Purpose of the Toolkit
In September 2008, the Baylor International Pediatric AIDS Initiative (BIPAI) published a toolkit entitled "Implementing Care and Treatment for Children with HIV/AIDS in Resource-Limited Settings." In keeping with the urgent need to expand care and treatment for children with HIV/AIDS highlighted in the recent UNICEF report "Children and AIDS, Second Stocktaking report." The purpose of that Toolkit was to provide a practical step-by-step guide for any group in how to plan, implement, monitor, evaluate and revise programs specifically addressing the needs of children and their families, infected and affected by HIV/AIDS and living in resource-limited settings. Included in the Toolkit there was guidance on how to decentralize such efforts to outreach or rural areas of resource-limited countries. BIPAI now presents an additional "Outreach Toolkit" providing a number of tools to assist decentralization of HIV/AIDS services. In many resource-limited countries, particularly in Africa, there is a serious shortage of manpower, most notably of physicians or at least of physicians trained and experienced in the care and treatment of children with HIV/AIDS. Therefore, the Toolkit also concentrates on methods to train and mentor health care professionals at outreach or primary health care sites.
Decentralization of services is usually necessary for scale up of HIV/AIDS services and BIPAI recommends that it be introduced in a gradual manner. Essentially, it is an orderly process of transferring select tasks that are delivered initially at the district hospital to the primary health centers. Services provided at the primary health center may be less comprehensive or specialized than those at the district hospital. This depends on the resources and personnel available at the primary health center, and health authorities' willingness to decentralize and permit less expert personnel to care for HIV/AIDS patients.
BIPAI is currently developing extensive outreach programs in all the countries in which COEs have been established. The strategy includes both BIPAI operated satellite sites and outreach to government run primary health centres. The satellite sites will provide the same service as that at the central COE. BIPAI personnel are providing training and mentoring at the primary health centres until such time as the local staff is fully capacitated to care and treat children without outside assistance. In addition, BIPAI is providing support at existing primary health centres to allow them to treat and care for children themselves. This support takes the form primarily of training, mentoring and capacity building. Please contact BIPAI if you require advice or technical assistance in this regard. The Field Story below illustrates one of the BIPAI outreach programs.
The Toolkit contained in this document consists of a series of tools developed by BIPAI personnel who have had direct experience in the implementation of outreach programs to primary health care centres of programs for the care and treatment of children with HIV/AIDS, including the provision of antiretroviral therapy. It also includes many useful tools to assist in mentoring of local health care professionals who may not have had much experience of treating children. The Toolkit is arranged in the following three sections:
How to Use the Toolkit
Tools for Outreach Clinical Mentorship in Pediatric HIV Care
The WHO recommends clinical mentorship as a method of supporting scale-up of HIV care in resource-constrained settings.
The following tools represent a collection of materials that have been developed in ongoing programs of on-site outreach clinical mentorship in pediatric HIV care to public sector facilities in resource-limited settings.
These materials represent a "generic" toolkit that can be adapted for use in a particular national setting. Specifically, national guidelines on HIV testing in children, assessment and treatment of malnutrition, and antiretroviral therapy regimen and dosing differ from country to country. For most effective use, these materials should be modified to reflect specific local guidelines. As a "generic" reference, current WHO guidelines are used where there are significant differences between individual national guidelines.
These materials are concrete tools for use by clinic staff and by mentors and are designed to help clinics develop a routine and systematic approach to providing basic quality care to children exposed to or infected by HIV.
This approach to mentorship is based on the premise that pediatric HIV care can be "de-mystified" by clearly defining what needs to be done, and that conversely, if these tasks are done the result is good basic care.
The tools are divided into three main categories: Site Assessment and Establishing Mentorship, Clinical Mentorship (including Clinical Documentation and Decision-Making and Reference Materials), and Monitoring and Evaluation.
Tips for Effective Use of this Toolkit:
- Focus on the systems level. In resource-limited settings challenges to good clinical care include shortages of health care workers and high staff turnover. Rather than focusing primarily on imparting clinical knowledge to individual health workers, this mentorship approach aims to help health facilities develop programs of clinical care that are systematic in their approach to children and that are sustainable despite rotation or turnover of individual staff members.
- Support task-shifting. Decide what needs to get done and who can help do it. Then focus one-on-one mentorship on each cadre of worker who is part of the team.
- Divide clinic activities into discrete "stations." For example: Registration, Nutrition Assessment and Triage, Clinical Assessment, Medication Dispensing and Adherence Assessment. Provide one-on-one mentorship to the health worker(s) at each station.
- Use a team approach to mentorship. When possible, provide mentorship as a team, with at least one mentor for each "station." This facilitates effective and efficient mentorship of multiple health workers engaged in concurrent, parallel activities.
- Use mentorship tools at each station. Use posted job aides, reference guides, and clinical documentation and decision-making tools as relevant at each of the stations. Use these as a concrete guide for the activities and teaching at each station.
- Use a checklist to monitor progress. Break down goals for clinic activities into very specific tasks. Monitor progress in proficiency and routine completion of these tasks (see example Mentorship Checklist) in order to determine what areas need more focus.