Transcript IMCI supervision

Patient Monitoring:
Chronic HIV Care and ART
Sandy Gove
WHO HIV Department
HIV Care/ART
Card is on the
last 2 pages of
this module
Patient
monitoring
needs to be
integrated
within
comprehensive
HIV care and
ART!
Patient monitoring guidelines are based on:



Standardized core and other data elements- agreed by WHO, CDC,
USAID, PEPFAR, multiple NGOS attending a WHO Patient
Monitoring meeting in March 2004
Collecting and analyzing only what is needed for patient
management and for clinic, district and national management
Allowing flexibility for additional data collection and analysis
However:



Clear distinction is made between what is essential and what
should be reserved for extra operational research or data
summaries.
If data collection is not simple, it can be a barrier to scaling-up ART.
MORE IS NOT BETTER!
TB experience…
TB







Standardized treatment
card
Standardized register
Globally standardized
definitions
Deliberately constrains
data collected
Based on long
experience
Recently, new TB-HIV
indicators
Disease-specific (vertical)
ART/ chronic HIV care Builds on TB experience
but with key alterations
 Also requires a simplified
disease-specific system


Can pave the way or fit
with similar methods for
diabetes, other 'true'
chronic illnesses
Paper base is important
for feasibility
New in HIV care
and not yet
eligible for ART
A
New in HIV care
and eligible for
ART
C
Non-naïve patients
to ART who are
not Transfer In with
records
Enrolled in HIV care and
not yet eligible for ART
B
(Total = new + continuing)
Enrolled in HIV care and
eligible for ART
D
(Total = new + continuingincludes those who decline ART)
Died in preART care
Lost
Transferred out
Enrolled in HIV care and eligible
and ready for ART
E
New on ART this month
G
Total ever started
on ART
in this facility F
New on ART this month
G
TI = Transfer In
with records
Add to cohort
according to ART
start date
Start or continue on original
first-line ARV regimen
H
Substituted to alternative
first-line ARV regimen
I
Switched to second-line
(or higher) ARV regimen
J
DEAD after starting ART
TO = Transfer out
LOST
STOPped ART
(some Restart)
HW fills out HIV care/ART card. If switch to second line, substitutions,
stop, etc.—> MO decides,
Card defines
consults, log book, clinician coding listminimal data to be collected.
record on card
HW codes are on the card
Pre-ART register
Monthly ART register
Cohort analyses at 6,12 months then yearly—
Calculate indicators for clinic use only
▪ Calculate agreed district, national,
international indicators
▪
Monthly (cross-sectional) report
Input to monthly drug orders if required
District
Regional team to MOH to AFRO, HQ, agencies
Patient monitoring system

Paper system is based on 6 items:


A patient-held card
A facility-held chronic care card







HIV Care/ART Card or
Same data elements in another format
HIV Care pre-ART register
ART Register
Monthly report (updated from
Cohort analysis report
Format of the card
can be changed.
Standardized variables
and codes
are what is important.
This can serve multiple needs:



Direct patient care (facilitates paradigm shift from Acute to Chronic
Care)
Drug supply monitoring and preparation of facility drug orders
Data summarized and reported to meet district and national
programme needs and track progress to targets (3x5; 2,7,10; etc)
HIV care/ART card- adapt in
country during IMAI adaptation

Agreement is being finalized on the
standardized data elements



Definitions
Coding
Freedom to:



Use different formats including full patient chart
Collect additional data
Country adaptation, as clinical guidelines are adapted


If no INH prophylaxis for HIV patients, no column on card
Etc
HIV Care/ART Card adaptation

Most important to standardize system
nationally with allowances for collecting
more data/different formats for patient
cards or charts:

Number pages per patient- visit


Wide range from .05 (multiple visits on single card;
extract key data) to 8 pages
Card versus multiple page chart
Substantial variation in data
retained on card/chart
Simplest, limit paper:




Clinical review assisted
by laminated form
Record key treatment
data and pertinent
positives
Other details may be in
patient-held exercise
book or 'patient passport'
Example: IMAI; Malawi
More elaborate:



All positives and
negatives of clinical
review recorded
Detailed treatment data
Requires full chart
What is really needed?
HIV Care/ART Card backside in
IMAI: patient education and support

Education:



Adherence


Support




HIV basics, disease
progression
Treatments available

Psychosocial
Disclosure
Family
Prevention


Preparation
Decide when readyresults clinical team
meeting
Support
Problem solving
2 registers:
(1) Chronic HIV Care PreART
When registered for HIV care
Date HIV+
Entry point
Start/stop dates prophylaxis- CTX, fluconazole
Pregnancy, TB
**When medically eligible for ART
**When medically eligible and ready for ART
(prepared for adherence, clinical team has met)
**When ART started plus unique patient identifier
Dead before ART
Lost or Transfer out before ART
2 registers:
(2) ART Register (incl. post-ART)





Cohorts formed in ART register (not PreART
register)– by month
Date ART started, unique identity number
Why eligible 1=clinical only 2=CD4 3=TLC
At start ART: function, weight, (CD4)
Same as PreART register (transfer)


Start/stop dates prophylaxis- CTX, fluconazole
Pregnancy, TB
ART register- continued



Original regimen (coded)
Substitutions within first line and switches
to second line-- reason (code) and date
Months 0 to 24:



Each month: current regimen (coded)
At 6, 12 months: function, weight gain > 10%,
(CD4)
Then each year: function, (CD4)
Why STOP ART- reason codes
1 Toxicity/ side effects
2 Pregnancy- planned treatment interruption
3 Treatment Failure
4 Poor Adherence
5 Illness, Hospitalization
6 Drug out of Stock
7 patient lacked financial Resources
8 other patient Decision
9 planned treatment Interruption (put reason
10 Other
)
Why change ARV drug or
regimen
1 Toxicity/ side effects
2 Pregnancy
3 Risk of pregnancy
4 due to new TB
5 New drug available
6 Drug out of Stock
7 0ther reason (specify)_____________
Reasons for switch to 2nd-Line Regimen only:
8 Clinical treatment failure
9 Immunologic failure
10 Virologic failure
2 registers 2 reports
Monthly report:

New and cumulative ever:
Enrolled in HIV care

Started on ART at this facility
Disaggregated by sex, pregnancy, age





Transfer in (already on ART)
Restart ART
Patients eligible for ART but not
started
ARV regimens- number on

Each regimen

First-line

Second-line
Lost, Dead, Stopped, Transfer out
Cohort data for last month:
Median CD4: baseline, 6 and 12 mo
on ART
Picked up ARVs 5/6 or 10+/12
months

Cohort analysis
(quarterly or other
periodicity)

Patient status:







Alive- on or off ART, regimen
Dead
Lost
Transferred out
Functional status
Proportion with > 10%
weight gain
Proportion with CD4>200
Cohort analysis: 6 mo, 12 mo, yearly

Proportion of patients on ART with weight gain > 10% (6, 12
mo)
Proportion working, ambulatory, bedridden

Proportion alive and on ART at 6,12 months then yearly

Proportion still on a first-line regimen
Proportion still on original first-line regimen
Proportion who have substituted to an alternative first-line
regimen
Proportion switched to a second-line (or higher) regimen






Proportion of CD4 counts done which are >200 (optional)
Proportion of viral loads which are below 400 copies/ml (optional)
Treatment Centre at
District Hospital/HC IV
Register at
Health centre
Clinical team
Nursing
assistant,
lay
providers
Consult, refer, back-refer, visit
MO,
MD
Clinical team
Visits by district or regional ART team/coordinatorHelp with registers, reports, cohort analysis
Nursing
assistant,
lay
providers
Malawi cohort and 'cumulative'
analyses
Cumulative- Total registered on ART since start
Cohort- Number registered in that quarter
 Alive and on ART







On original first-line regimen (Start)
On alternative first-line (Substituted)
On second-line regimen (Switched)
Stopped
Defaulted– ? call 'Lost' to distinguish from TB
Transferred out
Of those alive: ambulatory, at work, side effects,
drug adherence >95%
Malawi- logistics in managing
many patients on ART


Hanging files- cards are stored
sequentially
Patient held cards with number and date
starting ART
Matching electronic version
Designed so it can enter at various steps and be
interchangeable with paper
 Paper card- electronic  generate register
 Paper card to paper register electronic entry
 Paper card to paper register to monthly report, cohort
reports send or call by mobile phone  computer
entry
 Computer generated paper register




For 2006-2007
For use in facilities without electronics
For back-up when computer doesn't work
Compatible Palm entry (Satellife project)
Computer system centrally
needed by all:


For monthly and cohort report data
To handle Transfer In and Transfer Out
patients

Needs to link with drug supply
Country adaptation of the card,
register, report forms


Do at the same time as the adaptation of
the clinical guidelines
In Ethiopia, added 7 hours to first 3 day
adaptation workshop
HIV Care /ART Card, pre-ART and ART
registers in Uganda

First pre-tested in Masaka region (4 districts), Uganda
when training 70 health workers in February 2004.

Registers introduced during post-training on-site visits in
March and April 2004


Many health workers had made up their own registers.
Used in Hoima Region (4 districts) Uganda with pretest
of training materials to support use of the registers
HIV Care /ART Card in Uganda


Variables in the card and registers (TB status, clinical stage,
prophylaxis, FP status, ART eligibility /regimen, etc) are
embedded in the 4.5 day Basic ART clinical training
course.
Health workers learn the clinical care process and how to
fill out the card at the same time, with exercises and
practice.
HIV Care /ART Card, pre-ART and
ART registers training
 As
part of the 4.5 day Basic ART Clinical
Course workshop
 As
4 hour additional training for those who
will do patient tracking and monitoring in
the health facility
 Training
"refreshed" during on site posttraining visits: individual training
HIV Care /ART Card, pre-ART and ART
registers in Masaka

Used in 18 facilities (1 Regional Hospital AIDS Clinic, 1
ART Clinic -600 patients, 4 District Hospital AIDS Clinics,
12 HC IV and III)

Slightly revised after first 4 weeks of use
HIV Care /ART Card, pre-ART and ART
registers in Masaka
Feedback during on-site visits after training (not quantitative due to the
limited number of facilities and recent introduction):

HW: Useful tool providing streamlined information
Easy to fill out the card while doing the clinical
review- part of the same process
Easy to transfer info into the register
Easy to quickly perform clinical review on the
basis of data collected during previous visits

Trainers: 45 minutes needed to "refresh" on how to fill out the card
and show how to use the register.
HIV Care /ART Card, pre-ART and ART
registers in ART Clinic, Masaka

Progressively replacing a 4 page HIV Care /ART
record as ART is scaled-up from 100 to 600
patients
Feedback from health workers:
 HW: Useful tool providing streamlined
information


Around 20 minutes per patient are saved since using
this card
They like "everything on one page" – demographic,
clinical and ART data
Where electronics might enter:


District outpatient,
health centre III/IV:
paper card
Agreed data into
paper register;
monthly reports,
clinical team uses
date

Mobile phone



District or regional team
enters register data into
computer cohort
analyses, indicators
Enter agreed data into
palm or computergenerate monthly reports
Computer generation of
cohort analyses and
indicators
Number and percent of people with
advanced HIV infection receiving ART
In clinics with ART services, a
more specific indicator:
Numerator:
Patients on ART
Denominator:
Patients medically eligible and
ready for ART
These patients have all accessed
services.
UNGASS indicator based
on total patients receiving
ART
Denominator: estimated
patients with AIDS (15%
those infected)
Monthly analyses possible without
a register or electronics

% patients with good adherence

Review reasons for fair or poor adherence
Patients with special problems
 % patients referred
 Identify patients for review at clinical team
meetings
 Patient monitoring as tool for quality
improvement
Card sorts, stickers, flags
Motivation, needs to be satisfying and possibly fun

Training materials



Training to fill out HIV Care/ART Card
integrated within WHO Basic ART Clinical
Training course
Module on how to fill out registers, do card
sorts, monthly reports, use data- for health
worker or 'professional' lay provider or HW
Module on supervising and summing monthly
and cohort analysis reports (similar to TB
district coordinator training module)– district
coordinator
Current concerns

Importance of supporting card/register with
training materials


Timeliness



Need rapid regional review and further pretesting
Programmes are starting to treat patients
Training is happening
Staff are making up cards and registers in absence of
simple standards
Urgent need to address children

Draft card for further expert input
Further work & national
adaptation needed to deal with:

Logistic and information system to handle Transfer
in/Transfer out-- with records



Add retrospectively to cohort according to when started ART
Will become an increasing proportion of patients over time, with
return to work, normal mobility
Restart after treatment interruption

When is restart permitted? Different circumstances-



Goes back into the same patient record (line in the register)


Deliberate treatment interruption in first trimester pregnancy
Lost or very poor adherence- ? Restart
Adjust if planned treatment interruptions later recommended
Number, weeks of each treatment interruption retained on cardcould be used in special analyses
Non-naïve patient on ART from other sources

Goes into HIV Care PreART register (queue in rationed system)must qualify (determine that medically eligible) and be ready