Manager
HIV/OVC S&D
manager
Maternity
Area
Manager
HIV/ARV
site coordinator
VCT
outreach
coordinator
OVC coordinator
141
HBC coordinator
CCMT
Manager
includes
ART, OVC
and HBC
HIV
Preventi
on
Manager
Maternal
and child
health
Manager
Nutrition
manager
18.9
HIV/OVC strategy and decentralisation manager – job description
Broad job description

Develop, implement and co-ordinate strategies, systems, policies and protocols required to set up
and/or develop the comprehensive efficient decentralized HIV wellness and ARV programme in
conjunction with Mbashe CCMT and HIV Prevention managers in terms of the National comprehensive
HIV management, care and support programme in the Madwaleni – Xora area including:
 HIV awareness in the communities
 VCT at facilities (hospital and primary healthcare clinics) and in communities
 HIV wellness programme including HIV support groups for adults, caregivers of children and
pregnant women
 ARV management programme for adults and children
 Prevention of mother to child transmission (PMTCT) programme within Madwaleni – Xora area
 Inpatient integration programme

Facilitate, implement and co-ordinate strategies, systems, policies and protocols required to set up
and/or develop the following ancillary programmes in conjunction with Mbashe CCMT manager:
 Home based care programme
 Orphans and Vulnerable Children programme

Guide and facilitate the ARV site co-ordinator, OVC co-ordinator and HBC co-ordinator’s operational
management of their respective programmes, including the training and career development of each
member of staff within these programmes.

Develop strategies and systems to improve the monitoring and evaluation of the various elements of the
HIV/OVC/HBC programmes with a focus on services provided by the primary healthcare clinics and in
the community.

Monitor quality of data and evaluate statistical relevance of data.

Review and finalise reports required by hospital management, districts and Provincial HIV Directorate.

Monitor and ensure proper utilisation of government funding allocated to the ARV facility at Madwaleni
Hospital by the ARV site co-ordinator.

Determine staff requirements of HIV, OVC and HBC programmes and develop recruitment strategies to
build these teams where necessary.

Engage with local communities and increase community involvement and support of the HIV, OVC and
HBC programmes.

Liase with both internal and external stakeholders including districts, other government departments,
community, community based organizations and the private sector regarding their buy in and support of
the HIV, OVC and HBC programmes.

Develop private partnerships with government to facilitate the set up and expansion of the HIV/OVC
and HBC programmes.

Oversee administration of private funding according to memorandums of agreement with ECDOH.

Liase with and report to private funders including providing necessary reports and accounts.

Promote the support of private/public partnerships key to the HIV, OVC and HBC programmes with all
internal and external stakeholders at Madwaleni hospital management, districts, HIV Directorate, other
government departments, community, community based organizations and the private sector.
142
Madwaleni HIV programme - detailed breakdown of Weekly/Monthly duties
Weekly
Monday



Attend HIV programme sta
ff meeting 8h30 – 10h00 run by HIV/ARV site co-ordinator
Ensure transport co-ordinator has allocated transport appropriately for the week to HIV/OVC/HBC/VCT
outreach programmes on whiteboard (including transport requests for government vehicle to Madwaleni
hospital admin)
 High level monitoring of HIV programme – Inpatient programme
 High level monitoring of HIV programme – Preparation for week
 High level monitoring of ARV preparation home visits and same area ARV overdue follow up
 High level monitoring of OVC Mqhele/Bomvana clinic
 HIV programme meeting with HIV/ARV site co-ordinator and HIV clinician (16h00 – 17h00)
Tuesday
 High level monitoring of HIV programme: Adult HIV clinic (incl. clinical meeting).
 High level OVC Soga clinic (every second week)
Wednesday
 High level monitoring of HIV programme: Paediatric HIV clinic (incl. clinical meeting).
 High level monitoring of HIV wellness programmes at clinics – Xora, Mqhele and Nkanya
 High level OVC Madwaleni (every second week)
Thursday
 High level monitoring of HIV programme: PMTCT clinic (incl. clinical meeting).
 High level monitoring of HIV wellness programmes at clinics – Bomvana/Soga/Melitafa/Hobeni.
 High level OVC Nkanya (every second week)
 High level HBC – in service training run by HBC co-ordinator with rehabilitation team
Friday
 High level monitoring of HIV programme: Overdue ARV patient follow up
 High level monitoring of HIV programme: pap smear service
 Attend portion of general OVC meeting relating to planning, development and systems
 Attend end of general HBC meeting relating to planning, development and systems
 Meeting with HBC co-ordinator (9h30am – 10am)
 High level monitoring of DoSD home visits for OVC programme
 Meeting with OVC co-ordinator: (10h30am – 11h00am)
 Ensure transport co-ordinator has submitted government vehicle transport requests for following week
 *Facilitate joint staff meeting with HIV/ARV site co-ordinator, HBC co-ordinator and OVC co-ordinator
(11:30 – 12:30pm) at which the general functioning of all 3 programmes is discussed and at which task
lists are set up for the following week.
General weekly




Data capturers are up to date:
o Senior data capturer – new files have been captured, blood results have been captured and
filed, ARV starts have been captured, PMTCT consent forms captured, discharge summaries
from wards filed
o Junior data capturer – blood results have been sorted, OVC new files captured, OVC home
visits captured, OVC latest completed interventions completed, HBC visits captured
Transport in conjunction with transport co-ordinator
o review report – fuel and service requirements
o co-ordination to ensure optimal use made of each vehicle (grouping HIV/OVC/HBC/VCT
outreach needs together where possible)
Planning regarding any ARV drug shortages in conjunction with pharmacist
High level monitoring of all programmes stocks (with a focus on nutritional supplementation).
143
Monthly
Meetings
 Saving Mothers, Saving Babies: Peri-natal mortality meeting/steering team meeting
 Once a month attend nursing management meeting with HIV/ARV site co-ordinator to discuss broader
programmatic issues including staffing
 Last Wednesday of every month – HIV programme/Pharmacy department meeting with HIV/ARV site
co-ordinator and the outpatient HIV clinician
 First week of each month facilitate a meeting with HIV outpatient clinician, Middle Manager Xora CHC
and Clinic Supervisor from sub-district
 Meeting with hospital manager to update on programme developments and donor communications.
Accounts
 Prepare stipends payable to staff on 25th of month
 Pay stipends online to all staff by the last day of the month (including VCT counsellors)
 Pay advance requests submitted by OVC/HIV/HBC and VCT outreach co-ordinators
 Ensure all purchase approvals captured by last day of the month
 Ensure all accounting documentation is submitted to bookkeeper/DWF assigned person
 Review accounts prepared by bookkeeper/DWF assigned person by 8th of month and submit to donors
for reimbursement
 Pay any reimbursements for expenses incurred by staff in terms of reconciliation prepared by
bookkeeper by 8th of the month
 Follow up any previous re-imbursements not paid by donors
Statistics
 Review HIV programme statistics prepared by Administrator and HIV/ARV site co-ordinator prior to
input on District Health Information System (DHIS) by 30th of month
 Monitor that Administrator submits all statistics as required by ECDOH by 2nd of month
Reports
 Guide the HIV/OVC/HBC co-ordinators in their preparation of the monthly report, collect them, review
and add broader programme developments
 Prepare final monthly report for submission to hospital management, district management and donors
Human resource management
 Filling all vacant posts (including lay staff) – arranging advertising through Daily Dispatch, short listing,
interviewing and appointments.
 *Assess job satisfaction of staff members including professional development including action steps
which would improve job satisfaction. Where necessary discuss this with staff member (where
appropriate with the co-ordinator responsible for managing the staff member).
Three monthly
Meetings
 Set up and facilitate quarterly district meeting between Mbashe LSA/Madwaleni/PHCs HIV meeting
 Set up and facilitate donor budget spending meeting with HIV/OVC/HBC co-ordinators and clinical
management
Statistics
 Prepare and submit statistics to donors as per each donor’s requirements.
Budgeting
 Prepare ‘budgets spent against donor budgets available for the year’ report for donor budget spending
meeting (as above) including highlighting the budget items that require atttention.
144


Assess of spending of budgets and submission of proposals/motivations for new items requiring
funding.
Submit budget spending status reports to donors
Training
 Discuss training requirements with each co-ordinator and facilitate arrangement thereof with focus on
mentoring rather than didactic training.
 High level monitoring donor sponsored training scheduled for year.
Human resource management
 Conduct performance reviews of HIV, OVC and HBC co-ordinators and discuss general job satisfaction
and professional development initiatives. Also discuss job satisfaction of their staff and strategies to
address any problems.
VCT outreach assessment
 Assess and review VCT outreach programme results and discuss with VCT outreach nurse – including
report to donor.
Annual
Training
 Review donor provided training and submit training schedule request for following financial year.
145
18.10 HIV/ARV site co-ordinator – job description
Broad job description

Facilitate, implement and co-ordinate the daily running of comprehensive efficient decentralized HIV
wellness and ARV programme in terms of the National comprehensive HIV management, care and
support programme including
 HIV awareness in the communities
 VCT at hospital facilities and in communities
 HIV wellness programme including HIV support groups for adults, caregivers of children and
pregnant women at hospital
 ARV management programme for adults and children at hospital
 PMTCT
 Inpatient integration programme

Implement clinical protocols and co-ordinate clinical management, care and support of patients with
head HIV clinician and chief professional nurse

Co-ordinate interaction with primary health care feeder clinics and the appropriate referral of patients to
their local clinics together with HIV clinician responsible for clinics.

Supervise data collection and continue to improve system of data collection.

Monitor quality of data and evaluate statistical relevance of data together with HIV/OVC S&D manager
and head HIV clinician.

Review and finalise monthly statistics submitted to hospital management, districts and Provincial HIV
Directorate.

Provide input to the HIV/OVC S&D manager on developments in regard to the above functions for
purposes of monthly reports to hospital management, districts and donors.

Assist HIV/OVC S&D manager with determining the staff requirements of HIV/ARV programme and
recruiting such staff to build the HIV/ARV programme team where necessary

Manage counsellors on the HIV/ARV programme and the performance of their duties

Plan and co-ordinate training of the HIV/ARV programme team and other all hospital staff regarding
HIV/AIDS management, care and support and monitoring and evaluation of the HIV/ARV programme

Assist HIV/OVC S&D manager to promote the support of private/public partnerships key to the HIV/ARV
programme with all internal and external stakeholders Madwaleni hospital management, districts, HIV
Directorate, other government departments, community, community based organizations and the
private sector.

Assist HIV/OVC S&D manager to engage with local communities and increase community involvement
and support of the HIV/ARV programme
146
Madwaleni HIV programme - detailed breakdown of Weekly/Monthly duties
Daily operation
Every day



All professional nurses on duty and starting to see patients at 8am (they should have prepared from
7-8am)
All enrolled nurses and nursing assistants are on duty and that the professional nurses have
determined how they will be assisting on the day
All student nurses on duty and assigned tasks for the day and aware of their duties for the day
Monday



Run meeting of HIV dept at 8:30am
In patient programme:
o Ensure counsellors attend allocated ward with appropriate instructions from doctors’ lists;
o Support report back meeting by counsellors to nurses regarding both in and out patients.
Facilitate the reporting back process and the follow up action to be taken by both nurses and
counsellors;
o Ensure appropriate plans have been made for patients during the following week to ensure
required action is planned for and taken; and
o Ensure nursing staff capture clinically relevant information in database.
Co-ordinate any in service training initiatives held on Monday afternoons
Tuesday (50% of time in HIV clinic)


Co-ordinate the operation of the adult HIV wellness and ARV clinic:
o All staff are carrying out their assigned duties
o HIV support group starts at 11am until 1pm
o Lunch is being prepared for patients by patients
o Pharmacy staff are present to start dispensing ART (1 pharmacy assistant starts at 9am and
second starts at 11am)
Co-ordinate general clinical meeting at the end of Tuesday at 4pm between HIV clinician and
nursing staff on duty. This meeting is held to assess the functioning of the clinic on the day, discuss
clinical issues that arose and provide in service training on relevant patient cases seen during the
clinic. In addition:
o 1st week of the month includes previous month’s adult mortality discussion. Ensure report
has been printed, files drawn and nurses can present each patient’s case in meeting.
o 2nd week of month includes review of previous month’s statistics. Ensure statistic report has
been printed (including previous 6 months).
o 3rd week of month includes discussion of all patients from Madwaleni/Vukukhanye gateway
PHC with high viral loads and action to be taken;
o 4th week of month discussion of all professional staff issues.
Wednesday (30% of time in HIV clinic)


Attend hospital nursing management meeting at 7:30am with purpose of continued integration of
HIV services into all hospital services
Co-ordinate the operation of the paediatric HIV clinic:
o Ensure that transport has left to fetch children at PHCs
o All staff are carrying out their assigned duties
147
o
o

Caregiver support group starts at 11am until 12pm
OVC team has brought through toys and are facilitating playing while children wait to see
nurses, pharmacy and doctor
o Pharmacy staff are present to start dispensing ART (1 pharmacy assistant starts at 10am)
o Ensure children are taken home in the afternoon after clinic (with drivers going to PHCs)
Co-ordinate meeting at the end of Wednesday at 4pm between HIV paediatric clinician and nursing
staff on duty. This meeting is held to assess the functioning of the clinic on the day, discuss any
clinical issues that arose and provide in service training on relevant patient cases seen during the
clinic. In addition:
o 1st week of the month includes previous month’s paediatric mortality discussion. Ensure
report has been printed, files drawn and nurses can present each patient’s case in meeting.
o 2nd week of month includes review of previous month’s paediatric statistics. Ensure statistic
report has been printed (including previous 6 months).
o 3rd week of month includes discussion of all paediatric patients with high viral loads and
action to be taken;
o 4th week of month includes discussion on children who are not attending HIV clinic and need
to be actioned.
Thursday (30% of time in HIV clinic)




Take files of inpatients scheduled to start ART in wards to doctors TB/infectious diseases wards
meeting and give to relevant doctor for prescription
Attend doctors meeting in TB/infectious diseases wards with purpose to discuss case study patient
who is part of inpatient programme and challenges regarding effective operation of the inpatient
programme (separate short discussions after meeting should be held with appropriate doctors
regarding carrying out of plans for the inpatients in their wards)
Co-ordinate the operation of the PMTCT HIV clinic:
o Ensure that transport has left to fetch pregnant women from PHCs
o All staff are carrying out their assigned duties
o Pregnant women support group starts at 11am until 12pm
o Ensure that there is a doctor in the maternity department to see PMTCT clinic patients (with
a translator)
o Pharmacy staff are present to start dispensing ART (1 pharmacy assistant starts at 10am)
o Ensure pregnant women are taken home in the afternoon after clinic (with drivers going to
PHCs)
Co-ordinate meeting at the end of Wednesday at 4pm between maternity doctor attending to
PMTCT clinic and nursing staff on duty. This meeting is held to assess the functioning of the clinic
on the day, discuss any clinical issues that arose and provide in service training on relevant patient
cases seen during the clinic. In addition:
o 1st week of month includes review of all PMTCT patients still reflected as being on dual
therapy and whether they have delivered. Ensure report is printed and files are pulled for
discussion.
o 2nd week of month includes review of previous month’s PMTCT statistics. Ensure statistic
report has been printed (including previous 6 months).
o 3rd week of month includes review of all women who have delivered more than 6 weeks
previously who have not brought child for PCR testing. Ensure report printed and files pulled
for discussion.
o 4th week includes discussion of PCR positives for previous month from PMTCT programme
(if any).
Friday (10% of time in HIV clinic)
148

Co-ordinate the operation of the Women’s health clinic:
o All staff are carrying out their assigned duties
o Pap smears are done for women booked
o Co-ordinating with nursing staff that pap smear results are being followed up and discussed
with the patients (whether normal or not)
Monitoring and supervising preparation for week
Previous Friday

Ensure that administrator has printed dispensing lists and medication labels on Friday for the
following week
Monday



Check on Monday that files have been prepared for patients appointments on Tuesday, Wednesday
and Thursday – including file tags on front and inclusion of ART medication labels
Check that ARV start files have been prepared by administrator and that the doctors list has been
prepared
Check chief professional nurse has ensured that:
- sufficient prophylactic treatment is in stock
- sufficient surgical are in stock for the week (including sterilized pap smear
equipment for Friday)
- the doctors procedures trays have been prepared by the nurses
- the doctors forms are in stock
- the treatment room trays have been prepared by the nurses and the treatment
room is ready to take patients on Tuesday
Weekly operation
Staff on duty



Signed time book for last week (reviewing times entered for starting and stopping work by nursing
staff)
Signed nurses on and off duties for the week (before submission to matron’s office)
Check leave roster and make arrangements for tasks of any person on leave to be assumed by
another
Inpatient programme

Inpatients are being followed up and actioned from Monday morning meeting
Monitoring and supervising processing of previous week




Ensure data capturing and filing by data capturers up to date
Ensure all ARV starts captured on database and in paper register
Ensure all patients overdue are being followed up appropriately by administrator and ARV default
tracker
Ensure all files filed by filing clerk
Monthly operation and broader co-ordination
Inpatient programme
149

Co-ordinate and implement the operation and improvement of the inpatient programme including:
o Facilitating HIV dept nursing staff leadership and guidance to counsellors
o Facilitating training of ward nursing staff
o Facilitating buy in and participation of nursing staff in wards in HIV management and care
o Facilitate the flow of information between the wards and the HIV dept (especially doctors
lists, discharge summaries, deaths)
o Supervise capturing of information from doctors lists on database including deaths and
admission and discharge dates
Nurse mentoring towards improvement of clinical care provided by HIV dept



In service mentoring of nursing staff in conjunction with HIV clinicians and nurse mentor (where
applicable)
Auditing and reviewing care received by a number of patients each month to identify where further
improvements can be made
Auditing nurse completion of forms by random audit and providing feedback to nurses
Counsellor mentoring

In service mentoring of counselling services provided including co-ordinating nursing staff to sit
in on a number of counselling sessions provided by counsellors each month and providing
constructive feedback to the counsellor concerned
Co-ordination of training
Nurse training



Identifying training needs within Madwaleni HIV dept and hospital (keeping skills audit updated
quarterly)
Co-ordinating attendance of HIV dept and hospital staff at Mbashe LSA held trainings especially
VCT and PMTCT.
Requesting and where possible arranging other service providers to provide training
Student nurse


Gaining understanding from nursing school as to training that needs to be obtained by nursing
students while working in the HIV dept
Co-ordinating such training to be given by professional nurses during time in HIV dept
Counsellor training



Arranging and co-ordinating training supplied by donor to counsellors
Co-ordinating and evaluating the internal mentoring of the new counsellors by the experienced
counsellors
Arranging and co-ordinating training of topics relevant to counsellors’ work (including revision for
experienced counsellors).
Co-ordinating VCT services in hospital


Ensuring that there is a VCT trained nurse in each ward who is able to do HIV testing (co-ordinate
with the nursing services manager when determining ward allocation)
Ensuring that VCT services are available daily in OPD in conjunction with outpatient nursing
manager
150
Nutrition


Oversee the preparation of nutrition statistics required by the district
Check formula feed and nutritional supplements stock levels and ensure enough stock for the
month. Where necessary timeously order and arrange for pick up from district office
Educational material


Obtaining free educational material for patients on HIV, ARVs, PMTCT, nutritional, STIs etc from:
o Soul City
o Khomanani
o TAC
Monitor stock levels and ensure being used effectively within HIV dept and VCT outreach
Rostering of staff

Prepare monthly counsellor allocation rosters – OPD (VCT), Tuesday duties, Wards for inpatient
programme
Condom distribution


Co-ordinating condom distribution within the hospital, VCT outreach and community sites (spaza
shops and shebeens) through support groups
Ensuring sufficient stock levels of male and female condoms – ordering from district where
necessary and arranging for pick up.
151
18.11 Administrator – job description
Job purpose

Run the administration of the Madwaleni HIV/ARV programme on a daily basis.
Detailed breakdown of Weekly/Monthly duties

Taking minutes of HIV weekly meeting, typing up minutes, filing one copy and distributing one copy to
hospital manager and nursing services manager.

Preparing all ART start files for the week including all forms etc.

Preparing doctors’ list of all patients to start ART that week including collecting list back from each
doctor.

Capturing all ARV starts in the paper register (balancing against number of patients started by doctors)
and handing to data capturer for capture on database.

Holding ARV readiness list meeting with counsellors checking status and follow ups necessary for all
patients whose CD4 results qualify them to start ART, updating database patient notes section,
continually following up with counsellors re patients’ progress.

Printing ART repeat lists, pharmacy required ART stock requisition, dispensing lists and medication
labels for the week.

Managing the ART defaulter tracker245, assisting and overseeing his/her co-ordination of the following:
o printing ART repeat overdue list
o taking out all files, checking that the patients are in fact overdue (not database capturing error)
o updating database where patients are not overdue
o grouping patients requiring follow up by area
o attempting to phone/send messages to patients before a car is sent to follow up
o arranging driver-counsellor team to follow up patients who have not come
o conducting complicated follow up visits (with nurse/social worker assistance where necessary)
o working with Xora CHC professional nurse to arrange to follow up overdue Xora patients
(through Xora CHWs) or otherwise bringing files back to Madwaleni for follow up.
o making notes on database regarding results of follows ups done determining patients who
should be considered as lost to follow up (for authorisation from HIV/ARV site co-ordinator)

Co-ordinating the peer educators in conducting the follow up of patients who were supposed to start
ART and never came for their scheduled appointment date.

Monthly collecting CD4/VL statistics from peer educators, PMTCT and nutrition statistics from nurses,
TB and side effect statistics from doctors.

Monthly balancing register of patients who started ART against database ART starts

Preparing ARV statistics form from database report

Inputting ARV statistics on District Health Information System (DHIS)

Distribution of monthly statistics after review to requisite people (as per distribution list)
245
Post only introduced and funded from August 2009 (4 years into programme). Previously co-ordinated by administrator with
assistance from management. This post has improved the co-ordinated effort to track defaulting patients.
152

Attending hospital cost containment committee meetings regarding procurement and hospital budget
spending, reporting to HIV/OVC S & D Manager in this regard.

Arranging all procurement of goods in conjunction with HIV/OVC S & D manager though government
budget (including monitoring of stationary needs) including following with procurement regarding orders
and payment of invoices

General patient administration on database including recording transfers out, transfers in, putting group
1 patients, deaths etc.

Assisting clinical staff with all patient records and information which they may require.

Managing inpatient ARV starts including giving prepared files to HIV/ARV site co-ordinator for TB
doctors meeting for prescription, ensuring pharmacy assistants have dispensed in ward, ensuring
bloods were taken and ARV start recorded appropriately and submitted to data capturer for capturing.

Co-ordinating collection of HIV wellness visits data from peer educators at operating at PHCs and
handing to data capturer for capturing.

Preparing community health worker (CHWs) timesheets for submission to Small Projects Foundation
(SPF).

General admin e.g. faxing, distributing letters etc.
153
18.12 Data capturer – job description
Job purpose

Data administration and management for the decentralized Madwaleni HIV/ARV programme.
Detailed breakdown of Weekly/Monthly duties

Data capturing of all patient information (including new files), all blood and pap smear results, down
referrals to PHCs, information relating to pregnancy (incl. delivery date, child’s name and PCR results)
on HIV/ARV programme access database.

Filing all patient’s blood results in files (or if at PHC in clinic tray)

Sending ‘out of range’ blood results to HIV clinician for signing and action

Monitoring the filing of blood results at PHCs by peer educators

Creating suspension files for new files, moving files between drawers (i.e. from Madwaleni HIV
programme to ARV programme)

Capturing PCR results on separate excel spreadsheet

Filing Infant follow up forms and corresponding PCR results in mother’s file or if mother does not have
file in IFC files

Data capturing of pharmacy dispensing to ARV patients (following up with pharmacy assistants if don’t
receive list for ARV date)

Data capturing of all HIV wellness visits attended by HIV wellness patients

Ensuring that all form trays are kept full

Assisting all staff including peer educators with forms required in terms of information collection for
patients at Madwaleni and at PHCs

Collection of all VCT stats at Madwaleni hospital and 8 PHCs (including follow up). Entering and
validating such statistics prior to submission to HIV/OVC S & D manager for review

Collection of PMTCT consent forms and balancing with ante-natal VCT statistics reporting HIV positive
pregnant women from PHCs

Updating PMTCT spreadsheet reflecting HIV positive women from PHCs who have elected referral to
Madwaleni PMTCT clinic, arrived at Madwaleni PMTCT clinic and were started on dual or triple ART

Assisting with monitoring and evaluation requirements of private funders

Maintain backup of all statistical data and patient databases

Report generation as required

Managing and supervising junior data capturer (if any) and the carrying out of his/her duties

Managing and supervising filing clerk (if any) and his/her duties

Ordering suspension files, patient files, ink cartridges, paper etc timeously from administrator
154
18.13 Splitting the working week to optimise human resources
Monday
Tuesday
At Madwaleni
8:30 – 10:00
HIV team meeting
All HIV team staff
10:00 – 15:00
In patient
programme
Peer educators
15:00 – 16:00
Peer educator
report back on in
and out patients to
professional
nursing staff
Peer educators,
professional
nurses and
HIV/ARV coordinator
8:00 – 15:00
Adult HIV wellness
and ARV clinic
All HIV team staff
15:00 – 16:00
ART initiation
progress meeting
Peer
educators/Adminis
trator
16:00 – 17:00
General clinical
meeting and
training
Professional staff
run by HIV
clinician
Wednesday 8:00 – 15:00
Paediatric HIV
wellness and ARV
clinic
Paediatric HIV
clinician, HIV dept
246
At Madwaleni
10:00 – 15:00
Preparation for
administration of
adult, paediatric
and PMTCT clinics
incl. ART initiation
and repeats
Administrator,
Nursing assistant,
community health
workers
Clinical
preparation for
adult, paediatric
and PMTCT clinics
incl. ART initiation
and repeats
Professional and
enrolled nurses
ART initiation
home visits and
overdue patient
follow up home
visits
Peer educators
-
At PHC
At PHC
10:00 – 15:00246
Xora Paediatric HIV
wellness and ARV
clinic
Paediatric HIV
clinician (once
monthly), Xora
professional
nurses and Xora
CHWs
15:00 – 16:00
End of clinic
meeting
All above staff
-
-
9:00 – 15:00
Soga Adult and
paediatric HIV
wellness and ARV
clinic
(ARV clinic only
9:00 – 15:00
Mqhele Adult and
paediatric HIV
wellness and ARV
clinic
(ARV clinic only
-
At PHC
-
9:00 – 15:00
Nkanya Adult and
paediatric HIV
wellness and ARV
clinic
(ARV clinic only
-
A separate paediatric clinic for HIV wellness monitoring, ART preparation and ART initiation started at Xora CHC in July 2009.
155
nurses, CHWs and
Peer educators
16:00 – 17:00
Paediatric HIV
clinical meeting
and training
Professional staff
run by paediatric
HIV clinician
run every second
week)
HIV clinician and
pharmacy assistant
(once monthly),
Soga professional
nurses, Soga CHWs
and peer
educators
15:00 – 16:00
End of clinic
meeting
All above staff
Thursday
8:00 – 15:00
PMTCT clinic
Maternity clinician,
HIV dept nurses,
CHWs and peer
educators
16:00 – 17:00
PMTCT clinical
meeting and
training
Professional staff
run by maternity
clinician
9:00 – 15:00
Soga Adult and
paediatric HIV
wellness and ARV
clinic
(ARV clinic only
run every second
week)
HIV clinician and
pharmacy assistant
(once monthly),
Soga professional
nurses, Soga CHWs
and peer
educators
15:00 – 16:00
End of clinic
meeting
All above staff
Friday
8:00 – 11:00
Pap smear service
HIV Dept nurses
and 2 x CHWs
10:00 – 15:00
Preparation for
administration of
adult, paediatric
and PMTCT clinics
incl. ART initiation
and repeats
Administrator
ART overdue
patient follow up
home visits
Peer educators
-
156
run every second
week)
HIV clinician and
pharmacy assistant
(once monthly),
Nkanya
professional
nurses, Nkanya
CHWs and peer
educators
15:00 – 16:00
End of clinic
meeting
All above staff
9:00 – 15:00
Bomvana Adult
and paediatric HIV
wellness and ARV
clinic
(ARV clinic only
run every second
week)
HIV clinician and
pharmacy assistant
(once
monthly),Bomvana
professional
nurses, Bomvana
CHWs and peer
educators
15:00 – 16:00
End of clinic
meeting
All above staff
-
run every second
week)
HIV clinician and
pharmacy assistant
(once monthly),
Mqhele
professional
nurses, Mqhele
CHWs and peer
educators
15:00 – 16:00
End of clinic
meeting
All above staff
9:00 – 15:00
Hobeni Adult and
paediatric HIV
wellness and ARV
clinic
(ARV clinic only
run every second
week)
HIV clinician and
pharmacy assistant
(once monthly),
Hobeni
professional
nurses, Hobeni
CHWs and peer
educators
15:00 – 16:00
End of clinic
meeting
All above staff
-
18.14 Guideline for selection of peer educators/VCT counsellors and community health workers
Guideline for selection and management of lay counsellors (including community health workers,
peer educators and VCT counsellors) volunteering assistance to the Madwaleni HIV wellness and
ARV programme
Selection of peer educators and VCT counsellors
1. Potential peer educators and VCT counsellors are selected by the experienced peer educators from
their HIV support groups by the following process:
1.1.
Experienced peer educators select 2-3 active members of their HIV support groups and invite
them to attend the VCT and ART adherence counselling training provided by Aurum.
1.2. Upon completion of the 2 training sessions, the following persons vote by secret ballot for those
training attendees whom they think should be selected as peer educators (the top performers
during the training) and VCT counsellors (the next level of performers during the training):
- experienced peer educators
- all attendees of the training sessions
- HIV programme staff at Madwaleni
- Aurum trainer
1.3
The number of votes for each category is based on the staffing needs of the HIV programme
and the funding available to pay the requisite stipends.
By way of example: where the HIV programme needs and has sufficient funding for 5 new peer
educators and 5 new VCT counsellors, the top five performers will be selected as potential peer
educators and the next five performers will be selected as VCT counsellors.
2. It is intended that VCT counsellors may progress to peer educators should they show the requisite
potential. Therefore when selecting new peer educators, the experienced VCT counsellors (from
previous selection processes) must also be considered.
Selection of community health workers (CHWs)
3. CHWs are selected by the following process (see in conjunction with guideline for appointing volunteers
to the OVC, HBC, HIV and Rehab programmes at Madwaleni Hospital):
3.1.
The HIV/OVC S&D manager meets with the headman for area surrounding Madwaleni hospital
and asks him to discuss the appointment of CHWs with the community and put the
communities’ recommendations forward;
3.2.
The headman will be encouraged to recommend community members who have already been
providing voluntary services, specifically the OVC supporters in his area (a list can be provided
by the OVC co-ordinator of such persons);
3.3.
The headman should be encouraged to recommend at least 3 persons for each place available;
3.4.
Such recommended persons should then be interviewed by the HIV/OVC S&D manager, the
HIV/ARV site co-ordinator together with the headman/representative from the community.
4. The members of the HIV support groups require that a person may only be selected as a CHW if such
person has undergone an HIV test (despite the HIV status remaining confidential at all times).
5. Once the CHW is selected, he/she will attend the Aurum provided VCT/ART adherence training
session.
Continued training period for peer educators and CHWs
6. Once invited by the HIV/OVC S&D manager to volunteer as a peer educator, each potential peer
educator joins the HIV team for a 2 month period of further training and contribution to the HIV
programme.
157
7. Each potential peer educator is allocated to a different experienced peer educator for each week of the
training period to observe and work with such person. At the end of each week, the experienced peer
educator is required to submit an evaluation of the experience gained by the potential peer educator to
the HIV/ARV site co-ordinator (see list of training experience required by completion of 2 month training
period)247.
8. The HIV programme will pay for the potential peer educator’s transport for the first month on a weekly
basis.
9. The potential peer educator will be given an incentive/stipend of R800 (or R200 less than the monthly
government stipend paid to CHWs) at the end of each month irrespective of whether they are selected
to continue to assist on a full time basis or not.
10. All potential peer educators will go through a medical examination in the first week of their month of
training by the HIV programme doctor. If the HIV programme doctor is satisfied with the person’s health,
he/she may continue with the training otherwise the HIV team will only reconsider once the person’s
health has improved.
11. After 8 consecutive weeks with the HIV team, potential peer educators will be considered by the current
HIV team. If all team members are in agreement, the person will be asked to volunteer their services
on a full time basis. If the team members are not in agreement, the person will be thanked for all their
hard work and motivated to continue their active role in their support groups. The person will be helped
to understand that they continue to be invaluable to the success of the HIV programme as a whole.
Stipends paid to full time peer educators/CHWs/VCT counsellors
VCT counsellors
12. VCT counsellors immediately upon selection become a member of the VCT outreach team. They will
be taken on for continued training and supervision by the nurse heading the VCT outreach team.
13. All VCT counsellors will go through a medical examination in the first week of after appointment onto
the VCT outreach team by the HIV programme doctor. If the programme doctor is satisfied with the
person’s health, he/she may continue to provide voluntary services to the VCT outreach time otherwise
the VCT outreach team will only reconsider once the person’s health has improved.
14. VCT counsellors will receive an incentive/stipend for their voluntary services. This stipend is calculated
per day worked (which is calculated as the monthly stipend paid to government community health
workers as a daily rate). In 2009 this amounted to R50 per day.
15. VCT counsellors are also reimbursed for their transport cost to the hospital/VCT testing site and a
stipulated amount for lunch while away from home248.
Peer educators
16. Once the peer educator volunteer on a full time basis, she/he will be given an incentive/stipend of
equivalent to R200 less than the government stipend paid to lay counsellors at ARV sites (CHWs). In
2009, this amounted to R800 per month (which assists in covering the person’s transport to and/or
rental cost at Madwaleni hospital).
17. After 12 months of volunteering peer educator services to the HIV programme on a full time basis or
earlier if there has been exceptional performance, the peer educators will be given an incentive/stipend
247
In January 2010, the HIV programme appointed 2 of the experienced peer educators to take on this training and mentoring
role full time.
248
R10 in 2009
158
equivalent to the government stipend paid to lay counsellors at ARV sites (CHWs). In 2009, this
amounted to R1000 per month.
CHWs
18. CHWs are paid a monthly incentive/stipend as determined by the Eastern Cape Department of Health.
In 2009, this amounted to R1000 per month249.
Telephone expenses for VCT counsellors/peer educators and CHWs
19. VCT counsellors/peer educators and CHWs are often asked by HIV programme patients to call them to
provide input or assistance.
20. Each VCT counsellor/peer educator/CHW can motivate to the HIV/ARV site co-ordinator for the HIV
programme to make a contribution to their telephone expenses.
21. Once the ARV site co-ordinator has agreed, such person will receive reimbursement for a fixed amount
of airtime (R2009 - R60 per month).
Lunch provided to all stipended volunteers
22. All stipended volunteers are provided with one nutritious meal per day of work for the HIV
programme250. This meal is prepared at the hospital and made available in the HIV department’s
kitchen.
HIV programme obligation to pay stipends to peer educators/VCT counsellors
23. The HIV programme only carries an obligation to continue to pay the above incentives/stipends to the
peer educators and VCT counsellors for the period that it receives donor funding to do so.
Leave for peer educators/CHWs
24. Each peer educator/CHW will be entitled to the following annual leave per year:
24.1. 2 weeks leave during the year at a time agreed with the HIV/ARV site co-ordinator taking into
consideration the demands of the HIV programme.
24.2. 1 week leave during December at a time agreed with the HIV/ARV site co-ordinator taking into
consideration the demands of the HIV programme.
25. Each peer educator/CHW will be entitled to the following sick leave per year:
25.1. 2 weeks sick leave provided that in the case of peer educators, the HIV programme doctor has
seen the peer educator and agreed to sick leave.
25.2. Due to the HIV status of the peer educators, the HIV programme doctor may recommend further
sick leave for the peer educator’s long term wellbeing, however no incentive/stipend will be paid
during this period.
249
This stipend is very small for the amount of work that is being done and much lobbying is being done to have it increased.
However all stipends paid by the HIV, OVC and HBC programmes are linked to the government stipulated stipend to ensure
parity. Other programmes have experienced significant problems in sustaining HIV services by paying peer educators on a
different pay scale to CHWs.
250
Introduced January 2010.
159
18.15 HIV pre and post-test counselling protocols
THE HIV PRE-TEST COUNSELLING
PROTOCOL
1. INTRODUCTION:
1.1
Introduce yourself, explain your role and the VCT process.
1.2
Discuss confidentiality.
2. MOTIVATION FOR TESTING & RISK REDUCTION:
2.1
Explore reasons for testing and client’s history.
2.2
Discuss client’s sexual risk behaviour and risk reduction options.
2.3
Advantages and disadvantages of testing.
2.4
Window period and its impact on results.
2.5
Check client’s understanding of the above.
3. BASIC HIV/AIDS EDUCATION:
3.1
Explain and discuss what HIV and AIDS is, HIV transmission, prevention, safe sex,
3.2
HIV medication in the form of ART.
4. RESULTS-IMPLICATIONS:
4.1
Discuss feelings about possible results.
4.2
Discuss imagined consequences of a +ve/-ve result.
4.3
Discuss and identify possible supportive people.
4.4
Discuss disclosure.
4.5
Discuss joining the closest HIV support group – determine where the person lives
and which is the closest support group to patient’s home and which days and times it
runs.
5. DISCUSS RAPID TEST
5.1 What it measures
5.2 Accuracy
5.3 How the test is done
5.4 How the result will be given
6. CONSENT:
6.1
Make sure the client understands completely what the test means and what will
happen to them in their own terms, not yours.
7. ALLOW TIME FOR QUESTIONS
160
THE HIV POST-TEST COUNSELLING
PROTOCOL
1.
PREPARING CLIENT FOR RESULT:
1.1
Re-introduce yourself and confirm personal details of client
1.2
Confirm that client is ready to receive HIV test result
1.3
Clarify meaning of +ve versus –ve results
1.4
Give HIV results client
2.
IF HIV NEGATIVE:
2.1
Explore client’s reaction to the test result.
2.2
Review the meaning of the result. Does client understand?
2.3
Help client to consider result in terms of most recent risk exposure and remind about
window period.
2.4
Inform client that he/she should test again after 3 months to cover the window period
and provide with a date.
Risk Reduction & Staying HIV negative
2.5
Emphasize importance of planning to reduce risk
2.6
Explore practical risk reduction.
2.7
Discuss disclosure issues and partner status.
2.8
Emphasize prevention.
3.
IF HIV POSITIVE:
3.1
Follow client’s reaction, do not control or lead discussion.
3.2
Be there on client’s terms. Don’t rush.
3.3
Allow client to absorb result.
3.4
Review meaning of result. Does client understand?
3.5
Acknowledge challenges of dealing with a positive result.
Consider if client is able to absorb the following details. If not arrange a follow
up.
Personal Support
3.6
Identify and discuss people who can offer support.
Plan next step
3.7
Encourage the client to ask questions at this time if they want to.
3.9
Confirm again which HIV support group is closest to the patients home and
encourage them to attend. This will also be a place where they can ask further
questions that the person may have later on.
3.10 Give client option to schedule another individual counselling session he/she feels
that they are not ready to attend the HIV support group.
3.10 Ask the client whether they would be happy for you to call him/her in a week or two
to answer any of their questions and provide any further assistance (remember to
get a correct telephone number/address).
161
18.16 VCT statistic monthly record submitted by PHC to Madwaleni HIV programme
VCT statistics record for Xora clinics to be supplied to Madwaleni HIV programme
Name of clinic:
Month
Total Tested
Adult Male
Adult Female
Child Male (between 18
month and 14 years)
Child Female (between 18
months and 14 years)
Total HIV+
Adult male HIV+
Adult Female HIV+
Child Male (between 18
months and 14 years) HIV+
Child Female (between 18
months and 14 years) HIV+
Total Antenatal women
tested (include in Female
tested above)
Total Antenatal women
tested HIV+ (include in
Female tested HIV+ above)
Total PMTCT referral
consent forms received*
Total PCR male (children
under 18 months)
Total PCR female (children
under 18 months)
PCR male HIV+ (children
under 18 months)
PCR female HIV+ (children
under 18 months)
Bomvana
Jan-07 Feb-07
Mar-07 Apr-07 May-07
Jun-07
Jul-07
Aug-07
Sep-07
See PMTCT section for explanation
162
Oct-07
Nov-07
Dec-07
18.17 Summary of monthly PHC VCT statistics
Summary - VCT statistics Xora clinics Only for example purposes –
unreliable statistics
Total Tested
Adult Male
Adult Female
Child Male (between 18 month and 14 years)
Child Female (between 18 months and 14 years)
Total HIV+
Adult male HIV+
Adult Female HIV+
Child Male (between 18 months and 14 years)
HIV+
Child Female (between 18 months and 14 years)
HIV+
Total % HIV +
Total Antenatal women tested (include in
Female tested above)
Total Antenatal women tested HIV+ (include in
Female tested HIV+ above)
Total % HIV +
Total PCR male (children under 18 months)
Total PCR female (children under 18 months)
PCR male HIV+ (children under 18 months)
PCR female HIV+ (children under 18 months)
Bomvana
Nkanya
October 2007
Soga
Xora
143
19
57
137
18
117
126
21
104
31
36
6
1
5
1
1
9
1
8
0
Vukukhanye
Mqhele
Melitafa
Total
81
23
26
40
3
37
21
3
18
29
3
26
577
90
385
1
0
17
12
15
1
9
2
6
0
0
14
2
12
0
0
3
0
3
0
0
3
2
1
33
38
61
20
50
0
0
0
0
0
0
0
0
4.20%
1
6.57%
0
13.49%
1
11.11%
0
35.00%
0
14.29%
0
10.34%
2
10.57%
23
28
27
31
24
12
19
164
3
13.04%
8
28.57%
7
25.93%
2
6.45%
10
41.67%
3
25.00%
3
15.79%
36
21.95%
1
2
0
0
1
1
0
1
1
0
0
0
3
4
0
0
0
0
0
0
0
0
0
0
0
0
0
0
6
7
0
1
Well done to Bomvana clinic this month for testing the most community members in October and also showing the
biggest increase in HIV testing since last month! Well done Mr Willie, Sister Lisa and Mr Nhlatywa!
163
18.18 Checklist for VCT community outreach
CHECKLIST FOR VCT COMMUNITY OUTREACH
1. 1-3 tents (depending on VCT testing sites and weather)
2. 2 fold-up tables
3. 14 chairs
4. VCT outreach box containing:
4.1
English VCT consent forms (50)
4.2
Xhosa VCT consent forms (50)
4.3
VCT stat forms (6)
4.4
2 black markers
4.5
3 in-trays
4.6
100 webcols/cotton wool swabs
4.7
antiseptic (alcohol based)
4.8
100 lancets/needles
4.9
100 first instance rapid tests
4.10
30 confirmatory rapid tests
4.11
condoms (female and male)
4.12
referral forms for client testing HIV positive from another area
4.13
information cards on adolescent support group
4.14
information pamphlets on HIV, condom usage, ART, PMTCT, nutrition etc
5. sharps container
6. other container for waste
164
Pre – test counselled
seated waiting to be
seated
VCT counsellor 1
Counselling tent 1
165
Rapid test done waiting for results
Pre – test counselled seated waiting
for rapid testing
Waiting for pre-test counselling
Waiting for pre-test counselling
18.19 VCT outreach testing site layout
VCT counsellor 2
Counselling tent 2
Professional nurse
HIV testing tent
No man zone managed by
VCT counsellor 3
18.20 VCT consent form in English and Xhosa
English version: VOLUNTARY COUNSELLING AND HIV TESTING PROGRAMME
CONSENT FORM TO TEST FOR HIV
CLIENT’S NAME………………………………………………………………………….
PRE-TEST COUNSELLING DONE BY…………………………………………………..
I,………………………………………………………..(Client/Parent/Guardian), having been given pre-test
counselling by the above named person:
a) Feel that I have been fully informed about the Human Immunodeficiency Virus (HIV);
b) Feel that I have been fully informed about HIV testing;
c) Understand that I will able to have my HIV test results within 15-30 minutes and find this
satisfactory;
d) Give my consent, without reservation and without coercion, to the performing of tests for HIV.
SIGNATURE OF CLIENT …………………………………….. DATE………………….
(In case of a minor or incompetent person, signature of Guardian/Parent)
SIGNATURE OF COUNSELLOR ……………………………...DATE…………………
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Xhosa version: IMVUME YOKUBA NDICACISELWE, NDAMKELE UKUBA NDIHLOLWE IGAZI LAM
KUJONGWE UKUBA ANDOSULELEKANGA NA YINTSHOLONGWANE KAGAWULAYO
IGAMA LOMNTU OVUMAYO…………….......................................................……………………..
IGAMA LOMNTU OWENZA INGCACISO…………………….....................................................…
Mna ………………………. (igama lovumayo okanye umzali)
a) Ndiyavuma ukuba ndixilongwe igazi lam kuba ndicaciselwe ngokwaneleyo ngo gawulayo (HIV).
b) Ndivuma ukuba ndicaciselwe ngkwaneleyo ngendlela uhlolo oluzakwenziwa ngayo.
c) Ndacaciselwa ukuba iziphumo zohlolo ndiyakuzifumana emva kwemizuzu nje eyi (15 – 30)
yandanelisa lo nto kuba ayichithi xesha.
d) Ndivuma ukuhlolwa ndanelisekile ndingenangxaki ukuba mandihlolwe ugawulayo
Intsayino gama ngovumayo okanye umzali………………………. Umhla……………….
(ukuba ngumntwana okanye umntu ongenakho ukunika imvume kubhala umzali okkanye oswle abazali)
Intsayino gama ngucebisi…………………..........................………. Umhla……………….
166
18.21 VCT data collection stat sheet
Replace with revised version:HIV Counselling and Testing Register
Date:
Name of Department:
Sex
No
.
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Name (Last, First)
Age
M
F
Referral
Med
Self
Service Attended
Antenatal
TB
STI
Totals
167
Accept
Test
YES
NO
Screening
Test
Pos
Neg
HIV Test Results
Confirmatory
Test
Pos
Neg
ELISA
Pos
Neg
Comme
nt
18.22 Referral letter
Province of the Eastern Cape. Iphondo leMpuma-Koloni
Department of Health. Isebe LezeMpilo
DEPARTMENT VAN GESONDHEID
MADWALENI HOSPITAL
Private Bag / Ingxowa Eyodwa X519, ELLIOTDALE, 5070
Batho Pele / People First / Abantu KuQala
Referral to:
__________________________________
From:
Sister XXX
Date:
__________________________________
To whom it may concern
REFERRAL OF _____________________________________________________
Please be advised that I tested the above client for HIV on ____________________ as part of our VCT community
outreach. The client’s HIV rapid test result was reactive.
This client does not live in the Madwaleni Hospital catchment area and has requested me to refer him/her to your
health facility for continued follow up and support.
I have encouraged the client to attend HIV support group if your facility offers this service.
I also request that you take the patient’s baseline blood investigations including an ELISA and CD4 count.
Should you have any questions in the above regard, please contact me on XXX.
Yours sincerely
____________________________
Sister XXX
Nursing Sister
Madwaleni HIV Wellness and ARV programme
168
Madwaleni Hospital
18.23 Invitation to adolescent HIV support group
Dear ____________________
You are invited to join us for our next group
meeting where we learn, grow & have fun together !
Venue: Madwaleni Hospital VCT
Time: 3pm
Dates: 16 October 2008
30 October 2008
13 November 2008
27 November 2008
11 December 2008
We look forward to seeing you there!
For more information contact: Anele 083 986 1008
Dear ____________________
Uyamenywa ukuba ube kunye nathi xa sinomnye umhlangano
apho sifunda, sikhule, sisonwaba kunye.
Indawo: Esibhedlele/Madwaleni Hospital (VCT)
Ixeshe: 3pm
Imihla:
16 October 2008
30 October 2008
13 November 2008
27 November 2008
11 December 2008
Sijonge phambili ekubeni sibonane apho !
Ngolwazi olungaphezulu hlangana no-Anele kule nombolo:
169 079 535 3001. Lindiwe 083 986 1008
18.24 Example of annual VCT statistics
Madwaleni hospital - VCT Statistics
2008/2009
Medically referred
Self referred
Tested
Female Tested
Male Tested
Tested positive
% positive tests
Tested negative
% negative tests
Mar08
65
286
360
280
80
53
14.72
%
307
85.28
%
Apr08
52
352
404
309
95
43
10.64
%
361
89.36
%
May08
21
502
523
430
93
62
11.85
%
461
88.15
%
Jun08
29
434
463
295
168
35
Jul-08
32
568
600
386
214
57
7.56%
428
92.44
%
9.50%
543
90.50
%
Aug08
40
530
570
423
147
60
10.53
%
510
89.47
%
Sep08
17
308
325
228
107
49
15.08
%
276
84.92
%
Oct08
49
237
286
205
81
40
13.99
%
246
86.01
%
Nov08
32
388
420
287
133
46
10.95
%
374
89.05
%
Dec08
25
442
467
345
122
53
11.35
%
414
88.65
%
Jan09
55
285
340
234
106
47
13.82
%
293
86.18
%
Feb09
45
361
406
272
134
51
12.56
%
355
87.44
%
Total
462
4693
5164
3694
1480
596
11.54
%
4568
86.45
%
Madwaleni hospital and feeder primary healthcare clinics - VCT Statistics
2008/2009
No. of Clinics included
Tested
Female Tested
Male Tested
Tested positive
% positive tests
Total Antenatal women tested
Total Antenatal women tested HIV+
Total % HIV+
Total Antenatal women tested (incl maternity)
Total Antenatal women tested HIV+ (incl
maternity)
Total % HIV+ (incl maternity)
Mar08
7
837
643
194
133
15.89
%
112
15
13.39
%
119
17
14.29
%
Apr08
7
1216
924
293
118
9.70%
172
36
20.93
%
174
May08
7
1110
866
244
163
14.72
%
180
36
20.00
%
182
Jun08
7
971
674
297
123
12.67
%
165
30
18.18
%
166
Jul-08
7
1248
907
341
138
11.06
%
222
41
18.47
%
224
Aug08
7
1123
842
281
138
12.29
%
160
31
19.38
%
162
Sep08
7
844
615
239
132
15.64
%
133
25
18.80
%
135
Oct08
7
768
592
176
96
12.50
%
108
13
12.04
%
113
Nov08
7
1529
1040
489
156
10.20
%
140
32
22.86
%
142
Dec08
7
909
668
241
103
11.33
%
140
25
17.86
%
140
Jan09
7
881
637
246
139
15.78
%
181
43
23.76
%
184
Feb09
5
899
669
230
109
12.12
%
140
26
18.57
%
140
12335
9077
3271
1548
12.55
%
1853
353
19.05
%
1881
36
20.69
%
37
20.33
%
32
19.28
%
41
18.30
%
31
19.14
%
26
19.26
%
16
14.16
%
32
22.54
%
25
17.86
%
44
23.91
%
28
20.00
%
365
19.40
%
170
Total
18.25 VCT outreach follow up register
Date of HIV
testing
Testing location
Name
Surname
02/08/2009
Ntlonyana Store
Mandla
Bodlani
Consented to
follow up
Date joined HIV
wellness
programme
Telephone
number
Detailed address Follow up dates
15/8/2009 - telephone
discussion
23/8/2009 - telephone
discussion
15/9/2009 - telephone
Yes - telephone only O842405671
discussion
1/10/2009
18.26 VCT outreach outcomes evaluation tool
Period of target evaluation
1 March – 30 May 2009
1 June – 31 August 2009
1 September 2009 – 30
November 2009
1 December 2009 - 28 February
2010
Length
of
period
90 days
90 days
90 days
# VCT community
outreach days for
period
# of clients tested at
VCT outreach
# of
clients
tested
HIV+ at
VCT
outreach
Target Achieved Target Achieved Actual #
18
19
750
880
70
21
900
# of HIV+
clients who
joined HIV
programme
25*
Conversion rate
Set up of new VCT
outreach testing
points
Target Achieved
Target Achieved
50%
35.71% *
2
55%
2
2
23
1000
60%
2
25
1100
65%
2
90 days
*Please note that # of HIV+ clients who joined the HIV wellness programme and the conversion rate is only evaluated 3 months after the end of the HIV testing period
concerned e.g. in the period 1 March – 30 May 2009, 70 clients tested HIV positive. 3 month later on 31 August, the number that joined the HIV wellness programme (25) is
determined together with the conversion rate (35.71%).
171
18.27 List of HIV support group topics for 2009
Date
2 - 14 Feb
16 - 28 Feb
2 - 14 Mar
Topic
Resistance to ARVs (only 2 ARV regimens) and process after defaulting
Process for transferring in and out of ARV programme
Bringing in family members/friends with HIV early for assistance
16 - 28 Mar
Sexually transmitted infections (STIs): screening for STIs and bringing in
your sexual partner for treatment of an STI
31 - 10 Apr
13 - 24 Apr
Condom use - increased condom usage and assistance with community
distribution initiative
Pregnancy and HIV
27 - 8 May
11 - 23 May
1 - 13 June
Testing our children for HIV: How children can be infected with HIV, PCR
and Elisa testing.
What to do if your child tests HIV positive
Importance of pap smears as screening for cervical cancer
TB and HIV - INH prophylaxis
15 - 27 Jun
Early signs and symptoms of opportunistic infections:
- shingles (herpes zoster)
- Karposi sarcoma
- meningitis
- rashes
- thrush
- UTIs
30 Jun - 10
Jul
Breastfeeding vs formula feeding (advantages/disadvantages of both)
13 Jul - 24 Jul
27 Jul - 7 Aug
10 - 21 Aug
Patient journey education: Why support group, when to have bloods
investigations taken, checking your blood results - what do these results
mean?
Patient education on side effects (short term and long term)
Disability grants - who qualifies
24 Aug - 4
Sept
7 - 18 Sept
14 - 25 Sept
Patient education on ART medication - do not to accept any change to
medication (dose or appearance) without understanding why there is a
change.
Xhosa medicine and ARVs
Encouraging your sexual partner to test for HIV.
28 Sep - 9
Oct
What is IRIS (immune reconstitution inflammatory syndrome)? What
symptoms can we identify early and tell the nurse/doctor about.
172
18.28 Peer education training information
Condom usage and distribution
Condom usage – interactive discussion format
1. Why is it important to use condoms when we are HIV positive?
- Protect our partner from contracting HIV if our partner is HIV negative
- Protect ourselves from re-infection by our partner who is HIV positive
- Reduce STIs which we contract from our partners which we discussed for the last month of support
group
2. Discussion group to understand what obstacles prevent our patients from routinely not using condoms?
Examples
- No easy access to condoms?
- Partner does not want to use condoms?
- We do not like to use condoms ourselves?
- Are we worried that we cannot fall pregnant if we use condoms?
- Other reasons – get input from the support group members so that we can understand?
3. What suggestions can we give or assist with these obstacles?
- Condom distribution points in the community (see below)
- Open discussion with partner about risks of unprotected sex to their health/use of female condoms
- Discussion with regard to consulting our doctors on planning pregnancy and reducing risk involved
in having unprotected sex
- What other suggestions can we make?
Condom distribution
-
-
We want to establish condom distribution points at spaza shops and sheebeens in all the villages
which our support group members come from – we need your help.
Lets identity volunteers in each support group who are willing to:
o discuss stocking of free condoms with their spaza shop owner/sheebeen owner
o take a poster and box of condoms and put it in their spaza shop/shebeen
o monitor when it is finished and get replacement box from our peer reducator
Write down the patient’s name, telephone number and which distribution point such person will take
responsibility for.
Supply such persons with 2 boxes of condoms and a poster each.
173
ART patients – transfer out of Madwaleni HIV
1.
Last week we discussed:
a. You need to take ARVs every day for the rest of your life – ‘yonke mihle bomi bakho bonke’
b. If you default on taking your ARVs at the correct time each day – you will become RESISTANT to
the ARVs and the ARVs will no longer keep the HIV under control/sleeping in the body
2.
It is important to know that all hospitals and clinics in South Africa DO NOT HAVE ARVs!
3.
Where a hospital or clinic does have ARVs, the staff will not give you the ARVs unless you have the
correct transfer documents from Madwaleni hospital.
4.
It is therefore very important that if you want to leave the Madwaleni/Xora area to find work or for other
personal reasons that you make arrangements with the Madwaleni HIV programme staff.
5.
It is better for your health not to request a transfer before you have been on ARVs for at least 6 months
and had your first blood checks. The Madwaleni doctor and nurses can check your blood results and
make sure that your CD4 count has increased (amajoni omzimba onyukile) and viral load is
undetectable (ayibonakali).
6.
It is dangerous to transfer before 6 months on ARVs as we will not know if the ARVs are working
properly and if the HIV in your body is under control. If you go away you may become sick and you
may not be able to get assistance at the hospital/clinic where you are.
7.
If you want to transfer, it is very important that you come to the office at Madwaleni HIV department
and ask for a transfer. When you come, you must at least know the area where you are going and try
to find out which is the closest hospital or clinic.
8.
We will then phone the hospital or clinic and arrange that you are accepted as a patient there and that
they will give you ARVs when you go there. We will give you transfer documents which will include all
your blood results and details of your ARVs.
9.
You must look after these transfer documents carefully and give them to the nurse at the hospital or
clinic that you are going too.
10. You can also ask for a transfer if you are not on ARVs. We will help you find a hospital or clinic that will
look after you until you need ARVs. We will also send your transfer documents with all your blood
results to help them care for you.
11. PLEASE DO NOT LEAVE THE MADWALENI/XORA AREA WITHOUT ASKING FOR A TRANSFER.
You may get to the place where you are going and not find a hospital that will give you ARVs. This will
cause you to default your treatment. This means you will become resistant to your ARV treatment.
Every time you default there is less chance that the ARVs will work for you the next time and your HIV
will then become uncontrolled/out of sleep and you will become sick.
12.
Let us work together in making sure that you stay on
your ARV treatment for every day for the rest of your life no matter where you are in South Africa!
174
Note on shingles for discussion in HIV support group
1. Shingles is caused by a virus that affects us at a young age
2. It sits in the nerve cells and stays there for a long time – it is controlled by the body’s immune
system.
3. If the immune system is weakened by disease like HIV, severe stress or old age, it starts to
show up causing shingles.
4. If someone had chicken pox in childhood they may develop shingles when their immune
system is weakened in adulthood.
5. When shingles starts it gives a burning sensation – this is time for treatment! Do not wait
for the blistering.
6. Shingles affects the nerve band, that’s why we find it in a band on one side of the body.
7. It is treated with a drug called Acyclovir which is given 5 times a day for 5 days – all the clinics
have this treatment.
8. The earlier shingles is treated – the more effective the treatment is! In addition, if we treat
shingles early it helps in preventing the long term pain which many people experience who
have had shingles.
9. The nurses and peer educators need to inform patients of the dangers of shingles when it
affects the face especially in the eye and nose area as it can cause blindness
10. There is treatment for the pain caused by shingles.
11. Shingles is infective - people that have not had chicken pox (both adults and children) are at
risk of getting chicken pox from a person who has shingles.
175
18.29 Adult HIV wellness form – page 1
HIV PATIENTS CLINICAL FOLLOW UP RECORD (CONFIDENTIAL)
First name
Surname
Folder number
Date of birth
Female/Male (F/M)
Telephone number
Physical Address
Closest clinic to home
Name of treatment partner
Date informed HIV positive
Where was patient tested?
Patient counselled on HIV+
status? (Y/N)
Date first attended support
group
CD4 count history (if any)
Previous CD4 count (if known)
Date of above CD4 count (if
known)
Known allergies
ARV history before first visit
Previous ARVs? (Y/N) (incl.
NVP in labour)
Detail which ARVs
Have a sexual partner/s?
(Y/N)
Partner/s
Where do he/she live?
Healthy? (Y/N/Deceased(D))
Informed of HIV status? (Y/N)
Tested? (Y/N)
Positive(P)/Negative(N)
Folder number
VCT outreach / clinic / ante-natal at clinic / OPD / hospital ward /
HIV dept / other ..........................................................................
COMPLETED BY PEER
EDUCATOR WHEN PATIENT
FILE OPENED
Partner 1
Partner 2
Partner 3
Partner 4
Child 1
Child 2
Child 3
Child 4
Other information
Have children? (Y/N)
Children
Name
Birth date
Where do they live?
Child grant? (Y/N/Applied(A))
Healthy? (Y/N/Deceased(D))
Tested? (Y/N)
176
Positive(P)/Negative(N)
Folder number
Other information
Medical history (NB gynae/surgery if applicable)
RX
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Date of death
Place of death
Cause of death (dr to complete)
Start date
Stop date
(if
applicable)
COMPLETED BY NURSE AT
FIRST CONSULTATION AND
THROUGHOUT CLINICAL
MONITORING OF PATIENT BY
NURSE/DOCTOR
COMPLETED BY DOCTOR/NURSE/ADMIN
ONCE INFORMED OF PATIENT DEATH
177
18.30 Adult HIV wellness form – page 2
Wellness visit 1
Insert date
Weight (in kg)
Loss in weight >3kg since last visit
(Y/N)?
TB symptoms? (Y/N)
Using family planning? (Y/N/NA) (excl.
condoms)
Used condoms since last visit?
(Y/N/NA)
Are you currently pregnant? (Y/N/NA)
If pregnant, PMTCT done? (Y/N)
Made disclosure to partner? (Y/N/NA)
Made disclosure to children? (Y/N/NA)
Made disclosure to others? (Y/N/NA)
Are you taking any Xhosa medicine?
(Y/N)
Nutrition
Are you eating a balanced diet (Y/N)
Given nutritional supplements at this
visit? (Y/N)
Drink alcohol frequently (Y/N)?
Disability grants
Getting a disability grant? (Not eligible
(NE), Not applied (NA), Waiting (W),
Received (R))
If not and qualifies, referred to social
worker? (Y/N)
Cotrimoxazole (Bactrim)
Bactrim pill count correct? (Y/N/NA)
Number of Bactrim pills given at this
visit?
If not using Bactrim - due to stage1
(WHO1) or Dr decision (DD)?
Referred to a hospital since last
visit? (Y/N)
If so, Madwaleni (M), NMH (N), Other
(O)
Days in hospital
Diagnosis at admission
Concurrent TB? (Y/N)
New case (NC), Retreatment (RT),
Failure (RF), Interruption (RI)
Adherent to TB Rx? (Y/N)
Intensive(I)/Continuation(C) phase
Number of Months
Investigations
CD4 (per uL)
CD4%
Month for next CD4
Patient health complaints? (Y/N)
Referred to nurse? (Y/N)
Name of counsellor:
Next visit date:
Wellness visit 2
Wellness visit 3
COMPLETED BY PEER EDUCATOR
EACH TIME CAREGIVER ATTENDS
HIV WELLNESS PROGRAMME
WITH CHILD
(PRIOR TO ART START)
178
Wellness visit 4
18.31 Paediatric and Adult HIV wellness form – page 3
Wellness visit 1:
Patient history
Date:
List danger signs/red flags
Nurse action/prescribed Rx
1.
Weight:
2.
3.
4.
Refer to dr: □
Doctor notes:
Wellness visit 2:
Patient history
Date:
List danger signs/red flags
Nurse action/prescribed Rx
1.
Weight:
2.
3.
4.
Refer to dr: □
Doctor notes:
Wellness visit 3:
Patient history
Date:
List danger signs/red flags
Nurse action/prescribed Rx
1.
Weight:
2.
Refer to dr: □
Doctor notes:
179
3.
4.
18.32 Cotrimoxazole pill count training sheet
BACTRIM (COTRIMOXAZOLE) PILL COUNT CHECK
1.
2.
3.
4.
5.
Number of Bactrim pills given to patient at last visit?
How many days since last visit (including today, excluding day of last visit)?
Number of Bactrim pills patient should have taken since last visit?
Number of Bactrim pills patient should have left?
Actual number of Bactrim pills patient has left?
FILE QUESTION: IS PATIENT’S BACTRIM PILL COUNT CORRECT?
YES – IF CORRECT or 2 PILLS LESS or 2 PILLS MORE
NO – IF ANYTHING ELSE
EXAMPLE
Patient X received 40 Bactrim pills on 1/2/2005. He returns for his next visit on 15/2/005. He has 16 tablets left
which he hands back to Sister Willie.
1.
2.
3.
4.
5.
Number of Bactrim pills given to patient at last visit? 40
How many days since last visit? 14
Number of Bactrim pills patient should have taken since last visit? 28 (14x2)
Number of Bactrim pills patient should have left? 12 (40-28)
Actual number of Bactrim pills patient has left? 16
IS PATIENTS PILL COUNT CORRECT?
NO
Reason: Not within acceptable range 10-14
18.33 Cotrimoxazole pill count form
DATE:
Number of Bactrim pills given to patient at
last visit?
How many days since last visit (including
today, excluding day of last visit)?
Number of Bactrim pills patient should have
taken since last visit?
Number of Bactrim pills patient should have
left?
Actual number of Bactrim pills patient has
left?
IS BACTRIM PILL COUNT CORRECT?
180
18.34 Protocol for Cotrimoxazole prophylaxis – HIV positive adults
Co-trimoxazole (Bactrim®) Prophylaxis in HIV positive adults251
Cotrimoxazole is preventative therapy against pneumocystis cerinii (jiroveci) pneumonia (PCP) and
toxoplasmosis, as well as bacterial infections.
1. Who should receive Co-trimoxazole?




Any HIV positive adult (rapid test/Elisa +ve documented) who is classified as stage 2, 3 or 4 on
the World Health Organisation staging of HIV infection, remembering that once a patient is
classified on a clinical presentation, he/she does not return to the previous stage of recovery.
Any HIV positive adult not receiving anti-retrovirals with a documented CD4 count of <500
cells/mm3.
Any HIV positive adult receiving anti-retrovirals who has an unconfirmed CD4 count <350
cells/mm3 for a period of three months.
Any HIV positive adult receiving anti-retrovirals who has previously stopped taking
Cotrimoxazole (see above), but then suffers clinical and/or immunological treatment failure,
presenting with stage 3 or 4 illness and/or drop in CD4<350 cell/mm – restart Cotrimoxazole.
2. Contra-indications
 Cotrimoxazole is contra-indicated in the first trimester of pregnancy (possible congenital cardiac
defects) and during lactation, in newborns, and in patients with severe liver and renal disease.
3. Drug Dosage:
 Co-trimoxazole treatment should be administered ONCE DAILY, EVERYDAY of the week.
 Dose is two normal strength 480mg tablets (80mg/400mg TMP/SMX), alternatively one double
strength (DS) tablet of 960mg (160mg/800mg TMP/SMX)
4. When can prophylaxis be stopped?
 Any adult taking anti-retrovirals who has a confirmed documented CD4 count >350cells/mm3 for
> 3 months.
251
Madwaleni specific protocol.
181
18.35 Nurses guideline for clinical visit when patient joins HIV wellness programme
First HIV wellness clinical visit
When a patient has a pink file opened by a peer educator, the patient must see the nurse at that visit to:-
1. Look for signs of opportunistic infections particularly TB which means
 Ask the patient to volunteer any problems
 Ask TB screening questions
 Ask about STI symptoms
 Proceed depending on the answers given
2. Offer nurse level counselling on any aspect of HIV but particularly
 Ask about disclosure of status
 Ask about barriers to coming to support group
3. Check that any children under 8 years have had an HIV test
4. Fill in the previous medical history section of the file
5. Book for a Pap smear
6. Stop Cotrimoxazole (Bactrim) if CD4 is known and above 500.
182
18.36 Danger signs in adults
DANGER SIGNS IN ADULTS
Poor general appearance
New onset confusion
New onset inability to walk
Weight loss > 2kg per month
Pulse > 120 per minute
Respiratory rate > 30 per minute
Temperature >38.5
Blood pressure systolic <90 or diastolic <60
183
18.37 Red flag symptoms in adults
Red flag symptoms
Adherence




Often sends someone to collect ARV’s or comes late
Admits to missing several doses of ARV’s
Drinking excess alcohol
Non-disclosure of HIV status
Back pain / waistache
 Loss of feeling or weakness in arms or legs
 Incontinence of bowels or bladder
 Very painful when pressing on the vertebrae or deformity of the spine
Headache





Present for more than 2 weeks or severe pain
Fits
Persistent vomiting
Double vision
Neck stiffness
Diarrhoea / vomiting
 Blood in stool or vomit
 Remember danger signs!
Abdominal pain
 Lasting more than 2 weeks or severe pain
 Vaginal discharge / bleeding
 Pregnancy
Cough / short of breath / chest pain
 Lasting more than 2 weeks
 No response to amoxicillin for 5 days
 Blood in sputum
Rash
 Recently started new drug
184
 Feeling unwell or any temperature of 37.5 or above
 Involving the lips, mouth and eyes
18.38 Useful nurse protocols for HIV wellness – Syndromic management of STIs
Syndromic management of STI’s252
Vaginal discharge
Non-pregnant woman with no pain on moving cervix
Cefixime 400mg po stat
Doxycycline 100mg bd for 7 days
Metronidazole 2g stat
Pregnant woman with no pain on moving cervix
Cefixime 400mg po stat
Amoxicillin 500mg tds for 7 days
Metronidazole 2g stat
Evidence of vaginal cadidiasis
Clotrimazole pessary once at night (consider continuing for 3 days in the immunocompromised)
Non-pregnant women with lower abdominal pain +- vaginal discharge +- pain on moving the cervix
Ceftriaxone 250mg IMI stat
Doxycycline 100mg bd fro 14 days
Metronidazole 400mg tds for 14 days
Women who are pregnant, recently pregnant or very sick require admission and immediate
Ceftriaxone 1g IVI
Metronidazole 400mg
Genital ulceration
Benzathine penicillin 2.4 MU IMI stat
Erythromycin 500mg qds for 7 days (for 14 days if Pen allergic)
Aciclovir 400mg tds for 5 days
252
Eastern Cape STI syndromic management guidelines 2008.
185
Don’t forget pain relief!
Urethral discharge/dysuria in men
Cefixime 400mg po stat
Doxycycline 100mg bd for 7 days
If symptoms persist give metronidazole 2g stat
Scrotal swelling thought to be STI
Ceftriaxone 250mg IMI stat
Doxycycline 100mg bd for 7 days
186
18.39 Useful nurse protocols for HIV wellness – Diagnosing TB in HIV positive patients
Diagnosing TB in HIV positive patients
It is difficult to diagnose TB in patients with HIV because




The patient may not have a cough
The patient may not produce sputum
The sputum smears will often be negative
The chest X-ray is also sometimes normal
The TB is more likely to be outside the lungs (e.g. lymph nodes, brain, kidney)
Any patient coughing for more than 2 weeks but without Danger signs should have:


2 sputum’s sent for AFB’s
1 sputum sent for TB culture (this is very important)
Amoxicillin 500mg tads for 5 days
Features of TB other than cough / shortness of breath / chest pain







Weight loss
Anaemia
Lymph node swelling
Chronic headache
Chronic abdominal pain / swelling
Night sweats
Fevers
Any patient not responding to antibiotics or with Danger signs or other features of TB should have:





A thorough history and physical examination (by a doctor or specialist nurse)
+/- a CXR
+/- induced sputum
+/- lymph node biopsy
+/- fluid taken from chest / abdomen / lumbar puncture.
+/- ultrasound scanning
187
18.40 Routine blood investigations protocol
Schedule for blood taking and urinalysis (adult)
HIV wellness file opening visit- HIV ELISA, CD4, FBC, Cr, ALT, RPR, HepBsAg, urine dipstick
HIV Wellness patients- 6 monthly - CD4, FBC, Cr, ALT, RPR urine dipstick
ARV start date- CD4, FBC, Cr, ALT, RPR urine dipstick (only if not taken in last 3 months)
ARV patients- 6 monthly - CD4, FBC, Cr, ALT, RPR, viral load, urine dipstick
Additional monitoring bloods for specific regimens.
Nevirapine – ALT at start date, 2 weeks, 1 month, 2 months and 3 months
AZTFBC at 1 month, 2 months and 3 months
Tenofovir Cr at 1 month, 2 months and 3 months
Kaletra / Aluvia- Glucose, cholesterol, triglicerides after each 6 months of ARV’s
188
18.41 INH prophylaxis protocol
INH is for Wellness patients who have not had TB treatment in the
last 2 years but first we must rule out active TB
Ask:
Are you on ARV’s?
Have you had TB treatment in the last 2 years?
Cough for > 2 weeks?
Sputum?
Night sweats?
Fevers?
Weight loss?
Examine
Weight loss from file / OPD card?
Pulse above 100?
Pale?
If the answer to all 10 points above is NO prescribe
INH (isoniazid) 300mg daily for 6 months
Pyridoxine 25mg daily for 6 months
If the answer to ANY of the clinical points above is YES you need to investigate for TB / other illnesses.
189
18.42 ECDOH nutrition guideline for patients with HIV & AIDS
EXERT FROM THE NUTRTION SUPPLEMENTATION PROGRAMME – ECDOH DIRECTIVE 25/05/2006
TB, HIV&AIDS and DEBILITATING CONDITIONS:
Give food supplements based on BMI, and micronutrient(Vitamin/ mineral )supplement
ENTRY CRITERIA:
Please note:

Supplementation must be continued for only 6-8 months for TB patients if entered onto the
Nutrition Supplementation Programme.
 All HIV& AIDS clients with BMI less than 18.5 need nutritional supplementation.
 Children > 5 years < 18 years: When child’s weight drops over two consecutive months with TB
clients
 Adults > 18 years: BMI < 18,5 OR more than 10% and more unintentional weight loss during the
past six months, or 5% and more unintentional weight loss in three months.
 NB* All HIV & AIDS clients to receive micronutrient supplement regardless of BMI
 Adults – pre ART and on ART.(Incl children 10yrs & older)
 Give both food supplementation and micronutrient (Vitamin/ mineral supplements)
NB Food supplements should be issued as per BMI (see terms of reference)
 If presenting with other conditions which could have dietary implications e.g. diabetes, kidney
failure (renal insufficiency), cancer, etc refer to the nearest DIETICIAN for further
assessment before issuing any food supplements.
 Children 10 yrs & older to be treated as adults.
CHILDREN
Products available:
 Enriched supplement
 Fortified maize-meal
[Refer to the Recommended Quantities Table]
EXIT CRITERIA:
 No exit on micronutrient supplementation
 Food supplements – as per general exit criteria.
Successful:
 Children >5 -< 18 years who attain normal growth curve according to the growth chart within the
6 months period on the scheme for TB clients.
 Adults 18 years and above with a BMI > 20 with in the 6-8 months period on the scheme.
 HIV clients receiving HIV social grant and HHF secure.
Unsuccessful:
 Children >5< 18 years who do not attain a normal growth curve according to the growth chart
within the 6-8 months period for TB clients only.
 Adults 18 years with a BMI < 20
190
FOOD QUANTITIES.
ADULTS > 14 YRS
DISEASE CONDITION
Symptomatic HIV/AIDS ( Not on ARV’s)
AIDS on ARV’s
Pregnant on ARV’s
Pregnant not on ARV’s
Lactating on ARV’s
Lactating not on ARV’s
Pregnant women
Lactating women
TB Patients
Chronically ill (Cancer, etc)
AMOUNT/PORRIDGE
SERVING PER MONTH
3x1kg
3x1kg
3x1kg
3x1kg
3x1kg
3x1kg
3x1kg
3x1kg
3x1kg
3x1kg
NUTRIENT
SUPPLEMENT
2 x 1kg
2 x 500g packets
2 x 500g packets
2 x 500g packets
CHILDREN
AGE GROUP
0
3
6
1
3
6
- 3m
– 6m
– 12m
– 3yrs
– 6yrs
– 14yrs
DIAGNOSIS
INFANT FORMULA
AMOUNT
PORRIDGE
4 x 500g tins
6 x 500g tins
4 x 500g tins
nil
nil
nil
nil
nil
2x1kg
2 x 1kg
2 x 1kg
3 x 1kg
191
NUTRIENT
SUPPLEMENT
Nil
Nil
nil
1 x 1kg
1 x 1kg
18.43 Peer educator 12 point guideline to adherence counselling
MY GUIDE TO ADHERENCE COUNSELLING
1.
Introduce myself, establish a bond with the patient.
2.
Ask the patient if he/she wants to start taking ARVs and why?
3.
Ask the patient what the patient understands it means to be HIV positive? Explain anything the
patient has left out.
4.
Ask the patient what the patient understands about ARVs? Make sure the patient understands:
4.1.
ARVs will ‘kill’ most of the HIV in the patient’s body (called ‘undetectable viral
load’/’intsholongwane egazini’).
4.2.
This allows the body soldiers/amajoni omzimba (called CD4 cells) to get strong again and
fight of infection/illness.
4.3.
ARVs need to be taken every day for the rest of the patient’s life ‘bomi bakho bonke’.
4.4.
ARVs need to be taken every 12 hours to control the HIV.
4.5.
ARVs do not cure HIV, there are always places in the body where the HIV hides from the
ARVs. This is why the patient will always be HIV positive.
5.
Assist patient in choosing the most appropriate ARVs for him/her and teach him/her the names of
the ARVs.
6.
Assist the patient to choose a good time to take their ARVs. Discuss the patient’s daily routine to
select a good time for the patient (complete form: English patient time and ART choice/Xhosa:
patient time and ART choice).
7.
Explain to a patient what will happen if a patient does not take his/her ARVs correctly? Resistance
to the ARVs (the ARVs will stop working against the HIV), which means the HIV will increase again
and start killing the body soldiers again.
8.
Discuss patient ARV reminders:
8.1.
Treatment partner
8.2.
Cell phone/alarm
8.3.
Pill boxes (for literate patients)
8.4.
Patient treatment files (for literate patients)
9.
Ask the patient if there is anything that will make it difficult to take the ARVs or come to fetch his/her
next month’s supply of ARVs – help him/her by thinking of solutions to these problems.
10.
Discuss that ARVs like other drugs can have short term and long term side effects.
10.1. Not many people get side effects but we need to be aware of them.
10.2. Explain that all illness is not as a result of ARVs but could be an opportunistic infection or a
reaction to another drug.
10.3. Explain to the patient that if they feel ill, they need to continue taking their ARVs and come in
to see the nurse/doctor – the patient should not stop ART on their own.
11.
Discuss the importance of safe sex when a patient is on ARVs. Understand why the patient may
have problems practising safe sex, try to assist the patient with solutions.
12.
We are a team – the Madwaleni staff and the patient. If the patient has any problems, he/she needs
to let us know so that we can help.
192
REMEMBER TO SCHEDULE HOME VISIT
18.44 ART patient treatment file
The following 7 pages make up this file which the patient keeps with him/her.
English version
18.44.1
English cover page
ARV TREATMENT FOLDER
NAME: _________________________
START DATE: ___________________
193
18.44.2
English patient time and ART choice
WHAT IS THE BEST TIME TO TAKE MY ARVs EVERY DAY?
DATE:
NAME OF COUNSELLOR:
NAME OF TREATMENT
ASSISTANT:
WHAT AM I DOING?
WHAT ARE OTHER PEOPLE
DOING AROUND ME?
WHO IS WITH ME?
WHAT AM I DOING?
WHAT ARE OTHER PEOPLE
DOING AROUND ME?
WHO IS WITH ME?
MORNING
4 AM
5 AM
6 AM
7 AM
8 AM
9 AM
10 AM
NIGHT
4 PM
5 PM
6 PM
7 PM
8 PM
9 PM
10 PM
THEREFORE, THE BEST TIME TO TAKE MY ARVs IS:
____________ AM IN THE MORNING
____________ PM AT NIGHT
Efavirenz/Nevirapine? __________________
194
18.44.3
English: Side effect explanation
Understanding Your Treatment
Are The Drugs A Cure?
What Is Combination Therapy?
The current drugs are a treatment but not a cure. They stop the
progression of HIV and let your immune system start to repair itself, BUT
YOU STILL REMAIN HIV POSITIVE.
Combination therapy is the term used for using three or more drugs to
treat HIV. It is also called triple therapy or HAART (Highly Active Antiretroviral Therapy).
Even people who have been on combination therapy successfully for
several years still have small amounts of HIV in their bodies.
Do The Drugs Really Work?
This is often dormant in cells.
In every country that uses HAART, AIDS - related deaths and illnesses
have dropped dramatically.
What Is Adherence?
Adherence is the cornerstone of successful therapy. IT IS YOUR
Treatments work for women, men and children, and they work however
COMMITMENT TO FIGHTING HIV.
you were infected - whether sexually, through IV (intravenous) drug use,
or by blood transfusion.
What Are The Rules Of Taking Medication?
Taking drugs exactly as prescribed by your doctor will reduce the amount
1 x daily dosing means taking the prescribed drug every day at the same
of virus in your body to tiny amounts.
time (EVERY 24 HOURS)
Regular monitoring using blood tests checks that the drugs are still
2 x daily dosing means taking the prescribed drug EVERY 12 HOURS at
working.
the same time every day
How Long Will The Drugs Work?
Combination therapy has been used for over 10 years. Many of the
individual drugs have been studied for longer.
If you take the drugs in the prescribed manner you could use the same
combination for years.
Not following your doctors instructions can lead to drug failure and you
will have to start another (often stronger) combination.
What About Side Effects?
Many people worry about treatments because of the side effects:
Most side effects are usually mild
They can often be managed easily
The risk of serious side effects is very small
Most people find that treatments become an ordinary part of their daily
life
Ask your doctor about the most common side effects for the drugs you
are about to use.
Can I Change Treatments?
NOTE: WEEKENDS ARE NO DIFFERENT TO WEEKDAYS
TAKING DRUGS ON AN EMPTY STOMACH means no food (including tea,
coffee, juice or cool drink) for two hours before taking your drugs and at
least half an hour (sometimes longer - listen to your doctor) after your
prescribed drug.
Taking some of the drugs with food may help reduce the side effects and
improve the way they are absorbed (Follow your doctor's instructions)
Tips To Help:
Make sure you understand your treatment - if you are unsure ask your
doctor to repeat instructions
Take extra drugs if you go away for a few days
Keep a small supply where you may need them in an emergency - in
your car, in your handbag , briefcase
Get friends to help you if this is possible
Use an alarm (if there is one on your cellphone) or an alarm watch to
remind you
Get To Know Your Virus
The more you know, the more likely you will be successful.
This is something that must be discussed with your doctor. Most
treatments are fairly easy to follow but often the side effects may
concern you.
However you feel, DO NOT stop your treatment, take breaks in your
treatment OR omit doses without talking to your doctor.
195
18.44.4
English: Side effect explanation
Coping With Side Effects
Quality Of Life:
Much has been publicised about the side effects experienced by people
taking drugs to help fight HIV. In fact recent information from patients
shows that many of the side effects are not noticeable and when they
are, are relatively mild. It should be noted that ALL drugs have side
effects and these are normally recorded on the 'Product Insert', which
accompanies pills. Side effects therefore, you may notice, even extend to
'over the counter' products such as aspirin and paracetamol.
How are the symptoms affecting you? For example is the diarrhoea or
headache stopping you from working/going out?
Are your sleep patterns disturbed?
Are you unable to eat?
Is your sex drive affected?
Over 80% of people starting treatment for HIV/AIDS have some concern
about the side effects they are likely to experience but once treatment is Are you worried about your weight?
started fewer than 20% have any noticeable side effects. Nevertheless
they remain a big worry and you should ask your doctor about the side Compliance:
effects once you start treatment.
Are the side effects stopping you from taking your pills?
Generally you cannot predict how easy or difficult you will find it to take
Do you forget to take pills or delay taking them because of the side
any particular drug beforehand. Also doctors tend to think that their
patients exaggerate the side effects and they are not as bad as we say. effects
Your doctor is there to assist and if any of the side effects worry you
when they occur it is important to record in detail what concerns you.
If any of the above you are advised to contact your doctor immediately
since not taking the pills could lead to failure to control HIV.
You should record information such as:
Frequency:
How often do you get symptoms?
What are they?
Do they occur all day, all night or both?
Duration:
How long do the symptoms last?
Once or twice per week, do they last for 30 minutes or several hours?
Is there a set pattern e.g. when you take your medication or a regular
time after dosing?
Severity:
How bad are the symptoms?
Is there anything that helps alleviate the symptoms?
196
18.44.5
English: ART drug diary
Week....
Names of drugs taken in
MORNING
Names of drugs taken at
NIGHT
Names of drugs taken in
MORNING
Names of drugs taken at
NIGHT
Names of drugs taken in
MORNING
Names of drugs taken at
NIGHT
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Week....
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Week....
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
197
18.44.6
English: side effect explanation
198
18.44.7
English: patient appointments
PATIENT APPOINTMENTS FOR ARVs
2 weeks after start date
After 12 months:
Date:_________________________
1 month after start date
Date:_________________________
Date:________________________
2 months after start date
Date:________________________
Date:__________________________
3 months after start date
Date:__________________________
Date:__________________________
4 months after start date
Date:__________________________
Date:___________________________
5 months after start date
Date:___________________________
Date:__________________________
6 months after start date
Date:__________________________
Date:__________________________
7 months after start date
Date:__________________________
Date:__________________________
8 months after start date
Date:__________________________
Date:__________________________
9 months after start date
Date:__________________________
Date:___________________________
10 months after start date
Date:___________________________
Date:___________________________
11 months after start date
Date:___________________________
Date:____________________________
12 months after start date
Date:____________________________
Date:___________________________
Date:___________________________
199
18.44.8
Xhosa: cover page
i ARV TREATMENT FILE YAM
IGAMA: ________________________
UQALE NINI:_____________________
200
18.44.9
Xhosa: patient time and ART choice
LELIPHI ELONA XESHA LILUNGILE YO LOKUTHATHA AMAYEZA
WAM YONKE IMIHLA?
UMHLA:
IGAMA LOMCEBISI:
IGAMA LOMNTU
ONDINCEDISA UKUTYA
AMAYEZA WAM:
NDENZANTONI?
ABANYE ABANTU BENZA NI
ABAKUFUTSHANE NAM?
NGUBANI ONAM
NGELOXESHA?
NDENZANTONI?
ABANYE ABANTU BENZA NI
ABAKUFUTSHANE NAM?
NGUBANI ONAM
NGELOXESHA?
KUSASA
4 AM
5 AM
6 AM
7 AM
8 AM
9 AM
10 AM
EBUSUKU
4 PM
5 PM
6 PM
7 PM
8 PM
9 PM
10 PM
ELONA XESHA LAM LILUNGILE YO LOKUTHATHA AMAYEZA WAM NGU:
____________ AM KUSASA
____________ PM EBUSUKU
Efavirenz/Nevirapine? ___________
201
18.44.10
Xhosa: ART explanation
Yazi Amayeza Akho
Ndingawatshintsha Na Amayeza?
Yintoni Intlanganiso-mayeza
Lena yinto okufanele uyixoxe noGqirha wakho.Amayeza amaninzi kulula
ukuwalandela ,kodwa ziziphumo ezingekho zihle ezithi zibaxhalabise abantu.
Intlanganiso-mayeza ligama elisetyenziswa xa kuhlanganiswa amayezwa
angaphezu kwesithathu ukunyanga intsholongwana ye HIV.Enye indlela ebizwa
ngayo, ngamayeza amathathu okanye HAART (Highly Active Antiretrotroviral
Therapy).
Nokuba uziva njani na, musa ukuwayeka amayeza ungathethanga nogqirha
wakho.
Ingaba La Mayeza Ayayinyanga Na Intsholongwane Iphele Tu?
Ingaba Lamayeza Ayasebenza?
La mayeza akhoyo ayayithomalalisa intsholongwane,ayipheli tu.La mayeza
enza ukuba intsholongwane ingandi emzimbeni,ancede nomzimba ukuba
Onke amazwe asebenzisa le-ndlela yonyango i HAART, izinga lokubulawa yi AIDS womelele.KODWA UYAKUHLALA UNAYO INTSHOLONGWANE YE HIV
lehlile kakhulu.
Nabantu abasebenzisa le ntlanganiso-mayeza iminyaka emininzi bahlala
La mayeza ayasebenza ebantwini besifazana,emadodeni nasebantwaneni nokuba benayo le ntsholongwane ye HIV kodwa incinane.
intsholongwane ye HIV ikungene kanjani, ngokulalana,ngokuhlatywa yinaliti
okanye ukwethiwa igazi emzimbeni.
Yintoni Ukuthembeka Ekuthatheni Amayeza?
Ukuthatha amayeza ngendlela ugqirha akuxelele ngayo kunciphisa ubungakanani
Ukuthembeka ekuthatheni amayeza kukusa empumelelweni yonyango lwale
bentsholongwane ye hiv emzimbeni.
ntsholongwane. KUKUZIMISELA KWAKHO UKULWA NENTSHOLONGWANE
YE HIV.
Kubalulekile ukutsalwa igazi njalo-njalo ukukhangela ukuba la mayeza
asasebenza na.
Ithini imigaqo yokutyiwa kwamayeza?
Lamayeza Asebenza Ixesha Elingakanani?
Le ntlanganiso-mayeza seyisetyenziswe ngaphezu kweminyaka emshumi (10
years). Amanye amayeza sekufundwe ngawo ithuba elide.
Ukuba uthatha la mayeza ngendlela oxelelwe ngayo ngu Gqirha,
ungawasebenzisa iminyaka emininzi.
Ukungathathi amayeza ngendlela ugqirha akuxelele ngayo kwenza ukuba
amayeza angasebenzi,kufuneke ukuba utshintshe uthathe enye intlanganisomayeza.
Iziphumo Ezingekho Zihle Ngokusebenzisa La Mayeza
Abantu abaninzi abaphatheki kakuhle ngenxa yeziphumo ezithi zingabikho zihle
xa besebenzisa la mayeza.
1x ngemini,ithetha ukuba thatha iyeza kanye ngemini ngexesha elinye yonke
imihla.
2x ngemini,ithetha ukuba thatha iyeza kabini ngemva kweyure eziyi 12
ngexesha elinye yonke imihla.
Ukuthatha amayeza ungatyanga, kuthetha ukuba ungatyi (iti,ikofu,iziselo
ezibandayo) iyure ezimbini phambi kokuba uthathe amayeza nengxenye
yeyure emva kokuba uthathe amayeza.
Ukuthatha amanye amayeza nokutya kunceda ukwehlisa iziphumo
ezingekho zihle,incede nokuba amayeza angene kakuhle
emzimbeni.(Landela imigaqo kaGqirha wakho.)
Ingcebiso Zoncedo
Qiniseka ukuba uyayilandela kwaye uyayazi indlela yokuthatha amayeza
akho - ukuba awuqinisekanga cela ugqirha wakho akucacisele ngemigaqo
yokuthatha amayeza akho.
Exesheni elininzi iziphumo ezingekho zihle zincinane kakhulu.
Ubungozi beziphumo ezingekho zihle buncinane kakhulu.
Thatha amayeza angaphezulu kunala uqhele ukuwathatha xa uzawukhe
uhambe intsukwana ezimbalwa.
Ezi ziphumo zingekho zihle zinyangeka ngokukhawuleza okukhulu.
Abantu abaninzi bafumanise ukuba la amayeza yimpilo yabo eqhelekileyo
yemihla ngemihla.
Gcina amayeza ambalwa nokuba kusemotweni,etasini okanye ebhegini
ongathi uwasebenzise xa efuneka ngokukhawuleza.
Buza ugqirha wakho ngeziphumo ezingathi zingabikho zihle ngalamayeza
uzawuqala ukuwasebenzisa.
Cela abahlobo abangakunceda ngokukukhumbuza ukuthatha kwakho
amayeza.
Sebenzisa ialam yewotshi nokuba yeyeselfoni ukukukhumbuza ixesha
lokuthatha amayeza.
Yazi Intsholongwane Yakho Ye-hiv
Okona usazi ngentsholongwane kokona kungakusa empumelelweni
yokuyilwa intsholongwane kagawulayo
202
18.44.11
Xhosa: Side effect
Ukumelana Neziphumo Ezingezihle
UBUMI BEMPILO
Zininzi izinto ezithe zasasazwa malunga neziphumo ezingekho zihle ezithe
zehlela abantu abathatha amayeza okulwa nentsholongwane
kagawulayo(HIV).Enyanisweni,ngokolwazi lwamva nje olusuka
kwizigulane ezibhaliswe. Lubonakalisa ukuba ubuninzi iziphumo ezinge
zihle aziqapheleki,ezo zithi ziqapheleke zincinane kakhulu. Qaphela ukuba
onke amayeza aneziphumo ezinge zihle ezithi zibhalwe kumaphetshana
afumaneka ngaphakathi kwebhokisi yepilisi.Iziphumo ezingezihle zikhona
nakumayeza aqhelekileyo okwaziyo ukuzithengela ngokwakho njenge
asprin ne panado.
Zikuphatha kanjani eziziphumo?
Ingaba indlela yakho yokulala iyaphazamiseka na?
Ingaba indlela yakho yokutya iyaphazamiseka na?
Ingaba ziyakuphazamisa ukuhlangana nowakwakho?
Ingaba uyehla na ngokomzimba?
UKUTHEMBEKA
Bangaphezulu kwe 80% abantu abaqala unyango lwentsholongwane
AIDS) abathi babe nexhala ngeziphumo ezingezihle ezingathi zibehlele,
kodwa bathi bakuqala unyango babe ngaphantsi kwe 20% abaneziphumo Ingaba eziziphumo zingezihle ziyakuphazamisa ekuthatheni amayeza
akho?
ezingezihle eziqaphelekayo. Xa unexhala ngeziphumo ezingezihle
ezibangwa lunyango, buza uQhirha wakho.
Ingaba uyalibala ukuthatha amayeza akho?
Awunakukwazi ukuqikelela ubunzima okanye ubulula ozakubufumana xa
Ukuba ngaba unazo ezi zinto zingasentla, dibana no gqirha wakho
uthatha amayeza ngaphambi kokuba uwasebensise.Nogqirha baye
ngokukhawuleza kuba ukungathathi amayeza kubangela
bacinge ukuba izigulana ziyazibaxa iziphumo ezingezihle,azikho zibi
ukungaphumeleli kunyango lwakho.
angangokuba besitsho.
Nantsi itshathi ongayisebenzisa ukubhala yonke into ongayiqondiyo emva
Ugqirha ukhona ukuba akuncede, kodwa ukuba kukho isiphumo
esingesihle esithi svele sikuxhalabise,kubalulekile ukuba usibhale phantsi kokuba usebenzise amayeza.
njengoko sinjalo.
Kufuneka ubhale ulwazi ngoluhlobo lulandelayo;
Kangaphi?
Uzibona/uziva kangaphi?
Zeziphi?
Ingaba zenzeka emini, ebusuku okanye maxesha omabini?
Ubungakanani bexesha?
Zithatha ixesha elingakanani?
Kanye/ kabini ngeveki, ingaba zithatha ingxenye ye yure okanye iiyure
ezininzi?
Ingaba zenzeka ngamaxesha athile,umzekelo,xa uthatha amayeza
okanye emva kokuba uthathe amayeza?
Ububi Beziphumo
Zibi kangakanani?
Ingathi ikhona into ethi ikuncede ukuthomalalisa iziphumo?
203
18.44.12
Xhosa: ART drug diary
Iveki………
Igama leyeza nexesha
KUSASA
Igama leyeza Nexesha
EBUSUKU
Igama leyeza nexesha
KUSASA
Igama leyeza Nexesha
EBUSUKU
Igama leyeza nexesha
KUSASA
Igama leyeza Nexesha
EBUSUKU
Icawe
Umvulo
Lwesibini
Lwesithathu
Lwesine
Lwesihlanu
Umgqibelo
Iveki………
Icawe
Umvulo
Lwesibini
Lwesithathu
Lwesine
Lwesihlanu
Umgqibelo
Iveki………
Icawe
Umvulo
Lwesibini
Lwesithathu
Lwesine
Lwesihlanu
Umgqibelo
204
18.44.13
Xhosa: side effect diary
205
18.44.14
Xhosa: patient appointments
USUKULOKUBUYA LOMGULI
Kwa pharmacy malunga namayeza
Emva kweveki ezimbini uqalisile i ARVs
Emva ezilishumi nambini
Umhla:_________________________________________
__
Emva kwenyanga uqalisile i ARVs
Umhla:___________________________________________
Umhla:_________________________________________
__
Emva kwenyanga ezimbini uqalisile i ARVs
Umhla:___________________________________________
Umhla:_________________________________________
_
Emva kwenyanga ezinthathu uqalisile i ARVs
Umhla:___________________________________________
Umhla:_________________________________________
__
Emva kwenyanga ezine uqalisile i ARVs
Umhla:___________________________________________
Umhla:_________________________________________
Umhla:___________________________________________
Emva kwenyanga ezihlanu uqalisile i ARVs
Umhla:_________________________________________
_
Emva kwenyanga ezinthandathu uqalisile i ARVs
Umhla:___________________________________________
Umhla:_________________________________________
_
Emva kwenyanga ezisixhenxe uqalisile i ARVs
Umhla:___________________________________________
Umhla:_________________________________________
_
Umhla:___________________________________________
Emva kwenyanga ezisibhozo uqalisile i ARVs
Umhla:_________________________________________
Umhla:___________________________________________
Emva kwenyanga ezithoba i ARVs
Umhla:_________________________________________
__
Emva kwenyanga ezilishumi uqalisile i ARVs
Umhla:___________________________________________
Umhla:_________________________________________
_
Emva kwenyanga ezilishumi nanye uqalisile i ARVs
Umhla:___________________________________________
Umhla:_________________________________________
_
Emva kwenyanga ezilishumi nambini uqalisile i ARVs
Umhla:___________________________________________
Umhla:________________________________________
Umhla:___________________________________________
206
18.45 Xhosa: Home visit form
Ifomu Yokundwendwela ikhaya malunga nomguli
Igama Lomguli:________________________________________________
Igama Lekliniki:________________________________________________
Umhla wokundwendwela ikhaya:__________________________________
Inombolo Yomguli:_____________________________________________
Abantu abakhoyo ekhaya ngalemini undwendwele ngayo:_______________
Imeko Yekhaya/Inkalo zoncedo kunye negxaso ngemali
1.Igama le ndawo
______________________________________
2. Uthatha ixesha elingakanani ukuya eKliniki?
______________________________
3. Ingaba uhlala nabani?
Wedwa, nomlingane nomhlobo/abohlobo
nezizalwane?
4. Bangaphi abantu abalalayo nabahlala kule ndlu rhoqo
1
2
3
4
5
6
7
8
9
10
5. Bangaphi abantwana bakho?
1
2
3
4
5
6
7
8
9
10
6. Ngubani owazi ngesimo sakho ekhayeni lakho?
Akakho
7. Ingababa iqabane lakho liyasazi isimo sakho? (khetha)
Ewe
mnye
hayi
naye uxilongiwe
unentsholongwane
8. Niyayisebenzisa idyasi yomkhwenyana?
9. Mangaphi amaxesha osela ngawo utywala (khetha)
bonke
naye
andinqabane
Asabelani ngesondo
sizisebenzisa rhoqo
Ngamaxesha athile
asizisebenzisi rhoqo
Awuseli konke
Ngenyanga
10. Uxhomekeke kubani ngokwemali? (khetha)
bambalwa
kanye ngonyaka
kanye
kanye ngeveki
Inxaso-mali yokhubazeko
isizalwane ohlala naso
Isizalwane esiphangela ngaphandle/kude
11. Bangaphi abantu abaxhomekeke kuwe ngemali?
_______
Ulwazi Nonyaniseko Ekutyeni Amayeza
Umcebisi aqale achazele abantu abakhoyo ekhaya ngengculaza
nokubaluleka kokuthatha iARV’s rhoqo nendlela ezisebenza
ngayo andule aphendule imibuzo yabo. Aqhubeleke gale mibuzo:
1.Ingaba wena nosapho apha ekhaya niyafuna na ukuba usebenzise
iARVs
2.Ulibona njani ikamvalakho xa unokuthi utye/usebenzise la
mayeza?(khetha
awunathemba
3. Nceda undibonise apho ungcina khona Cotrimoxazole / Bactrim
zingabhetele
onazo apha ekhaya nalapho ugcina khona iARVs
________________________
4. Umohluko phakathi kwezi pilisi onazo kunye ne ARVs
______________
207
awuqinisekanga mhlawumbi izinto
uqinisekile kuza
kubangcono.
5. Ngubani
omnye omaziyo othatha ii-ARVs (khetha)
__________________________________________
Akakho konke
Ukwi-support group
sisizalwane
ngumhlobo wam/iqabane lam
Uncedo lwasekhaya
1.Ngaba umntu okuncedisayo ukutyeni / ekuthatheni ipilisi zakho
uhlala apha ekhaya?
2. Ukuba akahlali apha ekhaya ngubani okuncedisayo apha ekhaya
xa engekho ?
3. Yiyiphi imibuzo owakhe wayibuzwa okany wadibana nayo
kwikhaya lakho njengokuba besazi isimo sakho ?
4. Xa sifuna wena okanye ukudibana nawe singathetha nabani
………………………………………………
ekhaya ?
5. Abantu balapha ekhaya baye benze njani xa isigulana sithe
sagula Kakhulu?
Izimvo/imbono ngokuthe gabalala
1.Umcebisi athi abhale asichazele izinto athe wacebisa abantu
basekhaya ngazo .
2. Ucebise nange zinto ezimalunga nekhaya, nomguli,
ngomncedisi wamayeza, nolwazi ngeARVs notywala njalo njalo
-Igama nentsayino zomcebisi
………………………………………………………
Ukhetha eNevirapine okanye eEfaviranz? (kumama kuphela)
___________________________________________
208
18.46 ART start list
Patients scheduled for ART initiation
2009/01/13-15
No.
New adults
Surname
2009/01/13
Name
File no
Regimen
Weight
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
XXX
Magxagxa
Khonjwayo
Mchithakali
Kholeka
Ndwebileyo
Thandekile
Sindiswa
Bongiwe
Robert
Mcelu
Nkonyana
Kholiswa
Ntombilungile
Magxagxa
Themba
Ntlanganiso
Noluvuyo
XOR 43
MLT 16
SOG 65
SOG 4
SOG 96
MLT 83
MLT 42
MLT 57
BOM 166
101
MQH 103
XOR 560
XOR 544
XOR 576
1364
1439
XOR 570
1b
1b
1a
1a
1b
1a
1a
1a
1a
1a
1a
1b
1a
1a
1a
1a
1a
71kg
71.4kg
51.2kg
61kg
52.4kg
51.8kg
54.8kg
44.4kg
53kg
58kg
61kg
44.6kg
56.4kg
63kg
51.8kg
68.2kg
47.4kg
1
2
YYY
Milizi
BOM 130
1a
42kg
CHILDREN
2009/01/14
1
2
ZZZ
Mxhanywa
C203
D4T/3TC/Kal
4.2kg
PMTCT/Pregnant
2009/01/15
1
2
3
4
5
6
7
8
AAA
AAA
AAA
AAA
AAA
AAA
AAA
Tengile
Nondumiso
Mandisa
Nomfobe
Pelokazi
Thembeka
Pathiswa
1529
1155
1502
1515
XOR 48
1432
1463
1b
Dual therapy
Dual therapy
Dual therapy
1a
Dual therapy
Dual therapy
69.4kg
68.8kg
74.2kg
74.2kg
69.8kg
71.6kg
53.6kg
Inpatients
2009/01/15
1
2
BBB
BBB
Thandeka
Busisiwe
1522
1524
1a
1a
38kg
41kg
On TB Rx
Notes
Defaulter re-start
Defaulter re-start
Yes
Yes
Yes
Yes
Delayed/overdue
adults
209
For TB Rx
Lifelong
Yes
Lifelong
Yes
TB female ward
Male general ward
18.47 ART start tag
ARV start date Date: ___________
1.
2.
3.
Go to OPD for CXR
See nurse for assessment and Bactrim
See doctor for examination and
prescription
4. See nurse for baseline bloods if blood
results if more than 3 months old
5. See pharmacist for ARVs
Weight:
PA note:
Nurse note:
210
18.48 ART initiation consent forms: English version
MADWALENI HOSPITAL Patient Contract for Antiretroviral Therapy
Taken from the National Guidelines:
To be completed in duplicate; original in file, copy for patient
Name of Health Care Facility
.............................................
Name of Counsellor
.............................................
(Counsellor, nurse, doctor)
.............................
(name)
(designation)
Name of Patient
..............................................
Care-giver
............................................
(If patient a minor)
.............................
(name)
(relationship)
We the staff of the Madwaleni hospital commit ourselves to the following:





We will always treat you with dignity and respect
We will strive to offer the treatment that’s right for your/your child’s HIV disease and make you a
partner in treatment decisions
We will always listen to your questions and concerns and do our best to address these
We will continue to learn all we can about how to keep people with HIV healthy
We will help protect the community by teaching people how to prevent the spread of HIV





I (full name of patient or care-giver if minor) .............................................. …………………………
acknowledge that I have been shown and understand how and when to take/give the medicines properly and undertake to do
my utmost best to follow these instructions. I also understand and/or agree that:


Antiretroviral therapy (ART) does not cure HIV and that I will help protect others by taking precautions
to keep the virus from spreading
the medicines decrease the amount of virus in the body if they are taken properly, but if the medicines are
stopped or taken infrequently the amount of virus will increase again
if the amount of virus is kept low the body is able to make more CD4+ (soldier) cells which are needed to
protect against infections
if I do not take/give the medicines everyday as prescribed the virus may change (become resistant) and
the drugs may stop working
only two courses of antiretroviral medicines will be provided

I will need to visit the clinic every month to collect the medication

I may be referred to another clinic or institution for care if necessary

the medicines can often cause mild side effects such as diarrhoea, nausea and tiredness but that these
problems usually resolve after being on treatment for some time
I understand that having unprotected sex while on ART will decrease the effectiveness of the treatment?








the medicines can also occasionally cause severe side effects and that I should report any serious
problems to the clinic or another health facility as soon as possible
I should not stop taking/giving the medicines without first discussing this with the doctor
Other medicines including traditional medicines, immune boosters or those prescribed by another doctor
may interact with the antiretroviral medicines and possibly cause the drugs to be less effective or result in
serious side effects. I will report the use of such medication to the clinic staff.
I will ASK FOR HELP when I need it
Patient/Parent/Caregiver:
Nurse Practitioner:
_________________________________
_________________________________
Date:_______________
Date:_______________
Doctor:
_________________________________
Date:_______________
Pharmacist:
_________________________________
Date:_______________
211
18.49 ART initiation consent forms: Xhosa version
MADWALENI HOSPITAL Patient Contract for Antiretroviral Therapy
Taken from the National Guidelines:
To be completed in duplicate; original in file, copy for patient
Igama le Health Care Facility
.............................................
Igama lomcebisi
.............................................
(Counsellor, nurse, doctor)
.............................
(name)
(designation)
Igama lomguli
..............................................
Umntu ojonga umguli
............................................
(If patient a minor)
.............................
(name)
(relationship)
Thina bantu Madwaleni isibhedlela siyaezibophelela kwezi zinto zilandelayo:





Sizimisele ukukuphata nge sidima nange mbeko
Siza kuzama kangangoko sinako ukuba mawufumane amayeza wean nomntwana wakho ophile
nentsholongwane sincedisane nawe ekuthatheni amayeza
Sizimisele ukumamela ingxaki ozanazo nemvume zakho. Senze kangangoko sinako ukuziphumeza
Siza kuqhubeka sifunda ngedlela yokuphatha abantu abaphila nentsholongwane sibagane besempilweni
Siza kunceda umphakathi ngoku wufundisa ngendlela yokukhusela iHIV





Igama lomguli okanye umntu ojonge umguli ............................................................................................. ndiyavuma ukuba
ndifundisiwe ngendlela nange xesha lokuthatha ipilisi ndiyaqiniseka ukuba ndiyakuyilandela yonke imigaqo. Ndiqondile kwaye
ndiyavuma:


Ukuba Antiretroviral therapy (ART) aziyi nyangi iHIV koko ziyayi khusela intsholongwane ukuba
ingandi
Lamayeza anciphisa intsholongwane emzimbeni ukuba ngaba umguli uwasebenzise ngendlela
efanelekileyo kodwa ayayinyusa intsholongwane xa enga thathwe ngendlele efanelekileyo
Ukuba intsholongwane iphantsi umzimba uyakwazi ukuba unyuse amajoni la asikhusela kumangenela
ezifo
Ukuba andiwatyi rhoqo amayeza ngedlela endiyalwe ngayo intsholongwane iyazi fihla apha emzimbeni
atsho namayeza angasebenzi
Mabini amanqanaba alamayeza asekhoyo apha

Kufuneka ndiye ikliniki elekwenyanga ndiyo kufumana amayeza

Ndinako ukutshintshelwa kwezinye iklinik xa kuyimfuneko

Lamayeza abanazo iziphumo ezisecaleni nje ngoku hambiseka isilaphucaphu nokudinwa kodwa zonke
ezingxaki ziyaphela ngokuye uqhubekeke namayeza
Ndiyaqonda ukukhuba xandilala ngaphandle kokusebenzisa isikhuseli ndisitya i-ART lonto izakunciphisa
ukusebenza konyango lwam
Lamayeza asenokuyenza ixesha elide lento yeziphumo ndisela kufuneka ndikhawuleze ndiye kwi iklinik
yam ndiyokuxelela u nurse wam
Andifanelwanga kukuyeka amayeza ndinga qalanga ndihlale phantsi nogqirha sibonisane








Umanye amayeza afana nawmagqirha akadibani nezi ARVs ziyasebenza ukuba iARV zingasebenzi
kakuhle kutsho kubekho iziphumo ezisecaleni ezibi.
Kufanele ndiyokuchaza ingxaki enjalo eklinik

Ndiya kufuna uncedo apho ndilufuna khona
Mguli/Mzali/umjongi mguli: _________________________________
Date:_______________
Umcebisi:
_________________________________
Date:_______________
Ugqirha:
_________________________________
Date:_______________
Umphathi wamayeza:
_________________________________
Date:_______________
212
18.50 ART prescription form
MADWALENI ANTIRETROVIRAL TREATMENT PRESCRIPTION FORM
Name of Facility
Patient Name
Address
Patient Number
Folder Number
Nearest clinic
Details of new prescription (dose/frequency/route/duration)
Date:
Starting regimen / regimen switch (circle)
Drug1
Drug 2
Drug 3
Drug 4
ID number
Age at ARV start
Gender
Rx supporter
Contact phone no.
In/Out patient?
M
F
Substitution Date:
Substitution
Prescriber's name & Signature
Prescriber's name & Signature
(Note that regimen switch requires new prescription form and dispensing dates and file tags start again)
Pharmacy ART dispensing record
Dispensing dates
Name of drug
First
dd/mm/yy
Quantity
dispensed
Adherence
dd/mm/yy
Repeat1
dd/mm/yy
Repeat 2
dd/mm/yy
Repeat 3
dd/mm/yy
Repeat 4
dd/mm/yy
Pill count
Pill count
Quantity
dispensed
Pill count
Quantity
dispensed
Pill count
Quantity
dispensed
Pill count
Quantity
dispensed
Repeat 5
dd/mm/yy
Quantity
dispensed
Repeat 6
dd/mm/yy
Quantity
dispensed
Repeat 7
dd/mm/yy
Quantity
dispensed
Repeat 8
dd/mm/yy
Quantity
dispensed
Repeat 9
dd/mm/yy
Quantity
dispensed
Repeat 10
dd/mm/yy
Quantity
dispensed
Repeat 11
dd/mm/yy
Quantity
dispensed
Repeat 12
dd/mm/yy
Quantity
dispensed
Repeat 13
dd/mm/yy
Quantity
dispensed
Repeat 14
dd/mm/yy
Quantity
dispensed
Repeat 15
Repeat 16
Repeat 17
Repeat 18
Repeat 19
Repeat 20
Repeat 21
Repeat 22
Repeat 23
Repeat 24
dd/mm/yy
Quantity
dispensed
dd/mm/yy
Quantity
dispensed
dd/mm/yy
Quantity
dispensed
dd/mm/yy
Quantity
dispensed
dd/mm/yy
Quantity
dispensed
dd/mm/yy
Quantity
dispensed
dd/mm/yy
Quantity
dispensed
dd/mm/yy
Quantity
dispensed
dd/mm/yy
Quantity
dispensed
dd/mm/yy
Quantity
dispensed
TCB date
Dispensed by (sign)
Dispensing dates
Name of drug
TCB date
Dispensed by (sign)
Dispensing dates
Name of drug
TCB date
Dispensed by (sign)
213
18.51 ART clinical monitoring forms – page 1
ALWAYS ON RIGHT HAND TOP OF FILE FOR QUICK REFERENCE
Patient on ART - First 36 months of treatment
Name:
Date of commencement
of ARVs
Starting Regimen
1a □
1b □
Other
…………………………………………………………………………………………………
Started as IN/OUT
HIV Starting
ELISA
patient
Stage
reactive □
Cotrimoxazole stopped
Date:
Regimen substitution:
Date:
Date:
Investigations
Date
Weight
CD4
CD4%
Viral load
HB
ALT
RPR
Creatinine
Urine dipsticks
Side Effects
Adherence
(good,average,poor)
If on Kaletra
DTT
ART
Start
6 months
12 months
2 week
1 month
2 month
3 month
Date
Date
Date
Date
HBV pos □ neg
□
18 months
24
months
30
months
36
months
Date
Date
Date
Date
Glucose
Chol
Trig
If on NVP/AZT/TDF
ALT
HB
Cr
Other results
Pap smears
Other
214
18.52 ART clinical monitoring forms – page 2
Month _________
Patient history
Clinical/Nurse Check up/Unscheduled
List danger signs/red flags
1.
Nurse action/prescribed
Rx
Doctor notes:
Refer to dr: □
2.
Date:
3.
Month _________
Patient history
Clinical/Nurse Check up/Unscheduled
List danger signs/red flags
1.
Nurse action/prescribed
Rx
Doctor notes:
Refer to dr: □
2.
4.
Date:
3.
Month _________
Patient history
Clinical/Nurse Check up/Unscheduled
List danger signs/red flags
1.
Nurse action/prescribed
Rx
Doctor notes:
Refer to dr: □
2.
Clinical/Nurse Check up/Unscheduled
List danger signs/red flags
1.
Nurse action/prescribed
Rx
Doctor notes:
Refer to dr: □
2.
Date:
Weight:
4.
Date:
3.
215
Weight:
4.
3.
Month _________
Patient history
Weight:
Weight:
4.
18.53
Simplified clinical guideline to ART initiation and prescription
Which patients should start on ARV’s?
Medical criteriaAny patients with a CD4 count less than 200
Any patient with a stage 4 disease regardless of their CD4 count
Stage 4 defining conditions
These you may see in your clinicsKaposi sarcoma
Candida of the oesophagus
Invasive cervical carcinoma
HIV wasting-
Unintentional weight loss >10%
With either chronic diarrhoea or fever for 1 month
The other stage 4 conditions will usually be diagnosed in hospital
What are the possible ARV regimes?
D4T 30mg bd
1A
3TC 150 mg bd
Efavirenz 600mg od
D4T 30mg bd
1B
3TC 150 mg bd
Nevirapine 200mg bd
AZT 300mg bd
2
DDI 250mg or 400mg od
3TC 150 mg bd
Kaletra 3 capsules bd/Aluvia 2 tablets bd
216
18.54
Guideline to ART initiation and repeat adherence visits by pharmacy assistant
Guidelines to ART adherence counselling
by
pharmacy assistants
Initiation adult (no irregularities)















Confirm understanding of HIV
Why do you want to take ARVs?
What do you know about ARVs ? – explain anything left out
What are the names of ARVs you are going to take?
Show the patient each pill and ask which name goes with which pill?
Check the patient knows when to take each pill (visually show group of pills to be taken in the morning and at
night)
Check understanding of drug resistance - how to prevent it/importance of adherence
What do you know about side effects - explain side effects (anything patient has left out)
Reminders for adherence – treatment partner/alarm/pill box/ARV treatment file
Is there anything in their current situation that may make taking their ARVs difficult?
Why safe sex is important
Partners in their health
Never stopping ART without Dr input
Check understanding of pill box and ask patient to demonstrate how to pack
Check patient has been taught how to use the ARV treatment file
217
To Add:
Option – TB






What do they know about TB? (if problem – refer to TB counsellor)
TB can be cured if adherent
Pill burden
Adherence to TB drugs in the past – difficulties that may have experienced
Increased side effects
Matching TB return dates with ARV return dates
Option – chronic meds




First check Dr input regarding any chronic meds including dosages and drug interactions
Ask the patient if they are taking any other chronic meds?
Do they know what it is for?
Pill burden
Option – mother of child patient




Does the mother foresee any problems with her child taking these meds? (size/taste)
Dosaging – mother to demonstrate
Explain dosages change with weight changes (liquid to tablets)
Mothers support structures if she is not there for dosaging
Option – Substance abuse/traditional medicine
218





What is the pattern of their substance abuse?
Assistance for dosing ART
Consequences of substance abuse
Importance of continued trust with health team
Sangoma involvement – co-operative not in conflict
Option – illiterate
 Give the choice of pill box or not
 Give choice of ARV treatment file or not (treatment partner to complete)
 How will they remember TCB dates (attach appointment date page into OPD card)
Option – PMTCT lifelong
 Confirm understanding that patient taking ART for life not just for pregnancy
 Confirm that infant requires NVP stat dose and AZT for 7 or 28 days
Initiation – Prophylactic PMTCT
 Why not life long?
 Confirm understanding of 3 step process to ART:
o Prior to delivery: AZT twice daily at scheduled time
o During delivery: NVP stat at start of labour and AZT 3 hourly during labour
o After delivery: NVP stat dose for infant and AZT for 7 or 28 days
 Emphasise importance of delivery at hospital/health centre
219
 When patient will stop ART
Repeat visits
1 – 3 month













How have you found taking ARVs every day?
How have you been feeling (health wise)?
How have your family been supportive?
Have your reminders been working (phone/alarm/treatment partner)
Have you missed any doses in the last month that you can remember?
If yes, why?
Was there any special day that you had to leave your home and did not take your pills with you?
Are you having any problems remembering to take your pills on the weekends?
Did you have any problems with your pill box or your ARV file?
Pill count – in a positive way
Safe sex/substance abuse
Consider down referral (if not already done)
Consider TCB date to coincide with child repeat/any Dr appointment
4 month and onwards (except 9 months)
 How have you been feeling?
 Can you remembering taking your pills every morning and night for the last three days?
220




Have you missed any one of your ARV drugs in the last 3 days?
Can you remember not taking your ARVs on a weekend or other special day away from home or any other day?
Safe sex/substance abuse
Decide whether patient is generally adherent or whether there are problems with adherence
If adherent
 Inform patient how pleased you are with their progress and you are not going to be counting their pills
anymore
 Motivate to continue great work
If not adherent




Establish cause – consider if this requires Dr/nurse/pharmacist intervention
If it does not require professional intervention – continued adherence counselling
Pill count continues until adherent
Focus on motivating the patient
9 months – only positive feedback
 No adherence check
 Is there a difference between their health 9 months ago and today?
 When you started ARVs, you wanted to go on treatment for certain reasons. Do you remember what they were?
Can you see that happening?
 How are your family feeling about your health? Did you get any positive comments?
13 months
 Ensure patient has seen nurse/doctor already (otherwise send back)
221






How have you been feeling?
Can you remembering taking your pills every morning and night for the last three days?
Have you missed any one of your drugs in the last 3 days?
Can you remember not taking your ARVs on a weekend or other special day away from home or any other day?
Safe sex/substance abuse
Decide whether patient is generally adherent or whether there are problems with adherence
If adherent and the doctor has instructed pharmacy to consider 3 months supply:
 Inform patient how pleased you are with their progress and you are going to provide them with 3 months
supply if they want it
 If they do want it, discuss:
o where are you going to store the extra pills, will they be safe from other people and animals and from
weather conditions
o whether you can foresee a difficult situation where you are asked to help another by giving them your
ARV drugs (discuss responsibility of 3 months supply and consequences of giving to people not assessed
by a doctor)
o still encourage to continue attending support group for themselves and to help others
If not adherent
 Establish cause – consider if this requires Dr/nurse/pharmacist intervention
 If it does not require professional intervention – continued adherence counselling
 Continue supplying 1 month ARVs until adherent and healthy
 Continue to motivate patient
222
18.55
Diagrammatic representation of ARV patient journey to assist nurses
223
18.56
Guideline nurse consultations
1) Review file by checking




File tags
Previous medical history,
Results section (is it filled in up to date?)
Notes from the last visit
2) Deal with any issues arising from chart review.
3) Does the patient report any new problems? Are there any red flag symptoms or danger signs?
4) Check weight and check pulse.
5) Ask about ARV adherence.
6) Record your actions appropriately
Additional tasks for a clinical visit
1) Look for test results and copy to the front of file.
2) If results are not there check that they were taken at the previous visit. If they were not taken they must be
taken today.
3) Is the viral load lower than the detectable limit? If not move to high viral load guideline (see below) before step
5.
4) Is the CD4 count stable or increasing? Are the other blood tests normal?
5) If the CD4 count is above 350 stop Bactrim.
6) If the CD4 count has been above 200 for 6 months fluconazole prophylaxis for cryptococcal meningitis can be
stopped.
7) Ask about long-term side effects. Lipodystrophy, peripheral neuropathy, symptoms of lactic acidosis.
224
18.57
High viral load guideline for nurses
High viral load guidelines for nurses
If less than 400 copies this may be normal or suggest adherence problems

The patient will get extra adherence counselling from the nurse and peer educators

The viral load will be repeated at the normal time (6 months later)
If greater than 400 copies the patient is in serious danger of developing resistance to their
regimen. The system is:
Extra adherence counselling from the nurse and counsellors.

The patient and must come to collect ARV’s in person every month.

The pharmacy assistant will perform strict pill counts on their ARV’s every month

After 2 correct pill counts a repeat viral load will be taken.

The nurse and doctor will review the patient with the result of the second viral load to
decide whether they need to switch to regimen 2 ARV’s.
225
18.58
Short term side effect guideline for nurses
Serious short-term side effects of ARV’s
Rashes- Any NEW rash developing in the first 3 months of treatment is worrying. Nevirapine, Efavirenz, Bactrim and
TB treatment are all possible causes.
Abdominal pain- Nevirapine can cause hepatitis and DDI can cause pancreatitis both of which require hospital
admission.
Vivid dreams, dizziness, headache, insomnia, depression, delusions &hallucinations - Can all be caused by
efavirenz.
Anaemia- Can be caused by AZT and will present with fatigue, shortness of breath, dizziness.
If you suspect any of these please discuss with a doctor immediately
Serious drug interactions
Epilepsy- Phenobarbitol, Phenytoin, and Carbamazepine are best avoided regardless of the ARV’s being used.
Therapy should ideally be with valproate (Epilim)
TB treatmentEfavirenz- no dose adjustment required
Nevirapine- if the patient is established on NVP it is safe to start rifampicin with no dose adjustment. Otherwise it is
best to use efavirenz instead.
Kaletra- will reduce the dose of Kaletra so refer all patients to VCT before starting rifampicin.
Contraceptives - Oral contraceptives may not work properly in patients taking Kaletra / Aluvia
226
18.59
Useful nurse protocols for HIV wellness/ART management
Peripheral neuropathy in HIV for nurses
When a patient complains of ‘inkantsi’ or cramps in the hands or feet it may be peripheral neuropathy.
It usually affects both sides often beginning with the soles of the feet. If a patient has difficulty walking because of
pain under both feet it may be peripheral neuropathy.
There are many possible causes but the commonest in our patients are




TB treatment (intensive and continuation phase)
ARV’s (usually D4T or DDI)
Vitamin deficiencies
HIV itself
Syphilis
Step 1
Check the RPR is non-reactive
Prescribe 1 month of:Pyridoxine 25 mg od (50mg if on TB treatment)
Amitriptyline 25 mg od
Step 2
Review after 1 month:If getting worse consider a switch from D4T to AZT
If not on ARV’s discuss with Dr at next down referral
227
Lactic acidosis for nurses
It is caused by ARV’s-particularly D4T but also AZT and DDI.
It usually takes at least 6 months of ARV’s to cause lactic acidosis.
It is life threatening if severe.
The patient will have Danger Signs and Red Flags such as





Weight loss
High respiratory rate
High pulse rate
Chronic abdominal pain
Chronic fatigue
If you suspect lactic acidosis refer immediately to the Dr or to Madwaleni where we can do a finger prick lactate
test.
228
18.60
Repeat ART file list
229
18.61
Repeat ART dispensing list
18.62
PHC down referral consent
CLINIC DOWN REFERRAL CONSENT FORM
SURNAME:
NAME:
CLINIC:
File no:
I hereby consent to being referred to my clinic to
continue my ARV treatment. I understand that I will
now fetch my repeat ARV prescriptions at my clinic.
My first date for fetching ARV treatment at my clinic
is ………………………………….….
SIGNATURE
PHARMACY ASSISTANT NAME
DATE
230
18.63
Medication labels
231
18.64
ART stock requisition
232
18.65
ART repeat file tags
1 month visit
1.
2.
3.
4.
Check ARV start blood results back
See nurse for clinical visit
See nurse for Bactrim
See pharmacist for ARVs
Weight:
2 month visit
1.
2.
3.
4.
PA note:
Nurse note:
Nurse note:
Date:____________
Check 2 month blood results back
See nurse for clinical visit
See nurse for Bactrim
See pharmacist for ARVs
Weight:
4 month visit
1.
2.
3.
4.
Date:_________
Check 3 month blood results back
See nurse for nurse check up
See nurse for Bactrim
See pharmacist for ARVs
Weight:
PA note:
PA note:
Nurse note:
Nurse note:
233
Date:__________
Check 1 month blood results back
See nurse for clinical visit
See nurse for Bactrim
See pharmacist for ARVs
Weight:
PA note:
3 month visit
1.
2.
3.
4.
Date:____________
5 month visit
1.
2.
3.
Date:_________
6 month visit
PA note:
See nurse for nurse check up
See nurse for Bactrim
See nurse to take CD4 & Viral Load
If on Kal – take appropriate bloods
See pharmacist for ARVs
Weight:
Nurse note:
PA note:
___________________________________
Nurse note:
See nurse for nurse check up
See nurse for Bactrim
See pharmacist for ARVs
Weight:
7 month visit
Date:____________
1. Check 6 month blood results back
2. See nurse for clinical visit (incl. CD4,
VL, other blood results assessment)
3. See nurse for Bactrim assessment
4. See pharmacist for ARVs
Weight:
1.
2.
3.
4.
5.
Date: __________
8 month visit
Date:_________
1.
See nurse for Bactrim
2.
See pharmacist for ARVs
Weight:
PA note:
Nurse note:
PA note:
Nurse note:
9 month visit
Date:___________
10 month visit
Date:_________
1.
See nurse for Bactrim
2.
See pharmacist for ARVs
Weight:
1. See nurse for Bactrim
2. See pharmacist for ARVs
Weight:
PA note:
PA note:
Nurse note:
Nurse note:
234
11 month visit
1.
2.
Date:_________
12 month visit
1.
2.
3.
4.
5.
See nurse for Bactrim
See pharmacist for ARVs
Weight:
PA note:
Nurse note:
See nurse for nurse check up
See nurse for Bactrim
See nurse to take CD4 & Viral Load
If on Kal – take appropriate bloods
See pharmacist for ARVs
Weight:
PA note:
Nurse note:
13 month visit
Date:____________
1.
2.
Check 12 month blood results back
See nurse for clinical visit (incl. CD4,
VL, other blood results assessment,
consider 3 month supply of ART)
3.
See pharmacist for ARVs
Weight:
PA note:
PA recommends 3 month supply:
Y/N
Nurse note:
Nurse recommends 3 month supply:
Y/N
235
Date: __________
18.66
Guideline to HIV wellness and ARV readiness programme procedure at clinics
Going to Clinic (Peer Educator)
1.
2.
Peer Educator going from Madwaleni HIV/ARV site to clinic make sure you have taken everything in your
clinic tray in the office.
Make sure that you have the following:
 ‘Blood investigation submission form’ for blood specimens
 Patient files applicable to that clinic (in case patient arrives at clinic)
 Blood results for clinic
 Purple and red/yellow toped tubes for blood specimens (if the clinic may not have)
 At the beginning of each month – the prophylactic medication for the clinic with the new ‘HIV
Prophylactic medication’ form for the month.
HIV Support Group (Peer Educator/Nurse)
3.
4.
Hold and facilitate HIV support group.
Mark on the Clinic HIV Support Group Register all members present at support group.
After HIV support group
Prophylactic medication (Peer Educator/Nurse)
5.
6.
Dispense prophylactic medication to all HIV support group members who qualify for 1 month.
Fill the patient’s name in on the ‘HIV Prophylactic medication’ form for the month.
New files (Peer Educator/Nurse)
7.
8.
9.
10.
11.
12.
13.
14.
HIV support group members, who have attended HIV support group 3 times, will qualify to enrol on the
programme and require a patient file – check register to ensure they have attended 3 times (unless
nurse/doctor indicated otherwise).
Open a new file for the patient – this is a very important counselling session with the patient on an
individual basis.
Take extra time to explain the Bactrim pill count to the patient.
Take 8ml of blood for the following blood tests and urine for urine dipstick test:
 ELISA (red/yellow tube) – 2ml
 CD4 (purple tube) – 2ml
 FBC (purple tube) – 2ml
 RPR + ALT + Cr + HepBsAg (red/yellow tube) – 2ml
 Urine in urine container
Make sure you write the name of the patient on each tube of blood.
Make sure you complete the lab forms properly including the name of the clinic (to ensure comes back to
HIV department for capturing). Also ensure that the one sticker from the form is stuck to the tube of blood
and the other is put in the patient’s file.
Complete the first section of the ‘PHC blood investigations submission form ’ – ‘Blood specimens taken at
clinic and brought back to Madwaleni’ with patient’s details and the blood specimens taken.
Dispense prophylactic medication once a month and ensure that the patient’s name has been entered on
the ‘HIV Prophylactic medication’ form.
Old files (Peer Educator/Nurse)
15.
16.
17.
Each patient with an existing file completes an HIV wellness visit with a Peer Educator every two weeks
(one week if patient needs to start ART immediately). This is an ongoing counselling session in order to
counsel the patient about living with HIV and readying the patient for ARVs.
Ensure that if any blood results have been received for this patient that they are put in the patient’s file.
Also take time to explain to the patient what a ‘CD4 count’ means and what their CD4 count is.
Where the patient’s CD4 result is <210 focus the patient on readying for ARVs – specifically choosing a
treatment partner, safe sexual practices, disclosure to family members at home and getting their Bactrim
236
pill count correct (the patient’s Bactrim pills can be counted weekly to speed up the ARV readying
process).
18.
Dispense prophylactic medication once a month and ensure that the patient’s name has been entered on
the ‘HIV Prophylactic medication’ form.
After HIV/ARV Clinic (Peer Educator)
19.
20.
21.
22.
23.
Peer Educator to bring blood specimens back to Madwaleni. Remember to put the ‘PHC blood
investigations submission form ’ in the blue file for the clinic and complete the laboratory register with the
blood specimens submitted to them (refer to blood specimen and blood result procedure for clinics).
Put all patient files (where patient did not come to the clinic) back in the clinic drawer (otherwise to leave
at clinic provided not on ARVs).
Put back the clinic envelope in the tray.
Report back on any issues which should be followed up by Madwaleni HIV/ARV site.
At the end of each month bring back remaining prophylactic medication with ‘HIV Prophylactic medication
form’ for the month and give to these to the pharmacy department.
MOST IMPORTANTLY – MAKE SURE THE HIV SUPPORT GROUP MEMBERS UNDERSTAND THE PROCESS –
THEY WILL HELP YOU IF THEY DO.
237
18.67
Guideline to blood specimen and result procedure for PHCs
Blood specimens taken at the PHC
1.
2.
3.
Counsellor make sure you take a blank ‘blood investigation submission form’ to clinic each week
When blood specimens are taken at the clinic, counsellor tick which blood specimens have been taken in the
first section of the ‘ARV site form’ - ‘Blood specimens taken at clinic and brought back to Madwaleni’.
When the blood specimens are brought back to Madwaleni:
a. register bloods at lab in lab register; and
b. put the ‘blood investigations submission form’ in the blue file marked for the applicable clinic in the
HIV department office.
Blood results received from lab
1.
2.
3.
4.
5.
6.
When the lab has the results for the blood tests requested, the lab assistant with place the result in the
appropriate clinic file in the lab.
The counsellor will then go to the clinic file in the lab on the day before he/she is due to go to the clinic and take
the blood results for that clinic.
The counsellor will come back to the HIV department office with the blood results. The counsellor will then take
the blue file for the clinic and tick which blood results have been received from the lab on the ‘blood
investigation submission form’ in the second section ‘Blood results received from Madwaleni lab’. The
counsellor will also insert the date on which the results were fetched from the lab.
The counsellor will then submit the blood results to the data capturer for capturing.
Once captured, the data capturer will then put the blood results in the envelope in the clinic tray.
At the clinic the counsellor/nurse will put the blood results in the applicable patient’s file.
238
18.68
PHC blood investigations submission form
Blood investigation submission from clinics
To stay in ARV site file for PHC at all times – do not submit to lab
NAME OF CLINIC:
DATE:
Patient details
Name
Surname
Blood specimens taken at clinic and submitted to
Madwaleni lab
ELISA
VL
CD4
RPR
FBC
ALT
Cr
239
HepB
Urine
Blood results received from Madwaleni lab (insert
date)
ELISA
VL
CD4
RPR
FBC
ALT
Cr
HepB
Urine
18.69
Drug requisition for doctor’s PHC box
To be submitted to pharmacy on Friday morning and available for collection on Tuesday afternoon for HIV
wellness and ARV programme run at clinics run on Wednesday and Thursday
DESCRIPTION
ANTIBIOTICS
Solid dosage forms:
AMOXYCILLIN CAPSULE 500mg, PRP, 15's
CO-TRIMOXAZOLE TABLET 480mg, PRP, 56's
CIPROFLOXACIN TABLET 500mg,10'S
DOXYCYCLINE CAPSULE 100MG;PRP;14'S
ERYTHROMYCIN COATED TABLETS;PRP,20'S
FLUCLOXACILLIN CAPSULES PATIENT READY PACK;250MG;20'S
ISONIAZID TABLETS 100MG, 84’S
METRONIDAZOLE TABLETS 400MG;PRP, 21's
ANTIBIOTICS
Liquid dosage forms
AMOXYCILLIN POWDER FOR SUSPENSION 125MG/5ML;75ML
43ML OF DISTILLED WATER FOR RECONSTITUTION
CO-TRIMOXAZOLE SUSPENSION 240mg/5ml, 100ml
METRONIDAZOLE SUSPENSION 200MG/5ML;100ML
ERYTHROMYCIN ESTOLATE POWDER FOR
SUSPENSION,125mg/5ml5ML,100ML
95 ML OF DISTILLED WATER FOR RECONSTITUTION
ANTIFUNGAL AGENTS
AMPHOTERICIN-B LOZENGES 10MG; 20'S
CLOTRIMAZOLE VAGINAL TABLET (PESSARY) W/ APPLICATOR;500MG;1'S
GRISEOFULVIN TABLETS 125MG;28's
GRISEOFULVIN TABLETS 500MG;28's
FLUCONAZOLE TABLETS 200MG; 28's- see ARV's
ANTI-VIRAL AGENTS
ACYCLOVIR TABLETS 400MG;PRP; 30's
ANTI-PARASITIC AGENTS
ALBENDAZOLE TABLETS 200MG;2'S
(Zentel®)
ALBENDAZOLE PAEDS SUSPENSION
(Zentel®)
PRAZIQUANTEL TABLETS 600MG; 20 tablets
(Biltricide®)
ANALGESICS
IBUPROFEN TABLET;PATIENT READY PACK;200MG.15'S
(Brufen®200mg/ Nurofen®200mg)
PARACETAMOL TABLETS PRP;500MG;20'S
(Panado®/ Dolorol®)
ANALGESICS
Liquid dosage forms
PARACETAMOL ELIXER,120MG/5ML;50ML
TOPICAL PREPARATIONS
Creams and ointments: Antibiotic
CHLORAMPHENICOL EYE OINTMENT 1% ; 3,5G
Creams and ointments: Antifungal
BENZOIC ACID COMPOUND OINTMENTWIDE MOUTH;25G
(Whitfield's Ointment)
240
Tick if
req'd
Quantity
Quantity
issued
MICONAZOLE NITRATE CREAM 30G
(Daktarin® Cream)
Ear drops
OTOSPORIN EAR DROPS
Creams and ointments: Cortisone
HYDROCORTISONE CREAM 1%;20GM
(Stopitch®/ Mylocort®/ Biocort®)
Wart preparation
PODOPHYLLUM RESIN 20%,SALICYLIC ACID 25%
10G TUBE
(Posalfilin® Ointment)
Soaps: Anti-parasitic
MONOSULFIRAM SOAP 5%;75G
(Tetmosol® Soap)
Lotions: Anti-parasitic
BENZYL BENZOATE APPLICATION 25%;100ML
(Ascabiol®)
OTHER MEDICATIONS
AMITRIPTYLINE TABLET;PRP 25MG;28'S
(Tryptanol®)
CHLORPHENINRAMINE 4MG TABLETS;PRP, 21'S
(Allergex®)
FUROSEMIDE 40MG; 28'S
HYDROCHLORTHIAZIDE TABLETS 25MG; 28'S
METOCLOPRAMIDE TABLETS 10MG;PRP, 15'S
(Maxolon®)
PREDNISONE TABLETS 5MG;100'S
(Meticorten®)
PYRIDOXINE TABLETS;25MG;28'S
PERINDOPRIL TABLETS 4MG;28'S
(Coversyl®)
RANITIDINE TABLETS 150MG 1BOX
SPIRONOLACTONE TABLETS 25MG; 28'S
THIAMINE TABLETS 100MG
WARFARIN TABLETS 5MG; 28'S
SODIUM VALPROATE TABLETS 200MG;100'S
(Epilim® 200mg)
241
18.70
Example of PHC nurse dispensing list
242
18.71
Guideline to doctor and nurse-led ARV clinic at PHC from pharmacy perspective
UNDERSTANDING DOCTOR AND NURSE DOWN REFERRAL FROM THE PHARMACY PERSPECTIVE
WEEK 1
DOCTOR DOWN
REFERRAL
WEEK 2
NO ARV DOWN
REFERRAL
WEEK 3
NURSE DOWN
REFERRAL
WEEK 4
NO DOWN
REFERRAL
Doctor/Pharmacy
assistant at clinic:
Doctor led down
referral
 PA dispenses
ART to patients
due in week 1.
 PA leaves clinic
list and ARVs for
patients who were
due but did not
come in week 1 in
‘Doctor down
referral’ box
 PA leaves
prepacked ARVs
for patients due
on nurse down
referral date
(week 3) with
dispensing list and
clinic list in ‘Nurse
down referral’ box
NO doctor/Pharmacy
assistant at clinic
NO doctor/Pharmacy
assistant at clinic:
Nurse led down
referral
NO
doctor/Pharmacy
assistant at clinic



Nurse gives
counsellor week 1
clinic list (where it
reflects the
patients who the
nurse dispensed
ARVs to since
week 1).
Counsellor brings
back all ARVs not
collected since
week 1 in ‘Doctor
down referral ‘ box
Counsellor puts
week 1 clinic list in
data capture tray.



243
Nurse dispenses
ART to patients
due in week 3 out
of ‘Nurse down
referral’ box.
Counsellor brings
back week 3
dispensing list and
puts in data
capture tray
Nurse leaves
clinic list and
ARVs for patients
who were due in
week 3 but did not
come in ‘Nurse
down referral’ box.



Nurse gives
counsellor week
3 clinic list
(where it reflects
the patients who
the nurse
dispensed ARVs
to since week 3)
Counsellor
brings back all
ARVs not
collected since
week 3 in ‘Nurse
down referral ‘
box
Counsellor puts
week 1 clinic list
in data capture
tray.
18.72
Nurse guideline to issuing ART to patients at PHC
Nurse led ART clinic/ARV down referral
Guideline:
1. Paste the applicable medication label reflecting the patient’s name on the patient’s ARVs (if not already
done by the pharmacy assistant) and insert TCB date;
2. Indicate that you issued the patient’s ART on the “Dispensing List” left with the pre-packed ART by the
pharmacy assistant as follows:
a. Insert weight
b. Sign name under issued by
c. Only if the TCB date is different to that printed on the form – write the correct TCB date over
3. Tick on the front of the patient’s files that ART was issued and sign next to your tick.
4. Most importantly, record on the dispensing sheet in the patient’s file:
a. The date you issued the ART
b. The ART drugs and quantities issued to the patient
c. The TCB date given to the patient (which must be the next nurse led down referral date, unless you
want the patient to see the doctor).
Overdue patients
These are the ART patients that do not come on their due date. The pharmacy assistant pre-packs their ART and
leaves it with you for 7 days. Thereafter any uncollected ART is brought back to Madwaleni hospital by the peer
educators.
Guideline:
1. Paste the applicable medication label reflecting the patient’s name on the patient’s ARVs (if not already
done by the pharmacy assistant) and insert TCB date;
2. Indicate that you issued the patient’s ART on the “PHC Nurse Dispensing List” left by the pharmacy assistant
as follows:
a. Complete weight
b. Sign that you issued ART
c. Complete date you issued ART
d. State if person other than patient collected ART
e. Complete TCB date
3. Tick on the front of the patient’s files that ART was issued and sign next to your tick.
4. Most importantly, record on the dispensing sheet in the patient’s file:
a. The date you issued the ART
b. The ART drugs and quantities issued to the patient
c. The TCB date given to the patient (which must be the next down referral date).
244
18.73
Guideline to PMTCT counselling by community health workers/peer educators
Information important to know to decide how to counsel the mother (at 26 weeks
of pregnancy)
Which regimen the mother will take?




If a pregnant patient has a CD4 above 300 (and above 14%), she will use ARVs only
for her pregnancy (PMTCT patient) starting at 28 weeks gestation.
If she is a PMTCT patient, she will start on the following regimen:
o MOTHER
 AZT only (1 tablet in the morning and 1 tablet at night)
 NVP (1 tablet at commencement of labour)
 AZT (1 tablet every 3 hours in labour)
o INFANT
 NVP syrup for the baby after delivery (only once – 0.6mls if under 2kg
or 0.2mls per kg if over 2kg)
 AZT syrup for the baby for 7 days after birth (1.2 mls in the morning
and 1.2mls at night)
(if mother started AZT less then 4 weeks before birth then baby is
given AZT syrup for 28 days after birth)
If a pregnant women has a CD4 of less than 300 (or her CD4% is less than 14%), she
will use ARVs for life (she will start during her pregnancy and stay on the ARVs after
delivery of her baby)
If she is on lifelong ARVs and:
o Her CD4 count is between 200 – 300: she will start on 1a: D4T, 3TC,
EFAVIRENZ
o Her CD4 count is less than 200: she will have the choice between 1a: D4T, 3TC,
EFAVIRENZ or 1b D4T, 3TC, NEVIRAPINE
Delivery of the baby:

It is very important that all mothers deliver their babies at the clinic or hospital (not at
home) so that they get the NVP and AZT syrup for their infant.
Breastfeeding or formula feeding?





BREASTFEEDING IS BEST! Babies get all their mother’s antibodies and nutrients that
helps them develop and grow into strong healthy children.
But we know that mothers can transmit HIV in breast milk.
For all women on lifelong ARVs, the risk that the baby can be infected with HIV from
the breast milk is very small.
Mothers need to make a decision between exclusive breastfeeding (ONLY BREAST
MILK) or formula feeding. Mix feeding (mixing breast milk and formula is the worst as
it has the highest rate of HIV transmission). Mix feeding must be avoided.
Mothers should only choose to formula feed if they:
o Have enough money to buy 6-8 tins of formula every month for 6 months
(approx. R250 a month) as the government often has no Pelagon to give
mothers.
o Have access to clean water to mix formula feed (enough money to buy paraffin
to boil water)
o Are disclosing at their homes so that they are not worried to formula feed in
front of other people.
245

Mothers need to understand that there are many risks to their baby’s health associated
with incorrect formula feeding. If they cannot afford to buy it OR buy too little OR do
not have access to clean water OR cannot access a shop to buy formula - their babies
will be underfed and will become weak and sick. These babies do not grow properly
and many of them die.
When will PMTCT mothers stop ARVs?


All PMTCT patients will stop taking AZT after delivery.
Remember that pregnant women on lifelong ARVs must continue to take ARVs after
delivery.
When do we test the baby for HIV?





All babies will be tested for HIV at 6 weeks (by PCR).
If the PCR is positive, we do NOT need to do another PCR
If the PCR is negative and the baby is well, we do NOT need to do another PCR
If the PCR is negative and the child is unwell and failing to thrive, we will do another
PCR at 4 months to confirm negative status
If the mother is breastfeeding, we take another PCR, 6 weeks after she completes
breastfeeding.
246
Framework for PMTCT: Prophylactic dual ARV Therapy counselling:
Remember the focus of a pregnant women is not ARVs but the safe delivery of her
baby!
1. General talk about pregnancy
 Talk to the mother generally about how she is feeling about having her baby soon?
 Has she been going to her ANC visits at the clinic?
 Can she feel the baby moving?
 How is she going to get to the clinic/hospital to deliver her baby?
(inform the nurse/doctor of any information which worries you)
2. Does she understand what it means to be HIV positive? (discuss if she is not sure)
3. Does she understand that she could transmit (pass) HIV to her child? (discuss if she is not
sure)
4. Explain that by taking ARVs during her pregnancy she can reduce the risk of transmitting
HIV to her baby
 By taking ARVs correctly the HIV virus in her body (viral load) will become little, so
that there is less chance that she will transmit the HIV to her child.
 It is important for her to understand that there is still a small chance, even if she
takes the ARVs correctly, that the child may still get HIV.
5. Teach her the names of her ARVs:
 AZT and Nevirapine
6. Explain that taking the ARVs requires her commitment as she needs to:
 For the last 3 months of pregnancy – take AZT twice a day – morning and night at
the same time – set a time with her;
 During labour – take NVP when she starts her labour and then remind the nurse in
maternity ward that she needs to take AZT every 3 hours during her labour;
 After birth of her baby – give her baby AZT syrup twice a day for 7 days – morning
and night at the same time as she took her AZT before the birth
(remember 28 days if she only started AZT after 36 weeks).
7. Ask her if she has been counselled on whether she is going to breastfeed or formula feed
her baby? If she has not, arrange for a further counselling session either by you or the
nurse on this issue (not at this session as too much information).
8. DO NOT DISCUSS OR TEACH DETAILED SHORT OR LONG TERM SIDE EFFECTS (it is not
necessary). Explain that she might feel a little sick when she first takes them as her body
is not used to ARVs but it should get better after a few days. If it does not get better she
should come in to the clinic to see the nurse. SHE MUST NOT STOP TAKING HER ARVs ON
HER OWN.
9. Encourage her to deliver at her clinic or Madwaleni Hospital.
10.Discuss with patient that it is important that she enrols/stays on the HIV
programme after she delivers her baby so that we can continue looking after her
health and we can start ARVs for her when she needs them (CD4 below 200).
No home visit necessary and no pill box to be given to patient on ART start.
247
Framework for PMTCT: Lifelong triple ARV therapy counselling
1. General talk about pregnancy
 Talk to the mother generally about how she is feeling about having her baby soon?
 Has she been going to her ANC visits at the clinic?
 Can she feel the baby moving?
 How is she going to get to the clinic/hospital to deliver her baby?
(inform the doctor of any information which worries you)
2. Explain that there are two important things to focus on:
 Her pregnancy - the health of her baby AND
 Her own health
3. Does she understand what it means to be HIV positive? (discuss if she is not sure)
4. Does she understand that she could transmit (pass) HIV to her child? (discuss if she is not
sure)
5. Explain how ARVs will help her:
 By taking ARVs, the HIV virus in her body (viral load) will become very little:
o this means her body soldiers will increase, so that she can become healthy
and strong again.
o it also means that there is only a small chance that she will transmit the HIV
to her child
6. Explain that ARVs do not cure HIV and she will always be HIV positive
7. Explain that taking the ARVs requires commitment as she needs to take them every day
for the rest of her life
 Explain that she has to take the ARVs twice a day – morning and night at exactly
the same time
8. Explain that if she does not take them properly, there is a risk to her health and she
increases the risk of transmitting HIV to her baby:
 Explain that if she forgets to take the ARVs, or runs out of ARVs, her HIV will
become resistant to ARVs and they will stop working – they will stop reducing the
HIV virus in her body. This means:
o her body soldiers will continue to die and she will eventually get weak and
sick
o she is no longer protecting her child from getting HIV
9. Ask her if she thinks she is able to take them properly?
 Ask her if there is anything that will make it difficult to take them or come to fetch her
next month’s supply – help her by thinking of solutions to these problems.
10.Explain that she needs to start taking the ARVs as soon as possible because her CD4 is
low. If she starts taking ARVs during her pregnancy it will also help reduce the risk of her
transmitting HIV to her baby - BUT if she feels that she is being rushed into starting ARVs
and she is not ready, it would be better to start ART after delivery. She has to take ARVs
for the rest of her life, make sure she is ready to make this commitment!
11.If she says she is sure she wants to start ARVs - continue with counselling otherwise
inform the doctor and he/she will consider starting her only on PMTCT ARVs.
248
12.Teach the patient the names of the ARVs and choose the best time for her to take them.
13.Discuss ways for the patient to remember to take her ARVs:
 Discuss the importance of a treatment partner and ask her to choose such a person
to come with her on her ARV start date.
 Use of alarm clock/cell phone
 Teach the ARV treatment file
 Teach the pill box
14.Discuss short term and long term side effects
15.Explain that if she feels sick, she should come in to the clinic to see the nurse. SHE MUST
NOT STOP TAKING HER ARVs ON HER OWN.
16.Discuss with patient that it is important that she sees starting ARVs as a lifelong
commitment and not only about her pregnancy. We want her to join the HIV support
group at her closest clinic so that she can get support from other HIV positive people in
her community.
17.Ask patient if she has been counselled on whether she is going to breastfeed or formula
feed her baby? If she has not, arrange for a further counselling session either by you or
the nurse on this issue (not at this session as too much information).
18.Arrange the home visit with the patient.
249
18.74
PMTCT referral consent form
PATIENT CONSENT FOR REFERRAL TO MADWALENI PMTCT CLINIC
I,……………………………………………………..(patient’s name) acknowledge that it has been explained to
me by my clinic nurse that:
1. I am currently pregnant and have tested positive for HIV;
2. If my CD4 count is low and/or my pregnancy is regarded as high risk to me and my baby, I would benefit
from an obstetric consultation by a doctor and assessment for lifelong ARV therapy at Madwaleni’s
PMTCT clinic.
2.1. I can choose either:
2.1.1. to be referred to Madwaleni’s PMTCT clinic on a Thursday where I will be assessed for
starting lifelong ARV therapy; OR
2.1.2. to continue my antenatal care at my clinic.
2.2. If I choose to stay at my clinic, I will be started on ARV therapy only for my pregnancy. This ARV
therapy:
2.2.1. does not help to manage my HIV and improve my health; and
2.2.2. is less effective in reducing the chance that I transmit HIV to my baby.
I have chosen:


Referral to Madwaleni’s PMTCT clinic on ………………… (insert date) OR
(insert date at 26 weeks of pregnancy or later if CD4 count result received after 26
weeks (please phone Madwaleni for CD4 result if not back within 6 days)
Continued antenatal care at my clinic. I will come back to my clinic to start ARV
therapy on ………………………(insert date)
(insert date at 28 weeks of pregnancy or later if first ante-natal visit is after 28 weeks
of pregnancy)
3. If my CD4 count is high I would receive ARV dual therapy to minimize chances of HIV transmission to
my unborn child;
4. I have been informed that I can choose to go to Madwaleni to attend PMTCT support group and receive
ARV dual therapy or continue dual therapy at my clinic.
(only Xora clinic has a specific PMTCT support group all)
I have chosen:



To attend PMTCT support group at Madwaleni while continuing to receive dual
therapy at my clinic OR
To continue receiving dual therapy at my clinic and NOT attend PMTCT support
group at Madwaleni OR
To attend both PMTCT support group and dual therapy at Madwaleni
Prior to this date, patient should attend ante-natal visits at clinic and be encouraged to join weekly
HIV wellness programme/support group at clinic
SIGNATURE OF PATIENT
SIGNATURE OF NURSE
…………………………..
……………………………
250
DATE………………….
CLINIC…………………
18.75
Patient journey through visit to PMTCT clinic at hospital
PMTCT
patient
arrives and
goes to
reception –
(she does
not go to
her clinic
first for her
ante-natal
visit - we
will do it
here)
 Counsellor finds file and puts tag on
(either First PMTCT, Repeat PMTCT,
ARV start or ARV repeat) – if no file
open a file immediately
 Nursing student - write BP, pulse and
temp on white paper and staple to
inside of green card
 Ask patient for urine sample –take to
nurse for reading when patient’s turn
with nurse.
 Counsellor to do wellness visit (even
if patient is already on ARVs as new to
programme – focus on safe sex and
disclosure)
Counsellor checks for
blood results :
 If ELISA and CD4
not taken at clinic,
ensure bloods are
taken by nurse
today
 If blood taken at
clinic/1st visit at
Madwaleni ensure
blood results in file
(if not counsellor to
go to lab)
Patient comes back to same
Counsellor from dr:
Patient goes to
pharmacy if repeating
or starting ARVs (this
can be done earlier if
a repeat)
Patient goes to
doctor (if required
only) for:
 see dr’s instructions and
follow
 nurse to take ARV baseline
bloods if starting ART
 nurse/counsellor to check
that patient has next antenatal date (and that it
coincides with any ARV
repeat date).
 Obstetric consult
if req’d
 ARV start (if
starting today)
251
Patient to go to nurse:
 Nurse does ante natal visit
 If patient’s first visit and no blood
results from clinic/at lab – nurse to
take blood
 If patient had ELISA and CD4 taken at
clinic or 1st visit – check blood result
and determine ARV regimen
 Write ARV regimen on front to file for
counselling
 Determine if patient needs to see dr
for obstetrics (check if ‘high risk –
doctor’ /ARV start)
If nurse has reflected
ARV counselling to be
done – patient goes
back to same
counsellor
immediately for
counselling
18.76 First PMTCT visit tag
PMTCT First visit
Date:____________
1. Weight, vitals, urine dipstick
2. Open pink file + counsel patient
3. Check for blood results from clinic
4. Take blood investigations
5. See nurse for antenatal visit
6. See doctor for obstetric check
7. Doctor/Nurse’s instructions to:
Counsellor:
or
Nurse:
18.77 Repeat PMTCT visit tag
PMTCT
repeat visit
Date:____________
1. Weight, vitals, urine dipstick
2. See counsellor for wellness visit
3. Counsellor to ensure CD4 count in file
4. See counsellor for ART adherence counselling
5. Doctor/Nurse’s instructions to:
Counsellor:
Nurse:
252
18.78 Maternity ward tag
1.  Triple ARV therapy
 AZT/NVP
 No ARVs
2.  NVP stat in labour
 AZT 3 hourly in labour
3.  NVP syrup to baby
 AZT syrup to baby for 7 days bd
 AZT syrup to baby for 28 days bd
18.79
PMTCT follow up tag
PMTCT Follow up tag
Mother’s name: ____ _______________________
File Number: ______________________________
Expected delivery date: __________________
Actual delivery date: _____________________
Child’s full name: _________________________
Child’s sex: M/F
Feeding choice: EBF/EFF
Date of PCR: ____________________
PCR result:
Positive/Negative
253
18.80
Birth and infant follow up information – HIV database
254
18.81
Infant follow up form
MOTHER’S FILE NO:…………………………….
DATE:……/………/……
MADWALENI HOSPITAL INFANT FOLLOW UP CLINIC (IFC)
INFANT DEMOGRAPHIC DATA
HISTORY
DATE OF BIRTH: …………/…………/……… (dd/mm/yy)
NAME AND SURNAME: ………………………………………
SEX: M / F
CHILDS CAREGIVER: MOTHER / FATHER / GRANDMOTHER / RELATIVE/ OTHER(SPECIFY)
MOTHER / CAREGIVERS NAME: ………………………………………………………………….AGE: ……………
ADDRESS: ………………………………………………………………………………………………………………………
TELEPHONE: (1)………………………………………………………..(2)……………………………………………….
MOTHERS HEALTH: WELL / POOR/ DEMISED
FATHERS HEALTH: WELL / POOR / DEMISED
RETROVIRAL RELATED HISTORY
MOTHER POSITIVE: Y / N / PROB / UNK
MOTHER DIAGNOSED ANTENATALLY: Y / N / UNK
MOTHER RECEIVED ANTIVIRAL MEDS: Y / N / UNK DETAILS: ………………………………………………..
(DRUG(S)/DATE/ TIME)
CHILD RECEIVED ANTIVIRAL MEDS: Y / N / UNK
DETAILS: ………………………………………………..
(DRUG(S)/DATE/ TIME)
WAS MOTHER ON TRIPLE THERAPY IN PREGNANCY Y / N / UNK IF YES DETAILS
:………………………………………………………………………………………………………………………………
PREGNANCY AND BIRTH HISTORY
NUMBER OF TIMES MOTHER PREGANT (INCLUDING THIS CHILD): ………………….
PLACE OF BIRTH: HOSPITAL……………………………./CLINIC………………………../OTHER(SPECIFY)……………………………
GESTATION : TERM (37-42weeks);PREMATURE (< 37 weeks);POSTDATES(>42 weeks); UNK
MODE OF DELIVERY: NVD / ASSISTED / C-SECTION
BIRTH WEIGHT: ………………………….(Kg)
BREAST FED: Y / N / UNK
DURATION: ………………………..MONTHS
HIV SEROLOGY RESULTS
ELISA 1ST RESULT DATE
ELISA 2ND RESULT DATE
…………………..… POSITIVE / NEGATIVE
…………………..… POSITIVE / NEGATIVE
PCR 1ST DATE
…………………..………
RESULT POSITIVE / NEGATIVE
PCR 2ND DATE
…………………..………
RESULT POSITIVE / NEGATIVE
255
MADWALENI HOSPITAL
Infant Follow Up Clinic (IFC): Monitoring and Treatment Flowchart
Date
dd/mm/yy
dd/mm/yy
dd/mm/yy
dd/mm/yy
Age (wks/mts)
Weight (kg)
Feeding Option
EBF / MF
EFF /
Treatment
Co-trimoxazole
(Bactrim®)
Other (specify)
Lab Sticker
HIV ELISA
PCR
TCB Date (see
appointment card)
Final HIV Status
HIV POSTIVE / HIV NEGATIVE (circle appropriate option)
DATE
Mother/Father given final status and have signed below on confirmation of disclosure
Acknowledgement of final HIV status
I, …………………………………., the mother/father/primary caregiver of
……………………………. hereby confirm that I have been given the results of my child . I
understand that he/she is HIV negative / positive
Signature ………………………………Date……/………/………..
(Parent/Primary Caregiver)
Signature ………………………………Date……/………/………..
(Disclosing clinician)
256
18.82
PART clinic referral form
Patient Name
D.O.B.
Caregiver Name
HIV File no (if applic)
Referred from: Ward/support
group/ OPD
Date
Referred by
Date of ELISA / PCR
Mode of infection
Perinatal
ARV exposure history
Previous Illnesses
Abuse
NVP
Other:
Other:
TB
PCP
Meningitis
GE
1.
2.
BPN LIP
Current Illnesses
Current Medications
Blood results: Date
3.
4.
ELISA
CD4
FBC
VL
POSITIVE PCR INFANTS
Contact nos. of main caregivers
Appointment Dates
PART Clinic (Wed)
Booked:
Adult HIV support group
(place/date)
No booking required
Bloods taken, awaiting results (include test, date, lab sticker)
257
18.83
PMTCT PHC feedback
Bomvana Clinic - PMTCT referrals
Apr-08
Name
Thobeka
No-answer
No-honest
Notobile
Nokwayiyo
Surname
xxx
xxx
xxx
xxx
xxx
Chose
referral
Y
Y
Y
N
N
Date of
referral
2008/04/10
2008/04/24
2008/04/24
Date came to
Madwaleni
2008/0410
2008/04/30
2008/04/24
Date started
ART
2008/05/15
2008/05/15
2008/05/22
Dual/Triple
Dual
Dual
Triple
1
2
Name
Nosanele
Sizeka
Surname
xxx
xxx
Chose
referral
Y
Y
Date of
referral
2008/05/01
2008/05/08
Date started
ART
2008/05/22
2008/06/05
Dual/Triple
Dual
Triple
3
4
Nqabakazi
Noncedile
xxx
xxx
Y
N
Date came to
Madwaleni
2008/05/08
2008/05/22
2008/05/15 (already
has file_
Name
Ntombekay
a
Nokuthula
Surname
Chose
referral
Date came to
Madwaleni
Date started
ART
xxx
xxx
Y
Y
No.
1
2
3
4
5
May-08
No.
2008/05/08
2008/05/22
Dual
Jun-08
No.
1
2
Date of
referral
2008/06/05
2008/06/05
3
Khuselwa
xxx
Y
2008/06/19
4
5
6
Buyelwa
Nosikholiwe
Faniswa
xxx
xxx
xxx
Y
N
Y
2008/06/24
2008/06/05
2008/06/24
258
2008/06/12
Did not come
2008/06/24
2008/07/01 (already
has file)
2008/07/01
2008/06/19
Dual/Triple
Dual
Did not return
to initiate
ART
2008/07/08
Triple
2008/07/15
Triple
18.84
Example of PMTCT PHC feedback extracted from HIV database
259
18.85
HIV testing in children < 18 months protocol
Testing children under 18 months of age
Child between 6
weeks – 18
months
Test mother
with rapid test
If mother is HIV+ or
not available/dead or
refuses to test
Mother is
negative
Test child by
PCR
Do not need to test as
child negative†
(unless sexual abuse)
If negative ask if child is
breastfeeding (or stopped
less than 6 weeks ago)?
If YES, repeat PCR 6 weeks
after breastfeeding
stopped*
If NO – tell caregiver child
is negative!
If positive, tell caregiver result,
take CD4 and refer to
Madwaleni PART clinic
†Unless there has been suspected sexual abuse in which case it will be necessary to test the child.
* if mother continues breastfeeding for more than 6 months, repeat PCR every 6 months during breastfeeding period
260
18.86
HIV testing in children > 18 months protocol
Testing children over 18 months of age
Child over 18
months
Test mother
with rapid
test
If mother is HIV+ or
not available/dead or
refuses to test
Mother is
negative
Ask if child is still
breastfeeding (or stopped
less than 6 weeks ago)?
Do not need to test as child
negative†
If YES, test
child by PCR
If negative, do PCR
test 6 weeks after
breastfeeding
stopped*
If NO, test
child with
rapid test
If positive, tell caregiver
result, take CD4 (and ELISA if
tested using rapid test) and
refer to Madwaleni PART
clinic
If negative – tell
caregiver child is
negative!
†Unless there has been suspected sexual abuse or the child is sexually active in which case it will be necessary to test the child.
* if mother continues breastfeeding for more than 6 months, repeat PCR every 6 months during breastfeeding period
261
18.87
Paediatric HIV wellness form – pg1
PAEDIATRIC HIV PATIENT CLINICAL FOLLOW UP RECORD (CONFIDENTIAL)
First name
Surname
Folder number
Date of birth
Female/Male (F/M)
Name of Caregiver
Caregiver's relationship with child
Telephone number
Physical Address
Closest clinic to home
Date informed HIV positive (PCR or
ELISA)
Caregiver counselled Child’s HIV+ status
Date of proposed HIV awareness age
Known allergies
ARV history before first visit
PMTCT to mother? (Y/N/UK) if Y detail
PMTCT to child? (Y/N/UK) if Y detail
Previous HAART? (Y/N) if Y detail
Was/Is the child breastfed?
COMPLETED BY PEER EDUCATOR
ON DATE FILE IS OPENED (FIRST
VISIT TO PART CLINIC)
How long was the child breastfed?
(number of months from birth or "current")
Social grants
Not eligible (NE), Not Applied (NA),
Waiting
(w),Siblings
Receiving ( R)
Details of
Child
Support
Grant
1
Care Dependency
Grant
Foster Care Grant
2
3
4
Name
Date of Birth
HIV status (P / N / UT )
Other information
Stop date
Medical history (NB gynae/surgery if applicable)
RX
Start date
(if applicable)
1
2
3
4
5
6
COMPLETED BY NURSE AT FIRST
7
CONSULTATION AND
8
THROUGHOUT CLINICAL
9
MONITORING OF PATIENT BY
10
NURSE/DR
11
12
13
14
15
Date of death
COMPLETED BY DR/NURSE/ADMIN ONCE
Place of death
INFORMED OF PATIENT DEATH
Cause of death (dr to complete)
262
18.88
Paediatric HIV wellness form – pg2
Visit date
Visit date
Visit date
Date
Counsellor Lead
Missed last visit date? (Y/N)
Assessment
Who is bringing the child to clinic
today?
Who is with the child during the day
on
Aremost
theredays?
worries about HIV
transmission
frombeen
the child?
Has the Bactrim
given
correctly?
Is the child swallowing the Bactrim
well?
Does the child have a good
appetite?
Referred to a hospital since last
visit? (Y/N)
If so, Madwaleni (M),Nelson
Mandela (N),Umtata General
(U),Bedford (B),Other (O)
Number of days in hospital
Diagnosis at discharge
COMPLETED BY PEER EDUCATOR
EACH TIME CAREGIVER ATTENDS
HIV WELLNESS PROGRAMME
WITH CHILD
(PRIOR TO ART START)
What is the child's most recent
CD4 or %?
Does the child need ART based on
the CD4 count or %?
Name of counsellor
Nurse Lead Assessment
Age at this visit (in months)
Pulse rate
Resp rate
Temp
Weight (in kg)
Height (in cm)
Growth/Nutritional assessment
(Normal
/ UWFA / Kwash / Maras /
TB
screening
M-K)
Concurrent
TB? (Y/N)
TB symptoms (Y/N)
TB Contact (Y/N)
If TB Contact, who
If contact or symptoms initiate
screen
for TB
WHO Staging
Is there any stage III or IV illness?
If Y, detail
Chronic Medications
Cotrimoxazole (Bactrim)
MVT
Other (eg Fe Gluconate etc)
Investigations
Haemoglobin (g/dl)
Urine Dipstix
Other labs/Ix
Development milestones
Gross motor
Fine motor
Language
Social
Name of Nurse:
COMPLETED BY NURSE EACH
TIME CAREGIVER ATTENDS HIV
WELLNESS PROGRAMME WITH
CHILD
(PRIOR TO ART START)
Next visit date:
263
Visit date
18.89
Guideline to adherence counselling for children by community healthworkers/peer educators
The facts that we need to know before we start counselling a caregiver:
How do we decide which children need ARVs?





Remember with children we look at CD4% not CD4 count!
All babies under 12 months – we do not look at CD4% - if they are HIV positive they
start ARVs
12 months – 3 years: less than 25%
3 – 5 years: less than 20%
Over 5 years of age – we treat the children the same as adults and look at their CD4
count only (less than 200 needs ART, but watch closely from a CD4 of 350)
Which regimen will the child take?

If the child is 0 months to 3 years old or weighs less than 10kg:
o D4T, 3TC and Kaletra
o If the child is on TB treatment: D4T, 3TC, Kaletra and Ritonovir253 (4 ARVs)
(when TB treatment stops, stop Ritonovir)

If the child is over 3 years and weighs over 10kg:
o D4T, 3TC and EFV
o If the child is on TB treatment: ARVs do not change
If a child start ARVs on Kaletra and their weight increases above 10kg, they do not
change to EFV, they stay on Kaletra.
If a child start ARVs on EFV and their weight decreases below 10kg, they do not change
to Kaletra, they stay on EFV.


How do we decide what dosage of each ARV the child needs to be given by the
caregiver?



Remember the ARV dosages change with the weight of the child
We use the table to determine if the child’s ARV dosages need to be increased
Remember that when the child is young many of the ARVs are given in syrup form not
tablet form (many children under 4 cannot swallow tablets) and we need to explain to
the caregiver how to administer the syrups.
Other information

If the child vomits within 30 minutes of taking ARVs, the ARVs must be given again.
253
Madwaleni PART clinic initially used double dose Kaletra for children with TB but attempted to change to Ritonavir based on
the evidence of treatment efficacy. However after 6 months of continually not being able to procure a reliable supply of
ritonavir from Mthatha pharmacy depot, clinicians felt they had no choice but to revert back to double dose Kaletra.
264
Framework for counselling:
Remember you are counselling the caregiver which is different from counselling an
adult who is responsible for their own ARV treatment.
1. General talk about the caregiving of the child concerned
 Talk to the caregiver generally about the care of the child – is she struggling with
the child being unwell
 Establish a bond with the caregiver which will put the wellbeing of the child at the
centre
2. Does she understand what it means for the child to be HIV positive? (discuss if she is not
sure)
 Discuss how the caregiver feels about the child’s HIV status
3. Discuss concerns about HIV transmission
 Explain that the child cannot transmit HIV to any member of the family or
neighbours unless he/she is bleeding and contact is made with contaminated blood
(make sure family is not afraid to share food, utensils, cleaning aids such as
facecloths with the child)
4. Ask the caregiver what she understands about ARVs and how they will help her child?
Make sure the patient understands:
 ARVs do not cure HIV
 ARVs will ‘kill’ most of the HIV which allows the body soldiers (CD4 cells) to get
strong again and fight of infection/illness.
 ARVs need to be taken every day for the rest of the child’s life ‘bomi bakho bonke’
 ARVs need to be taken every 12 hours to control the HIV
5. Assist the caregiver to choose a good time to give the child his/her ARVs. Discuss the
caregiver and the child’s daily routine and habits to select a good time for the child.
 Remember children go to bed early, so help her choose a time when the child is
awake.
6. Explain that if the caregiver does not give the ARVs to the child at the specific times, there
is a risk to the child’s health because the ARVs will stop working (resistance).
 This means that the HIV will start to increase and start killing the body soldiers
again. The child will start getting sick again.
7. Ask the caregiver if she thinks she is will be able to give the ARVs to the child correctly
every day?
 Ask her if there is anything that will make it difficult to give the ARVs correctly every
day or to come to fetch her child’s next month’s supply – help her by thinking of
solutions to these problems.
 Explain the importance of involving the child in taking his/her ARVs (the extent of the
involvement depends on the age of the child).
8. Teach the caregiver the names of the ARVs and demonstrate how to give each drug
 Remember that many of the ARVs which children need to take are syrups not tablets
and we need to demonstrate to the caregiver how to pull up the syrup in a syringe (up
to the correct mark on the syringe) and give it to the child in the back of the mouth
(use demonstration bottles in office)
9. Ask the caregiver if she thinks she will have any problems with getting the child to take
the ARVs?
 Discuss with the caregiver whether the child will be able to swallow the tablets (if
any)
 Try to help the caregiver with solutions if the child does not want to take syrups or
tablets (e.g. mask bad taste using a sweet or for babies interrupting feeding to
administer and then continue feeding)
 If there is a problem that you cannot solve – ask nurse/doctor for help in advising
caregiver.
265
10.Explain to the caregiver that the dosages (amount of) each ARV which the child must be
given will change over time as the weight of the child goes up (as the child gets bigger)
 Explain that every time the caregiver brings the child to the clinic, we will weigh the
child and determine the correct amount of each ARV to be given to the child – we
will explain this to her if it changes when we give her the new month’s supply.
11.Discuss ways for the caregiver to remember to give the ARVs:
 Use of alarm clock/cell phone
 Teach the ARV treatment file (for literate caregivers)
12.Discuss side effects briefly - explain that a few children get side effects to the ARVs but
this is not common (less in children than in adults). Explain that the child might feel a
little sick when he/she first takes the ARVs as his/her body is not used to ARVs but it
should get better after a few days. If it does not get better the caregiver should bring the
child to the clinic to see the nurse. SHE MUST NOT STOP GIVING THE CHILD THE ARVs
ON HER OWN (Do not teach the adult side effects to caregivers – it is not necessary).
13.We are a team – the Madwaleni staff, the caregiver and the child. If the caregiver has any
problems, he/she needs to let us know so that we can help – the health of her child is very
important to all of us.
14.Arrange the home visit with the patient.
266
18.90
Cotrimoxazole (Bactrim) prophylaxis in children
Cotrimoxazole prophylaxis prevents PCP/PJP, a severe form of pneumonia, in children with HIV infection. It
also protects against some bacterial infections, causing chest and ear infections, as well as toxoplasmosis
and non-typhoid salmonella infections. Prophylaxis with Cotrimoxazole has also been shown to decrease
diarrhoea.
Who should receive Cotrimoxazole prophylaxis?


ALL infants born to HIV positive mothers from 4-6 weeks of age.
Any HIV positive child with any clinical signs or symptoms of HIV infection, regardless of age or CD4
count.
When can Cotrimoxazole prophylaxis be stopped?



Occurrence of certain side effects such as Stevens Johnson syndrome (severe skin rash involving mucous
membranes), renal and hepatic toxicity or severe haematological toxicity.
In an HIV exposed child prophylaxis can only be stopped when HIV infection has confidently been excluded
(i.e. negative HIV PCR <18 months or negative HIV ELISA >18 months) AND the mother is not breastfeeding.
In HIV infected child Cotrimoxazole prophylaxis can only be stopped if:
1. The child has been on HAART for more than 6 months
2. AND the child is over 18 months
3. AND there has been immune reconstitution i.e. the CD4 count is above the appropriate age limit (see below)
on two repeated CD4 counts 6 months apart.
4. AND the child has showed clinical response to HAART with no recent admissions or acute illnesses.
Age
CD4 limits
1-3 years
CD4% 25%
3-5 years
CD4% 20 %
Older than 5 years
CD4 absolute < 350
How is Cotrimoxazole given?


It is given once daily, every day of the week
The approximate dosages are:
Age
Weight
Cotrimoxazole once daily dose
6wks – 2 months
Less than 5 kg
2,5 ml
2 -12 months
5 – 9.9 kg
5 ml
12 – 24 months
10 – 14.9 kg
7.5 ml
24 – 60 months
15 – 21.9 kg
10 ml or 1 tab
Older than 60 m
More than 22 kg
15 ml or 1.5 tab
If the child is allergic to Cotrimoxazole the alternative is Dapsone 1mg/kg.
Note:
Cotrimoxazole prophylaxis can be stopped and started by all levels of health care providers provided the
above criteria are adhered to.
267
18.91 PART Clinic Blood Draw
Wellness Programme
1 – 3 years old:
Older than 3 yrs:
Baseline:
FBC, CD4, ALT, Creatinine, HepB surface antigen
3 monthly:
Hb, CD4
Baseline:
as above
6 monthly:
Hb, CD4
ART Programme (age does not matter)
Baseline:
FBC, CD4, ALT, Creatinine, Viral load.
(take HepBsAg if not previously taken)
Regimen
Time base
Blood tests
D4T, 3TC, EFV
6 monthly
CD4, VL, ALT, Hb
D4T, 3TC, Kaletra
6monthly`
CD4, VL, ALT, Hb,
Trig, Chol, Glucose
AZT, ddI, Kaletra
6 monthly
CD4, VL, ALT, Hb,
Trig, Chol, Glucose
ABC, 3TC, EFV
6 monthly
CD4, VL, ALT, Hb
Appropriate tubes:
CD4, VL, Hb (or FBC) –
one small purple top for each test, at least up to the “500” line.
We can use the large purple tops for children over 5 years, 2ml of blood.
ALT, Trig, Chol, HBsAg -
One small red top for each test.
We can use the larger yellow tops for children older than 5.
Glucose -
One grey top tube – only come in large.
268
18.92 Development assessment guideline – PART clinic
Age
3 months
Gross Motor
Fine Motor
Pull to sit: no head
lag.
Follows through
180.
Prone: supports on
forearms, lifts head,
buttocks flat.
Communication
Personal / Social
Coos and chuckles.
Excited when fed.
Hands open.
Quietens to familiar
sound.
Reacts to familiar
situation.
Holds object placed
in hand.
Turns head towards
sound.
Rolls over.
Watches hands.
Pulls at clothes.
6 months
Pull to sit: braces
shoulder.
Prone: extended
arms lift head and
chest
Reaches for object.
Babbles.
Radial approach to
toys.
Repetition.
Transfers.
Puts everything in
mouth.
Laughs aloud.
Responds to image
in mirror.
Turns to mothers voice.
Starts to hold bottle.
Supine: plays with
feet.
Shows likes and
dislikes.
Sits with support
9 months
Sits without support.
Rolls.
Crawls.
Holds a cube in each Deliberate vocalisation.
hand.
Babbles.
Points.
Imitates sounds.
Pulls to stand.
Drinks from cup.
Bear creep.
Pincer grip.
Knows own name.
Finger feeds.
Walks around
furniture sideways.
Release on request.
2-3 words with
meaning.
Pushes arms into
sleeves.
Understands simple
commands.
Plays games.
Picks up, drinks and
puts down cup.
Walks with feet apart
and arms up
15
months
Holds bottle.
Understands “no” and
“bye-bye”.
Rocks on all fours.
12
months
Stranger anxiety.
Looks for toys when
out of sight.
Walks alone.
2 cube tower.
Jabber with expression.
Stairs: creeps up,
goes down
backwards.
Holds two cubes in
one hand.
2-6 words.
Points to object on
request.
Spoon feeds with
mess.
Indicates wet nappy.
269
18
months
Walks alone with
arms down.
3 cube tower.
6-20 words
Scribbles
Handles spoon well.
Looks at pictures.
Cannot turn unless
standing still.
Takes off shoes and
socks.
Throws a ball.
Climbs onto a chair.
24
months
Runs.
6 cube tower.
<50 words.
Stairs: up and down
two feet per step.
Obvious hand
preference.
Short phrases.
Stairs: up – one foot
per step, down – 2
feet per step.
9 cube tower.
Knows name and sex.
Toilet trained.
Copies circle.
Uses pronouns.
Climbs.
Cuts with scissors.
Talks incessantly.
Dress with
supervision.
Walks on tip toes.
Builds a bridge.
48
months
Stairs: up and down
one foot per step.
Copies cross.
Full name and age.
Builds a gate.
Recognise colours.
(4 years)
Stands on one leg 35 seconds.
Dresses and
undresses.
Hops.
Make believe play.
Asks for food, drink and
toilet.
Kicks a ball.
Spoon feeds without
mess.
Pretend play.
Squats and rises
without hands.
36
months
(3 years)
60
months
Walks along narrow
line.
(5 years)
Hops on each foot
separately.
72
months
Sits up without using
hands.
(6 years)
Walks backwards
along straight line.
Eats with a fork.
Washes and dries
hands.
6 cube steps.
Fluent speech.
Copies square and
triangle.
Knows 3 opposites.
Eats with spoon and
fork.
Dresses and
undresses alone.
Uses knife and fork.
Draws a man.
Chooses own
friends.
10 cube steps.
Learns comparatives.
Copies diamond.
270
Cooperative play.
18.93 Guidelines to paediatric patient journey < 12 months at diagnosis
HIV PCR positive children under 12 months old with a positive PCR result must be started on ART
readiness the day of diagnosis i.e. the day the positive PCR result is disclosed to the mother.
Visit 1 (disclosure visit):
1. See the Nurse for disclosure of positive HIV result. Note that the patient may have been referred by the
clinic and thus the mother should have already had post test counselling and had the result disclosed to
her. It is still important to reiterate the post test counselling here in our clinic.
2. Counsellor to open a paediatric (blue) file for the child ASWELL as an adult (pink) file for the mother if
she does not already have one. (The mother will follow the routine Adult HIV wellness programme.)
Insert the appropriate growth chart. Attach the “Positive PCR” tag.
3. Take vital signs (Wt, Ht, T, HR, RR). Record in OPD card and write weight on front tag.
4. Patient and caregiver go back to see the nurse.
 Transcribe vitals into blue file
 Take history
 Treat any minor complaints
 Baseline Bloods:
- First check PCR result is in the file
- FBC, ALT, Creat, CD4, HBSAg and Viral load.
 Prescribe Cotrimoxazole (Bactrim) and MVT monthly (see protocol).
 Refer to doctor only if unwell
5. Counsellor to conduct individual counselling session
 Basic HIV education/post test counselling. Note the importance of stressing that HIV positive
children can thrive if their health is carefully monitored in and HIV clinic and if ARV’s are given to
the child correctly as per the prescription.
 Clinic orientation
 Cotrimoxazole (Bactrim) prophylaxis
 Nutritional counselling – formula/breastfeeding etc
 Start basic adherence counselling for ARVs
6. Caregiver to attend support group with all members of the clinic (10am-12pm)
7. TCB 1 week
Note. If the nurse or counsellors feel that this mother or care giver may need further counselling or
time before she is ready to embark on lifelong HIV therapy for her child, then it may be indicated on
the file that they are to come back to “repeat visit 1” in one week.
Visit 2 (ARV start visit):
1. Get file
2. Take vital signs (Wt, Ht, T, HR, RR). Record in OPD card and write weight on front tag.
3. Check that all results taken at previous visit are in the file. Find and file any outstanding results. If not
phone the Lab and record the telephonic results in a note on the file.
4. Patient and caregiver to see the counsellor:
 Individual counselling and complete counsellor lead questionnaire on the wellness visit sheets.
 Ensure compliance to Bactrim.
 Further adherence counselling on the chosen ART regimen. In this group of children it will be D4T /
3TC / Kaletra unless stated otherwise by the doctor. It is important to make sure the caregiver can
open all the bottles and can draw up all the liquids to the right amount. This MUST be done as
practice in the counselling session.
5. Patient and caregiver are to see the nurse for a “clinical visit”
 Transcribe vitals into blue file
 Take a history
271
 Plot weight and height on appropriate growth chart
 Make a nutritional and developmental assessment
 Check blood results
 Prescribe and dispense Cotrimoxazole (Bactrim) and MVT
 Vit A if not given in the last 6 months
6. Patient and care giver to see the doctor:
 Take history, past medical history
 Examination
 Review CXR
 Prescribe ARV’s according to the Current ARV dosing table.
7. Patient and care giver to see the pharmacy assistant
 Dispense ARV’s
 Ensure caregiver can open all bottles and draw up all liquids to the correct amount.
8. TCB 2 weeks for adherence visit
Further visits follow the normal schedule of events for any child on ARV’s with 6 monthly blood draws and
clinical visits and 3 monthly prescription reviews.
272
18.94 Guidelines to paediatric patient journey > 12 months at diagnosis
Children diagnosed as HIV positive that are over 12 months old at the time of diagnosis are enrolled into
the Paediatric Wellness Programme. While attending follow up in this clinic they will regularly be assessed
as to whether or not they need ARV’s.
Remember!
Children are not just small adults! Their immune system is very immature as compared to that of
adults and thus the damaging effects of HIV can happen a lot more quickly than in adults.
The above statement is especially true for younger children. Thus we will treat those children under 3 years
old slightly differently than those over 3 years old. The younger ones will have more frequent “clinical visits”
and CD4 blood draws than the older children.
Thus, children younger than 3 years:
The schedule allows for 3 monthly blood draws and immunological evaluation, 3 monthly growth and
development check and 3 monthly staging.
Month
Type of visit
1
Initial / First Visit (with blood draw)
2
Clinical Visit with Doctor Review
3
Check up 1
4
Check up 2 (with blood draw)
5
Clinical Visit
6
Check up 1
7
Check up 2 (with blood draw)…and so on…
Those older than 3 years old:
The schedule allows for 6 monthly blood draws and immunological evaluation, 6 monthly growth and
development check and 6 monthly staging
Month
Type of visit
1
Initial / First Visit (with blood draw)
2
Clinical Visit with Doctor Review
3
Check up 1
4
Check up 2
5
Check up 3
273
6
Check up 4
7
Check up 5 (with blood draw)
8
Clinical Visit
9
Check up 1….. and so on…
Remember!
All HIV positive children under 12 months will be referred to the doctor on the day of diagnosis to
initiate workup for HAART initiation.
The First Visit
This would be the first visit that a child presents to our PART clinic with a diagnosis of HIV. The child may
have come from our own Infant Follow-up Clinic (IFC), from the OPD or a feeder clinic, or from the
paediatric ward.
Note the diagnosis of HIV in a child is 

Under 18 months - a positive HIV DNA (qualitative) PCR
Over 18 months - a reactive rapid HIV test WITH A POSITIVE HIV ELISA as confirmation
The steps or procedure to follow on the first visit would be:
8. Counsellor to open a paediatric (blue) file for the child ASWELL as an adult (pink) file for the mother if
she does not already have one. (The mother will follow the routine Adult HIV wellness programme.)
Attach the appropriate TAG – either 1-3yrs or >3 years. Insert the appropriate growth chart.
9. Take vital signs (Wt, Ht, T, HR, RR, BP if >3yrs). Record in OPD card and write weight on front tag.
10. Individual session with a counsellor
 Basic HIV education/post test counselling
 Clinic orientation
 Cotrimoxazole (Bactrim) prophylaxis (see protocol)
 Expectations of patient/caregiver
4. Caregiver to attend support group with all members of the clinic (10am-12pm)
5. Patient and caregiver are to see the nurse.
 Transcribe vitals into blue file
 Take history
 Treat any minor complaints
 Baseline Bloods
- First check PCR or ELISA result is in the file
- FBC, ALT, Creat, CD4, HBSAg (also take ELISA if not previously taken, i.e. the child was
referred to us with a positive rapid test)
 Prescribe Cotrimoxazole (Bactrim) and MVT monthly.
Age
Weight
Cotrimoxazole once
daily dose
MVT once daily
dose
6wks – 2 months
Less than 5 kg
2,5 ml
2.5 ml
274
2 -12 months
5 – 9.9 kg
5 ml
2.5 ml
12 – 24 months
10 – 14.9 kg
7.5 ml
5 ml
24 – 60 months
15 – 21.9 kg
10 ml or 1 tab
5ml
Older than 60 m
More than 22 kg
15 ml or 1.5 tab
1 tab

Age
Vit A and Deworming must be given at least 6 monthly.
Vit A
Deworming (give one of…)
Mebendazole
Albendazole
6wks – 6 months
50 000 IU
Not given
Not given
6 – 12 months
100 000 IU
Not given
Not given
12 – 24 months
200 000 IU
100mg BD for 3
days
200mg stat
Older than 24
months
200 000 IU
500mg stat
400mg stat


Refer to the doctor only if sick.
Give a review date of two weeks’ time.
The Nurse Clinical Visit And Doctor Review
1. Get file
2. Take vital signs (Wt, Ht, T, HR, RR, BP if >3yrs). Record in OPD card and write weight on front tag.
3. Check that all results taken at previous visit are in the file. Find and file any outstanding results. If not
phone the Lab and record the telephonic results in a note on the file.
4. Counsellor – individual counselling and complete counsellor lead questionnaire on the wellness visit
sheets. Check and give feedback on CD4 count to caregiver. NOTE: if the CD4 is low according to
our clinic guidelines (see below), then the counsellor may initiate the ART counselling prior to
the doctor’s consultation with the patient.
CD4 ranges for initiating ART in children over 12 months old
Age
CD4 limits
0-12 months
Regardless of CD4 – start ART
1-3 years
CD4% < 25% - start ART
3-5 years
CD4% < 20 % - start ART
Older than 5 years
CD4 absolute < 350 – start ART
5. Caregiver to attend support group with all members of the clinic (10am-12pm)
6. Patient and caregiver are to see the nurse.
 Transcribe vitals into blue file
 Take a history
 Plot weight and height on appropriate growth chart
275
 Make a nutritional and developmental assessment
 Check blood results. Act on or refer any abnormal results
 Prescribe and dispense Cotrimoxazole (Bactrim) and MVT
 Send to doctor for clinical and immunological staging.
7. The doctor should now be able to make a decision as to whether the child needs antiretroviral therapy
(ART) at this point or not. If ART is indicated the doctor will initiate the adherence counselling process
and the child’s name is to be put on the list for ART start. If ART is not yet indicated the child can
continue on the wellness schedule.
8. The child must be given a review date in one month time.
Check up
1. Get file
2. Take vital signs (Wt, Ht, T, HR, RR, BP if >3yrs). Record in OPD card and write weight on front tag.
3. Counsellor – individual counselling and complete counsellor lead questionnaire on the wellness visit
sheets.
4. Caregiver to attend support group with all members of the clinic (10am-12pm)
5. Patient and caregiver are to see the nurse.
 Transcribe vitals into blue file
 Check that the patient is not losing weight
 Take history
 Treat any minor complaints
 Prescribe and dispense Cotrimoxazole (Bactrim) and MVT
6. Send to doctor only if ill
7. Give review date of one month time
Check up (with blood draw)
1. Get file
2. Take vital signs (Wt, Ht, T, HR, RR, BP if >3yrs). Record in OPD card and write weight on front tag.
3. Counsellor – individual counselling and complete counsellor lead questionnaire on the wellness visit
sheets.
4. Caregiver to attend support group with all members of the clinic (10am-12pm)
5. Patient and caregiver are to see the nurse.
 Transcribe vitals into blue file
 Check that the patient is not losing weight
 Take history
 Treat any minor complaints
 Prescribe and dispense Cotrimoxazole (Bactrim) and MVT
 Blood draw: Hb and CD4
6. Send to doctor only if ill
7. Give review date of one month time
Remember!
Children under 3 years will have 2 check up visits with a blood draw on the second check up.
Children over 3 years will have 5 check up visits with a blood draw on the 5th check up.
The Nurse Clinical Visit
9. Get file
10. Take vital signs (Wt, Ht, T, HR, RR, BP if >3yrs). Record in OPD card and write weight on front tag.
276
11. Check that all results taken at previous visit are in the file. Find and file any outstanding results. If not
phone the Lab and record the telephonic results in a note on the file.
12. Counsellor – individual counselling and complete counsellor lead questionnaire on the wellness visit
sheets. Check and give feedback on CD4 count to caregiver.
13. Caregiver to attend support group with all members of the clinic (10am-12pm)
14. Patient and caregiver are to see the nurse.
 Transcribe vitals into blue file
 Take a history
 Plot weight and height on appropriate growth chart
 Make a nutritional and developmental assessment
 Check blood results
 Prescribe and dispense Cotrimoxazole (Bactrim) and MVT
 Deworm and Vit A if not given in the last 6 months
 Send to doctor if the child’s CD4 is low, the child is unwell or there is a concern with growth
etc that may need assessment for ART
7. The child must be given a review date in one month time.
This cycle will continue until such time as the child needs HAART indicated either by a CD4 count lower
than the above limits or the child develops a stage 3 or 4 HIV related illness.
277
18.95 HIV wellness tag for paediatric patient 1-3yrs
PART Wellness Schedule (1-3years)
Visit type
Date
Weight
First Visit (+Bloods):
___________
______
Clinical Visit:
___________
______
Check up:
___________
______
Check up (+Bloods):
___________
______
Clinical Visit:
___________
______
Check up:
___________
______
Check up (+Bloods):
___________
______
Clinical Visit:
___________
______
Check up:
___________
______
Check up (+Bloods):
___________
______
Clinical Visit:
___________
______
18.96 HIV wellness tag for paediatric patient > 3yrs
Check up:
___________
______
PART
Wellness
Schedule
(>3 years) ______
Check up
(+Bloods):
___________
Clinical Visit:
___________
______
Visit
Checktype
up:
Date
___________
Weight
______
Check up (+Bloods):
___________
______
First
Visit
(+Bloods):
Clinical
Visit:
___________
___________
______
______
Clinical
Visit:
Check up:
___________
___________
______
______
Check
Check up
up 1:
(+Bloods):
___________
___________
______
______
Check
2:
Clinicalup
Visit:
___________
___________
______
______
Check
Check up
up:3:
___________
___________
______
______
Check
Check up
up 4:
(+Bloods):
___________
___________
______
______
Check
5: (+Bloods): ___________
Clinicalup
Visit:
___________
______
______
Clinical Visit:
___________
______
Check up 1:
___________
______
Check up 2:
___________
______
Check up 3:
___________
______
Check up 4:
___________
______
278
18.97 PART – WHO Staging
WHO Staging
(Modified for Madwaleni from Interim Revised WHO clinical staging)
Stage 1
Stage 4
Asymptomatic
Extra pulmonary TB
Lymph nodes
Severe Malnutrition (Wt <60% expected)
PJP (PCP)
Stage 2
Chronic herpes simplex infection
Hepatosplenomegaly
Oesophageal candidiasis
Chronic Skin complaints (eg PPE, Seb Derm)
Kaposi’s Sarcoma
Chronic mouth ulcers, sores and angular chelitis
Cryptococcal Meningitis
Enlarged parotid glands
HIV encephalopathy
Herpes Zoster (Shingles)
Recurrent/Chronic ear infections esp. otorrhoea
Stage 3
Pulmonary TB
Moderate Malnutrition (Wt 60-80% expected)
….and many others that we might not diagnose
at Madwaleni. For a comprehensive list see the
Interim Revised WHO Clinical Staging of HIV
and AIDS in Children
Persistent diarrhoea (>14 days)
Oral candidiasis
Acute necrotising gingivitis
Severe recurrent pneumonia (admitted for Rx)
Chronic HIV-assoc lung disease (LIP and
Bronchiectasis)
Perisistant Anaemia (<8), neutropaenia (<0.5)
or thrombocytopaenia (<50)
279
18.98 Danger signs in sick children
General Danger Signs
Ask



Look

Is the child unable to drink or breast feed?
Does the child vomit everything?
Has the child had convulsions/fits during this illness?
Is the child lethargic/drowsy or unconscious? If yes check blood sugar
If the Child is coughing / having difficulty breathing:
Ask:
 How long?
Look/ listen
 Any general danger sign?
 Chest indrawings?
 Stridor in a calm child?
If yes call doctor immediately and initiate IMCI actions.
 Count respiratory rate.
FAST BREATHING
If the child is:
Fast
breathing is:
2 months to 12 months
50 or more
breaths per minute
12 months up to 5 years
40 or more
breaths per minute
If the child is having diarrhoea:
Ask:
 For how long? More than 14 days?
 Is there blood in the stool?
 How much and what fluid is the mother giving the child?
Look/Feel:
 Any general danger sign?
 Irritable and restless?
 Sunken eyes?
 Offer ORSOL – not able to drink/drinks poorly? (vs drinking eagerly/thirsty)
 Skin pinch slow or very slow (>2 seconds)
If yes Call doctor and initiate IMCI actions.
If the child has a fever (give paracetamol for fever over 38C):
Ask:
 For how long?
Look/Feel for:
 Stiff neck?
 Bulging fontanelle?
If yes, suspect meningitis, call doctor and initiate IMCI actions.
NB if doctor immediately available, wait for them to perform LP and administer Dexamothasone
before giving Ceftriaxone.
If the child has an ear problem:
Look:
 Tender swelling behind the ear?
If yes suspect mastoiditis. call doctor and initiate IMCI actions.
280
Then check for malnutrition and anaemia:
Ask/look:
 Has the child lost weight?
 Plot weight on RTHC. Weight under 60%EWFA? Flat curve or loss of weight?
 Visible severe wasting?
 Oedema of both feet?
 Severe palmar pallor or Hb<6?
If yes, call doctor and initiate IMCI actions.
281
18.99 Paediatric ART prescription and dispensing record
PAEDIATRIC MADWALENI ANTIRETROVIRAL TREATMENT PRESCRIPTION FORM
Name of
Facility
Patient
Name
ID number
Age at ARV start
Address
Patient
Number
Folder
Number
Nearest
clinic
Gender
M
F
Rx supporter
Contact phone no.
In/Out patient?
Any specific Dr instruction to
pharmacy re dosing
Details of new prescription
Date:
Starting regimen
Drug1
Drug 2
Drug 3
Drug 4
Prescriber's name & Signature
Pharmacy ART dispensing record - First 3 months only
First
Adherence
Repeat
1
Repeat
2
Repeat
3
Dispensing dates
dd/mm/yy
dd/mm/yy
dd/mm/yy
dd/mm/yy
dd/mm/yy
Name of drug
Quantity
dispensed
Pill count
Pill count
Quantity
dispensed
Pill count
Quantity
dispensed
Pill count
Quantity
dispensed
NEW
DOCTORS
PRESCRIPTI
ON REQ'D
EVERY 3
MONTHS
TCB date
Dispensed by
(sign)
Details of revised prescription
Date:
Updated regimen
Drug1
Drug 2
Drug 3
Drug 4
Repeat 4
Repeat 5
Repeat 6
Dispensing dates
dd/mm/yy
dd/mm/yy
dd/mm/yy
Name of drug
Quantity
dispensed
Quantity
dispensed
Quantity
dispensed
Dr instructions to pharmacy re dosing/adherence
issues:
282
TCB date
Dispensed by (sign)
Details of revised prescription
Date:
Updated regimen
Drug1
Drug 2
Drug 3
Drug 4
Repeat 7
Repeat 8
Repeat 9
Dispensing dates
dd/mm/yy
dd/mm/yy
dd/mm/yy
Name of drug
Quantity
dispensed
Quantity
dispensed
Quantity
dispensed
Repeat 10
Repeat 11
Repeat 12
Dispensing dates
dd/mm/yy
dd/mm/yy
dd/mm/yy
Name of drug
Quantity
dispensed
Quantity
dispensed
Quantity
dispensed
Dr instructions to pharmacy re dosing/adherence
issues:
TCB date
Dispensed by (sign)
Details of revised prescription
Date:
Updated regimen
Drug1
Drug 2
Drug 3
Drug 4
Dr instructions to pharmacy re dosing/adherence
issues:
TCB date
Dispensed by (sign)
283
PAEDIATRIC MADWALENI ANTIRETROVIRAL TREATMENT PRESCRIPTION FORM Month 13 - 27
Patient
Name:_____________________
Details of revised prescription
Wt:_________
Date:
Updated regimen
Drug1
Drug 2
Drug 3
Drug 4
File No:_________
Repeat 13
Repeat 14
Repeat 15
Dispensing
dates
dd/mm/yy
dd/mm/yy
dd/mm/yy
Name of
drug
Quantity
dispensed
Quantity
dispensed
Quantity
dispensed
Dr instructions to pharmacy re dosing/adherence issues:
TCB date
Dispensed
by (sign)
Details of revised prescription
Wt:_________
Date:
Updated regimen
Drug1
Drug 2
Drug 3
Drug 4
Repeat 16
Repeat 17
Repeat 18
Dispensing
dates
dd/mm/yy
dd/mm/yy
dd/mm/yy
Name of
drug
Quantity
dispensed
Quantity
dispensed
Quantity
dispensed
Dr instructions to pharmacy re dosing/adherence issues:
TCB date
Dispensed
by (sign)
Details of revised prescription
Wt:_________
Date:
Updated regimen
Drug1
Drug 2
Drug 3
Drug 4
Repeat 19
Repeat 20
Repeat 21
Dispensing
dates
dd/mm/yy
dd/mm/yy
dd/mm/yy
Name of
drug
Quantity
dispensed
Quantity
dispensed
Quantity
dispensed
Repeat 22
Repeat 23
Repeat 24
dd/mm/yy
dd/mm/yy
dd/mm/yy
Dr instructions to pharmacy re dosing/adherence issues:
TCB date
Dispensed
by (sign)
Details of revised prescription
Wt:_________
Date:
Updated regimen
Dispensing
284
dates
Name of
drug
Drug1
Drug 2
Drug 3
Drug 4
Quantity
dispensed
Quantity
dispensed
Quantity
dispensed
Dr instructions to pharmacy re dosing/adherence issues:
TCB date
Dispensed
by (sign)
Details of revised prescription
Wt:_________
Date:
Updated regimen
Drug1
Drug 2
Drug 3
Drug 4
Repeat 25
Repeat 26
Repeat 27
Dispensing
dates
dd/mm/yy
dd/mm/yy
dd/mm/yy
Name of
drug
Quantity
dispensed
Quantity
dispensed
Quantity
dispensed
Dr instructions to pharmacy re dosing/adherence issues:
TCB date
Dispensed
by (sign)
285
18.100 Antiretroviral (and other) Drug Dosages Chart for Children (Madwaleni October 2009)
First Line Antiretrovirals
Second line / Substitution
Antiretrovirals
Weight
Band
(kg)
Stavudine
(d4T)
Other Drugs
Weight
Lamivudine
Lopinovir/Rit
Efavirenz
Abacavir
Zidovudine
Didanosine
Cotrimoxazole
MVT
(3TC)
(Kaletra)
(EFV)
(ABC)
(AZT)
(ddI)
(Bactrim)
Once
daily
(kg)
Twice daily
Twice Daily
Once daily at night
Twice
daily
Twice daily
2.5ml
2.5ml
<3
2.5ml
2.5ml
3-3.9
Twice daily
<3
Once daily
Consult with a clinician experienced in prescribing ART for neonates / young infants
3-3.9
6ml
3ml
1ml
4-4.9
6ml
3ml
1.5ml
5-5.9
7.5mg
3ml
1.5ml
Dosing <10kg not
established
Band
3ml
6ml
Avoid
3ml
6ml
2.5ml
2.5ml
4-4.9
3ml
6ml
5ml
2.5ml
5-5.9
5ml
2.5ml
6-6.9
5ml
2.5ml
7-7.9
5ml
2.5ml
8-8.9
5ml
2.5ml
9-9.9
7.5ml
5ml
1010.9
7.5ml
5ml
1111.9
7.5ml
5ml
1213.9
10ml or 1tab
5ml
14-
6-6.9
7.5mg
4ml
1.5ml
3ml
9ml
7-7.9
10mg
4ml
1.5ml
4ml
9ml
8-8.9
10mg
4ml
1.5ml
4ml
9ml
9-9.9
10mg
4ml
1.5ml
4ml
9ml
1010.9
15mg
6ml
2ml
200mg
6ml
12ml
1111.9
15mg
6ml
2ml
200mg
6ml
12ml
1213.9
15mg
6ml
2ml
200mg
6ml
12ml
14-
20mg
½ tab
2.5ml
250mg
7ml
200mgmane
286
See Separate Table for ddI dosing
Avoid
16.9
100mgnocte
1719.9
20mg
½ tab
2.5ml
250mg
8ml
2024.9
20mg mane
1 tab mane ½ tab
3ml
300mg
10ml
2529.9
30mg
1 tab
3.5ml
350mg
3034.9
30mg
1 tab
4ml
3539.9
30mg
1 tab
>40
30mg
1 tab
16.9
10ml or 1tab
5ml
1719.9
200mg
10ml or 1tab
5ml
2024.9
300mg
tab
300mg tab
10ml or 1tab
5ml
2529.9
400mg
300mg
tab
300mg tab
2 tabs
1 tab
3034.9
5ml
400mg
300mg
tab
300mg tab
2tabs
1tab
3539.9
5ml
600mg
300mg
tab
300mg tab
2tabs
1tab
>40
nocte
30mg nocte
Adapted from the Antiretroviral Drug Dosing Chart for Children (2009)
Compiled by J. Nuttal and S Raiman for the Paeditric HIV/TB Policy Reference Group, Western Cape Department of Health
287
18.101 Growth charts used in PART clinic
288
289
290
291
18.102 Nurse protocol – treating anaemia in children
Look for palmar pallor. Is there:
 Severe palmar pallor?
 Some palmar pallor?
If any pallor, check haemoglobin (Hb) level.
Severe palmar pallor
or
Hb <6g/dl
SEVERE ANAEMIA
Some palmar pallor
or
Hb 6g/dl to 10g/dl
ANAEMIA
No pallor
NO ANAEMIA

Refer URGENTLY

Give iron and counsel on iron rich diet (as
below)
Assess Feeding and counsel
Treat for worms if due
Follow up in 2 weeks
If child is less than 2 years assess feeding
and counsel.
Treat for worms if due





Give Iron for Anaemia





Give three doses daily. Supply enough for 14 days.
Follow up every 14 days and continue treatment for 2 months
The dose of iron is 2mg of elemental iron for every kilogram of weight. The dose given to the child depends
on the type of iron supplement stocked. At Madwaleni Hospital we stock Ferrous Gluconate (Kiddievite), but
this must be checked regularly with the pharmacy to ensure suppliers have not been changed.
Tell mothers to keep iron out of reach of children because an overdose is very dangerous!
Give iron with food if possible. Inform the mother that it can make the stools look black.
Weight
Ferrous Gluconate
(Kiddievite)
Ferrous Lactate
Drops
Ferrous Sulphate
tablet
(40mg elemental iron
per 5ml)
(25mg elemental iron
per 5 ml)
(60mg elemental
iron)
Give ONLY ONE OF ABOVE three times daily with meals
3 – 5.9 kg
1.25 ml
0.3 ml (½ dropper)
NO
6 – 9.9 kg
2.5 ml
0.6 ml (1 dropper)
NO
10 – 25 kg
5 ml
0.9 ml (1 ½ dropper)
½ tablet
Iron rich diet



Meat (esp kidney, spleen, chicken livers), dark green leafy vegetables, legumes (dried beans, peas
and lentils).
Iron is absorbed best when eaten with Vitamin C (in fruit and MVT supplements).
Tea, Coffee and whole grain cereal interfere with iron absorption
292
18.103 Doctor protocol – management of lipodystrophy in children on HAART
Background
Lipodystrophy, also known as Fat Redistributions Syndrome (FRS), occurs in 18-33% of children on
HAART. The most common offender is Stavudine (D4T). The incidence increases with length of time on
HAART. The limited evidence available suggests Abacavir (ABC) to be the best substitution for Stavudine
in children as Zidovudine (AZT) may also cause lipodystrophy. The features are usually irreversible and
hence action should be taken as soon as lipodystrophy is suspected for the best outcome.
Note: this is different to the dyslipidaemia and insulin resistance usually associated with the protease
inhibitors (eg Kaletra/Alluvia) and are not causally related as far as we know. Stavudine may also cause
dyslipidaemia.
Diagnosis
Lipodystrophy is a clinical diagnosis. There are no reproducible objective measurements to use for
monitoring and diagnostic purposes. Typically it produces


peripheral wasting of subcutaneous fat (lipoatrophy): facial, limb, and buttocks wasting or
central increase in subcutaneous fat (lipohypertrophy): increase in abdominal girth, breast
enlargement, “buffalo hump”, and development of lipomas
 or both.
Undress the child if you are concerned, facial wasting alone is not usually helpful in making a confident
diagnosis.
Management
1. If the child is well controlled on the current regimen consider a single swap from Stavudine (or
Zidovudine) to Abacavir.
2. Take baseline viral load and CD4 count to ensure the child is well suppressed on the current
regimen. (Remember: you must NEVER change a single drug in a failing regimen)
3. Fill in a drug order form and hand it in to the Madwaleni Pharmacist (the form is titled Province of
the Eastern Cape, Dept of Health, Motivation for a named Patient and a copy can be found in the
green “PART clinic documents” expanding file. Clearly state whether the syrup or tablets must be
ordered. (This will be faxed to the provincial pharmacist for authorisation)
4. Abacavir can be started the following month providing the child’s viral load is well suppressed.
5. Remember to explain the acute hypersensitivity reaction (although rare) that can occur with ABC.
6. If the viral load is unsuppressed the child will likely need a complete regimen change together with
appropriate adherence counselling. Discuss with someone with experience in prescribing ART
before changing.
7. Clarify to the caregiver that the change will prevent the symptoms getting worse but will not
necessarily improve the current body appearance
8. The event should be reported as an SAE. This form (Adverse Drug Reaction and Product Quality
Problem Report Form) can be found in the SAMF at the back, or in the “PART clinic documents”
expanding file. This form must be faxed to NADEMC on (021) 488 6181.
293
18.104 Group 1 ART initiation – doctor protocol
Framework for the use of Group 1 ARV’s in adults
Group 1 ARV’s are ALWAYS a bridge to group 2. If possible always ask the patient if they would be prepared to move
to group 2 ARV’s before you start.
There are essentially two reasons for using group 1 ARV’s:1) ARV’s need to be started quickly, as we have no other adequate treatment and there is not enough time for
counselling. For example, as a lifesaving/ sight saving measure we should consider starting ARV’s immediately for:



Kaposi sarcoma
CMV retinitis
Cryptosporidium parvum diarrhoea
2) The patient is too sick/confused to be counselled about taking ARV’s on his or her own. In general the patient will
have been in hospital for a minimum of 2 weeks and had either extensive investigation to rule out other treatment
options or had at least 2 weeks of effective treatment for an OI before group 1 ARV’s are considered. Examples
include:



HIV encephalopathy
Chronic unexplained diarrhoea- too sick for counselling
CD4 count low (<50), responding to OI treatment and engaging with counselling but too sick to take ARV’s
alone in the beginning.
294
18.105 Guideline to inpatient programme
Group 1 - Palliative step-up group (see Doctor protocol on patients qualifying for Group 1)
1.
2.
3.
4.
5.
6.
7.
8.
9.
Patients’ baseline bloods to be taken in the ward by ward staff – ELISA, CD4, RPR, ALT, FBC, Cr,
HBV and Urine Dipstick
Ward doctor together with ARV clinician to decide which patients qualify for Group 1.
Ward doctor will then write a referral letter to the pharmacist requesting ARV drugs to be dispensed
to individual patient through the relevant ward nurse.
Ward doctor will also inform the HIV Dept by completing the patient’s details on the “Inpatient
programme list” (see attached) which is submitted weekly to the HIV Dept.
The pharmacist will keep a file with these referral letters.
Ward nursing staff will administer ARV drugs to Group 1 patients.
Ward doctor together with the ward nursing staff will determine if and when the Group 1 patient is
competent to be educated about the ARV drugs which he/she is taking and the adherence issues
relating thereto.
The ward nursing staff/doctor will then advise the HIV/ARV site co-ordinator through the “Inpatient
programme list” and the patient will be transferred to Group 2 for ARV education so that they can
become responsible for taking their ARV drugs.
If the Group 1 patient at no time becomes competent to be educated about the ARV drugs and
adherence thereto but is going to be sent home, the Group 1 patient must identify a treatment
partner who lives at home who will then be educated as a Group 2 patient.
Group 2 – Fast track inpatients
1.
2.
3.
4.
5.
6.
7.
8.
Patients’ baseline bloods to be taken in the ward – ELISA, CD4, RPR, ALT, FBC, Cr, HBV and
Urine Dipstick.
Ward doctor with ward nursing staff will decide which patients qualify for Group 2 on a Monday
(week 1) ward round.
Ward Doctor/Nursing staff will complete the “Inpatient programme list” with the names of these
patients and submit to the HIV/ARV site co-ordinator.
The HIV/ARV site co-ordinator will allocate a counsellor to educate these Group 2 patients for 1
week in:
 HIV awareness (general information relating to HIV – what is HIV, transmission of HIV, safe sex,
disclosure issues, good nutrition etc)
 ARV information (shortened version of ARV adherence counselling – what do ARV drugs do,
names of ARV drugs, side effects, personal commitment required to taking ARV drugs for the
rest of your life etc)
 HIV programme information (How the programme generally works, that we want to fast track
them and open files for them, that on discharge they will be expected to attend the clinic once a
month to partake in support group and fetch their repeat prescription of ARV drugs).
Ward nursing staff together with the allocated counsellor will evaluate the Group 2 patient’s
education and qualification for the ARV readiness programme (using the Group 2 form in patient’s
chart).
Group 2 patients that have not completed the education successfully will either:
 if progressing with their HIV/ARV knowledge - continue to be educated by the allocated
counsellor for a further week.
 if not progressing receive a final counselling session by the allocated counsellor where the
HIV programme is explained again and it is explained that the HIV programme is always
available to them upon discharge from the ward.
Group 2 patients that have completed the education successfully will be enrolled on the ARV
readiness programme.
On the following Monday (week 2), the allocated counsellor will open a pink file for the Group 2
patient and will focus on the following issues over the week:
 Safe sex
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

Disclosure of HIV status to treatment partner
Future home visit - they will be visited at their home within a month of discharge by a
community health worker to teach their family about ARV drugs and adherence to them (this
will be combined with a TB sputum check)
 Cotrimoxazole pill count – the patient will be issued with 56 Cotrimoxazole tablets and told
how to take them and that we will conduct a pill count a week later to see the patient has
taken his/her Cotrimoxazole as required
 Determine whether they will be able to come to Madwaleni to fetch their repeat ARV drugs
monthly (find out details of exactly where they live, which is their closest clinic, which
hospital would they usually go to, what the transport cost to Madwaleni is etc)
The following Monday (week 3), the allocated counsellor will report to the ward nursing staff on the
Group 2 patient’s success with ARV readiness (using group 2 form):
 Where the patient has got his/her Cotrimoxazole pill count incorrect or where the patient has
not disclosed his/her HIV status to his/her treatment partner or does not want the community
health workers to conduct a home visit or there is a concern that he/she may not come in
monthly to fetch their ARV prescription – the patient will stay on the ARV readiness
programme and continue to be evaluated on a weekly basis by the ward nursing staff
together with the allocated counsellor.
 Where the patient has completed his/her ARV readiness successfully, the ward doctor will
indicate on both the group 2 form and the “Inpatient programme list” that patient is ready to
start ART.
The allocated counsellor will then conduct adherence counselling with these Group 2 patients on
the same Monday (week 3). They will also arrange that the patient approach them before discharge
for a home visit to be scheduled.
Once the allocated counsellor has completed adherence counselling, he/she will write patient’s
name on the board in the HIV Dept for starting ART on that Thursday (week3).
The HIV Dept will prepare the inpatient files for starting ART.
The files will be taken to the Doctors’ meeting on Thursday morning by the HIV/ARV site coordinator for signing the prescriptions. Once signed they will be taken to the pharmacy assistant for
dispensing the ARVs to the patient in the ward.
The HIV programme nurse will then take the inpatients’ baseline bloods (before the patient takes
the first dose of ART).
The new ARV patient will be given an adherence visit date 2 weeks later – also on a Thursday. If
they are discharged before this date, the adherence visit will be moved to the preceding Tuesday (to
fit in with the rest of the repeat visits of ARV patients).
The following Monday (week 4), the allocated counsellor will check that the new ARV patients in the
ward are taking their ARV drugs correctly. Where there are problems these will identified early and
further counselling will be done.
9.
10.
11.
12.
13.
14.
15.
16.
(Please note that the above programme need not be implemented over 3 weeks but can be fast tracked
if patients are visited by counsellors more frequently – the above programme has focused on TB
patients who usually spend 44 days in the ward)
Group 3: inpatients on discharge from Group 2/Madwaleni Hospital (treated as an outpatient)
Discharge from Group 2 but staying in hospital
1.
2.
Where the ward nurse/doctor is of the opinion that the patient is well enough and will benefit
from attending the HIV wellness programme including the HIV support group run on a Tuesday
at the HIV Dept, the ward doctor will discharge the patient from Group 2 despite the patient still
being admitted at the hospital. The ward doctor will indicate this on the “Inpatient programme
list”.
The allocated counsellor will provide ‘discharge counselling’ session in the ward on the Monday
of discharge which will discuss the following:
 the patient must to attend HIV support group at the HIV Dept at 11am on each
Tuesday;
 the patient will be prepared for starting ARVs at the HIV Dept on Tuesdays;
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3.
 the patient is expected to attend the HIV Dept in order to evaluate the patient’s
commitment to taking ARVs.
The allocated counsellor will then check that patient has attended the Tuesday HIV wellness
clinic. If the patient does not, he/she will continue to motivate the patient to attend each Monday
when in the ward.
Discharge from Madwaleni Hospital
4.
Where patients are discharged from the hospital either before or after being prescribed ARV
drugs, they will receive a further ‘discharge counselling’ session at the HIV Dept which will
discuss the following:
 Short reinforcement summary of HIV information (specifically safe sex and disclosure) and
ARV information (specifically the benefits of taking ARV drugs)
 How the HIV programme works:
 If they do not have a file – they need to attend 3 HIV support groups at any of the
clinics to have a file opened for them;
 If they have a file but are not ARV patients yet – they need to attend any of the HIV
support groups at the clinics every weeks until they have completed the ARV
readiness programme;
 If they are an ARV patient – they need to attend the HIV support group and ARV
down referral date monthly at their clinic to get their repeat ARV prescription and
for ongoing clinical monitoring.
 If the patient is on ARVs – please check how many ARVs he/she has and refer them to HIV
Dept nurse if they require further supply before leaving the hospital to ensure they have
enough ARVs until their next dispensing date.
 If they are not interested in the HIV programme immediately, they can join it at any time in
the future.
ALL PATIENTS TO BE EDUCATED AND COUNSELLED OUTSIDE OF THE WARD IN SUNLIGHT. TB
NEW CASES TO WEAR MASKS FOR THE FIRST 7 DAYS OF TB TREATMENT AND TB
RETREATMENT PATIENTS TO WEAR MASKS AT ALL TIMES DURING EDUCATION OR
COUNSELLING
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18.106 Group 2 – counsellor form
GROUP 2 – Counsellor Form
Continue with ART adherence Y/N: (Doctor)
Week 1
Week 2
Week 3
Week start date:
Week start date:
Week start date:
Name of educator:
File number opened:
Educated in:
Educated in:
-
HIV awareness
-
ARV information
-
-
Safe sex
-
Disclosure
-
Home visit
-
Pill count
-
Collection details
Patient success in:
HIV program
information
-
Pill count correct?
Y/N
-
Disclosed to
treatment partner?
Y/N
-
Agrees to home
visit?
Y/N
-
Concerns about
ability to collect
medication?
Y/N
End of week
Assessment of education:
Ready? Y/N
Ready for ARV’s? Y/N
# Bactrim issued:
If not ready:
1. For extra week
OR
2. For final
counselling session
Bloods taken
FBC
If ready:
Adherence
counselling
- Schedule home
visit on discharge
ALT
Counsellor comments to doctor/nurse:
RPR
HIV ELISA
CD4
CR
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HBV
Urine Dipstick
18.107 Inpatient programme list – doctor communication tool
Inpatient programme list/record sheet:
Patient name
Discharge without a file
File
number
Date
Ward:
Date
Instruction
Date
Comment
Support group
Date
Instruction
Comment
Instruction
Comment
Died
File number
Date
Cause
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