Facilitators guide

Republic of Kenya
Ministry of Health

Antiretroviral Drug
Therapy in Kenya

The ART/HMIS

Training Materials
(Facilitator’s Guide)

National AIDS and STI Control Programme
(NASCOP)

August 2006

Table of Contents

Module I: Introduction to the Course.................................................................................. 1
Module II: Pre-test .............................................................................................................. 3
Module III: Overview of HIV/AIDS.............................................................................. 6
Part 1: The HIV/AIDS Situation............................................................................. 6
Module III: Overview of HIV/AIDS............................................................................ 10
Part 2: The ART Programme in Kenya................................................................. 10
Module IV: Introduction to ART-A Conceptual Framework....................................... 12
Module V: Introduction to ART Data Collection System. ............................................... 14
Module VI: Data Collection ......................................................................................... 16
Part 1: Overview of Data Collection Tools........................................................... 16
Module VI: Data Collection.............................................................................................. 18
Part 2: Comprehensive Care Clinic Card.............................................................. 18
Part 3: Pre-ART Register ...................................................................................... 19
Part 4: ART Register............................................................................................. 20
Module VII: Aggregation and Reporting.......................................................................... 21
Part 1: Completing the Monthly Summary Sheet ................................................. 21
Module VII: Aggregation and Reporting.......................................................................... 23
Part 2: Completing the Cohort Summary Sheet.................................................... 23
Module VIII: ART Programme Measures ........................................................................ 24

ART/HMIS Materials - Facilitator=s Guide i

Instructions on HMIS Training Materials

The Facilitator’s Guide is divided into eight (8) modules. Module I is an introduction to the
Course while Module II contains a pre-test for the participants. Module III looks at the
HIV/AIDS Situation while Module IV looks at the Clinical Perspective of ART. Module V
gives an introduction to ART/HMIS while Module VI looks at the data collection tools.
Module VII looks at Data Aggregation and Reporting while Module VIII covers the overview
of ART Programme Measures.

Each Health Centre and Hospital staff member who comes for the course shall be given
the following materials which should be used during the course and thereafter kept at
the facility as reference material for all staff members:

1. Participant’s Notes
2. Participant’s Workbook
3. Procedures Manual

Each District Trainer who comes for the Training of Trainers (TOT) shall be given the
following documents:

1. Facilitator’s Guide
2. Facilitator’s Workbook (To be given out at the end of the TOT)
3. Participant’s Notes
4. Participant’s Workbook
5. Procedures Manual

Each District Health Office is given the following as reference material:

1. Participant’s Notes x 5 copies
2. Participant’s Workbook x 5 copies
3. Procedure’s Manual x 10 copies

ART/HMIS Materials - Facilitator=s Guide ii

Module I: Introduction to the Course

PURPOSE: To introduce the facilitators and the participants to each other
To go through the agenda and communicate the course objectives to
the participants
To explain logistics arrangements
To introduce the contact person for logistics affairs

OBJECTIVE: Upon completion of this module, participants should be able to
understand the purpose of the course and their roles

METHOD: Short personal statement from all participants and facilitators
Lecture

MATERIALS: Overheads/Slides
ART/HMIS Training Materials: Facilitator's Notes & Participant's
Notes
Exercises: there are no exercises for this module
Handout (agenda of the course)
Folders, pens, paper

PREPARATION: Ensure that LCD or Overhead projector is working and white board or
flip chart is available
Prepare set of stationery for each participant
Tables and chairs set in a most suitable shape, depending on the
number of participants.

LEARNING ACTIVITIES 30 minutes

Introduction (20 minutes)

Welcome participants

Explain that the course starts with a round of personal introductions. Ask each participant their
name and function, station of work, and have them add a personal touch. (Make sure that
everybody speaks loudly and clearly). Be creative; develop exercises for helping participants
to get to know each other and this will help you get to know the participants. Different
introduction exercises can be done for the first few days of the course; they need not be
limited to the first day.

Hand out and review agenda and give information on logistics arrangement, if any..

Explain to the participants the agenda of the course

• Emphasise the need for active participation.
• Tell participants they must attend the entire course and be on time. This is important
given the heavy programme and sequence of course activities.

ART/HMIS Materials - Facilitator=s Guide Page 1

• Participants who miss part of the course may not be able to understand the section that
follows.
• Most of the teaching materials and exercises may be handed out or can be found in the
Participant’s Workbook. (Facilitators receive the Facilitator’s Workbook - a similar
workbook to the participants’ – but with answers and teaching points for the exercises.)
• The Participant Notes include copies of the Slide/Sheet, with space where participants can
write notes.
• Participants will also receive an ART/HMIS Procedures Manual

Lecture (4 minutes)

Show Module I Slide 1 and Review the main objectives of the course Training in ART /HMIS.

Explain:

• The purpose of the course is to familiarise the participants with the newly developed ART
Data Collection and Reporting Tools. The course will prepare members of the clinical
team and district coordinators on how to complete a pre-ART register, ART register,
quarterly report form and cohort analysis form using data from the Comprehensive Care
Clinic Patient card.
• The new ART Data Collection Tools will be the standard tools for data collection and
reporting in all NASCOP registered ART sites
• Introduce participants to the concept of monitoring and evaluation in antiretroviral
therapy
• To train members of the clinical team and district coordinators to calculate a few key
indicators, analyze them, and identify and solve problems
• After attending this course, participants should start using the system in their stations of
work.

Summary

Welcome the participants again and wish them a fruitful participation in the training programme.


Module II: Pre-test
PURPOSE: To administer a pre-test and explain how results will be used

OBJECTIVE: Upon completion of the module:
Participants should be able to understand why they are completing the
pre-test
Facilitators should understand how to grade the pre-test and how to use
the information from the results

METHOD: Discussion (before test)
Administer, grade and analyse test
The analysis of the test results should lead to adjustments in the course
set-up. More time should be spent on weak points identified in the
pre-test.

MATERIALS: One copy of the pre-test for each participant
Pre-test answers begin on page 37 of the Facilitator’s Workbook.

PREPARATIONS: Make sure you have a copy of the test for each of the participants.

LEARNING ACTIVITIES 1 hour, 5 minutes

Lecture (2 minutes)

Explain the following points to the participants:

• The purpose of the pre-test is to give the facilitators an idea of what participants
already know or do not know before the course.
• The facilitators will use the results of the pre-test to adapt the course so that it will
respond better to what the participants know and do not know.
• The pre-test aims at motivating the participants, to arouse their interest. The pre-test
indicates to the participants the knowledge and skills that they are expected to acquire
during the course.
• The participants will not be graded and the results on this test will and should not
affect the participant’s participation in the course.
• The participants will not be given scores and the facilitators will discuss the correct
responses during the relevant modules of the course.

Explain instructions for the test (3 minutes)

• Everyone should work on their own
• The participants do not have to put their name but put a code that only they can
remember which should be the same for the post-test.
• The test includes questions on mathematical skills, clinical knowledge and the use of
data. No one is expected to know all the answers.


Hand out and collect test (45 minutes)

Time allocated for the test is 45 minutes. However if it appears that many people have not
finished, give extra time so that all can complete it. It is more important to finish the pre-test
than to finish it within a certain time limit.

Do not go over the answers after the test. Do not answer any questions about the test, since
participants will take the same test at the end of the course.

Grading the Test (time depends on # of participants)

Analyze the results in the evening of the first day of the course. Each question is awarded 1
point (for a totally correct answer) or 0 points (for incorrect or only partially correct answer).
Remember this is not for certification; it is for you as facilitators to be able to know in which
area your participants are weak.

The test with the correct answers is indicated in bold from Page 37 of the Facilitator’s
Workbook.

Here is how to analyse the pre- and post-test results. For each question, we want to find out
the percentage of correct answers. (This quickly shows us where people had difficulty; the
lower the percentage, the fewer people were able to answer the question.)

The formula for the percentage of correct answers is:

Number of persons who got a particular question right X 100
Total Number of respondents

This will give you the percentage of persons who got question 1, 2, 3, 4 etc. correct

For example, if 5 people got question A1 right out of 20 respondents,
It will be:
5 x 100
20
= 25% of the respondents gave a correct response to question one.

Then look at all the questions to find which were answered incorrectly most often. For
instance, question B1 is on ART Indicators. If this question and the related questions have not
been answered well, the module on ART Indicators needs to be emphasised during training.

Discuss the Results (15 minutes)

Discuss the results during the evening meeting for facilitators and decide whether to make
any changes in the course content, or timing based on the results.


The next morning tell participants in a general way how they did in the test. You may tell
them which type of questions they did well or poorly on, but do not tell them any answers or
answer any questions about test questions, since they will be taking the same test at the end of
the course.

This chart will help you organise your grading of the pre-test.

Question # Covered in Module Number who % who answered
answered correctly correctly (number
who answered
correctly /total
number of
respondents)
A1 Module IV
A2 Module IV
A3 Module IV
A4 Module V & VI
A5 Module VIII
B1 Module VI
B2 Module VI
B3 Module VI
B4 Module VI
B5 Module VI
C1 Module VIII
C2 Module III
C3 Module III
C4 Module III
C5 Module V


Module III: Overview of HIV/AIDS
Part 1: The HIV/AIDS Situation
PURPOSE:
• To give an overview of the HIV/AIDS situation
• To brief participants on responses to the HIV/AIDS problem in
Kenya.

OBJECTIVES: At the end of the module, participants will be able to understand:

• The HIV/AIDS situation
• The implications of HIV/AIDS in Kenya
• The responses to the HIV/AIDS Problem

METHOD: Lecture

MATERIALS: LCD or overhead projector, white board or flip chart, markers and
handouts.

PREPARATION: Ensure that all materials i.e. LCD or Overhead projector are working
and white board or flip chart is available, including markers.

LEARNING ACTIVITIES 1 hour


Explain the purpose and the objectives of the module.

Show Module III Part 1 Slide 1 with objectives

Tell the participants that the purpose of this module is:

• To give a global and regional overview of the HIV/AIDS situation
• To brief participants on responses to the HIV/AIDS problem in Kenya

At the end of the module, participants will be able to understand:

• The HIV/AIDS situation
• The implications of HIV/AIDS in Kenya
• The responses to the HIV/AIDS Problem

Introduce the module by saying that this module is extracted from the training materials provided
during the ART clinical training.

Explain that this section is put here for the benefit of those who could have not been exposed to
the clinical training but are expected to handle ART data.


Lecture: HIV/AIDS Global Epidemiology (5 Minutes)

Show Module III Part 1 Slide 2 and explain generally the HIV/AIDS situation.

Explain that by the end of 2004, an estimated 40 million people (both children and adults) were
estimated to be living with HIV/AIDS in the world.

Tell the participants some of the statistics (of adults and children) estimated to be living with
HIV/AIDS worldwide in 2004 shown on the overhead/slide.

Invite questions from the participants and make clarifications.

Show Module III Part 1 Slide 3

Explain that in 2003, fourteen thousand (14, 000) new HIV infections occurred daily of which
2,000 was among children <15 years and 12,000 new HIV infections were among adults or
persons of reproductive age (15-49 years). 50% of this group (15-49 years) are women.

Over 95% of these new infections occur in the developing world.

In 2003, between 2.5 and 3.5 million persons died of HIV/AIDS.

Lecture: HIV/AIDS in Kenya (9 Minutes)

Introduce the module by giving an overview of the HIV/AIDS situation in Kenya.

Show Module III Part 1 Slide 4 highlighting the HIV/AIDS situation in Kenya.

Explain that HIV/AIDS is a global problem that also affects Kenya.

In the early 1990s, over 200,000 HIV infections in adults were recorded per year. This number
has since declined to below 100,000 per year now. It is estimated that 300 to 500 people in Kenya
are infected daily and about 1,000,000 (between the ages 15 to 49) are currently living with
HIV/AIDS out of which 200,000 require antiretroviral treatment. It is estimated that 100,000
children are living with HIV while about 60,000 people over 50 years are also living with the
HIV virus.

According to the Kenya Demographic and Health Survey (KDHS) carried out in 2003:

• The KDHS indicates that 7% of Kenyans are infected every year.
o 86,000 new infections among adults and 30,000 in children are recorded yearly.
• However, in some regions the rate is as high as 30%
o North Eastern province stood at 1%
o Nyanza province was 15%
• The HIV prevalence rate is almost twice as high in urban (10%) as in rural (6%) areas.
• HIV prevalence in girls in 15-19 age group is six times higher than in males of the same
age group.


• 150,000 deaths were recorded every year and the number is likely to rise because of the
large numbers of HIV infections in the early 1990s.
o 30,000 deaths among children are recorded and around 140,000 adult deaths.
• 60% of the TB patients are also HIV infected.


Explain that in Kenya, with a population of about 32 million in 2004, 1.2 million Kenyans were
living with HIV/AIDS.

Approximately 1.6m children <15 years have been orphaned by the death of one or both parents
from AIDS

Invite questions from the participants and make clarifications.

Lecture: HIV/AIDS Implications for Kenya (6 Minutes)


Explain that as a result of the HIV/AIDS pandemic in Kenya, there has been a lot of suffering
just as the saying goes, ‘If you are not infected, then you are affected’. There is a very strong link
between poverty and HIV. High poverty levels lead to increased HIV rates while at the same time
the pandemic worsens poverty levels. 56% of Kenyans live below the poverty line. Some of the
sufferings brought about include:

Sickness:

Tell the participants that the increasing number of HIV/AIDS patients has also seriously
overwhelmed the health care services. In major hospitals for example, HIV/AIDS patients now
occupy 50% of hospital beds.

As a result of sickness of a relative, some children are unable to attend school because they attend
to the sick or pupils may not attend classes if their teacher is sick or when the children themselves
are sick.

There is also loss of man-hour when the worker is sick. Sickness brings about low contribution
to food production which can result in hunger. Sickness also leaves a huge cost to the family by
paying for medication.

Deaths:
Tell the participants that deaths due to HIV/AIDS have continued to escalate, affecting the most
productive of the population. This has resulted in increased levels of:
• Poverty especially if the bread winner is the one affected (sick or dead)
• Children-headed households
• Orphan-hood (the number of orphans has risen from 150,000 in the early 1990s to a
staggering 1.6 million in 2004).
• Widowhood and
• General vulnerability


Tell the participants that the list of implications is endless, invite questions and make
clarifications.

Lecture: Response to the HIV/AIDS Situation (10 Minutes)

There have been three distinct phases to Kenya’s response to the pandemic. Initially, there was
widespread denial in the late 1980s and early 1990s followed by an adoption of a multisectoral
policy in the mid 1990s and finally strong government leadership and political commitment since
2000. This was evidenced by the creation of the National AIDS Control Council and other organs
at lower levels like AIDS control Units in all ministries.

The first AIDS case was diagnosed in the mid 1980s.The Ministry of Health set up an AIDS
Control Committee in 1987 which came up with the first5-year plan to combat AIDS. The second
plan covered 1992 – 96. Strong political will was epitomized in 1999 when AIDS was declared a
national disaster by President Moi. From 1999 there has been an increase in the level of
stakeholder (local and international) involvement by way of more resources directed to the fight
against AIDS.

The national response to the pandemic in the last twenty years has shifted focus from general
prevention and supportive care to specific health services. These include testing and counseling
and antiretroviral treatment.


Explain that not with standing the critical role of Information Education and Communication
(IEC) about HIV/AIDS; other measures taken include the following:
Prevention, Care, and Treatment

In the area of prevention, the focus has been on prevention of mother to child transmission
(PMTCT), Counselling and Testing, Abstinence, being faithful, condom use especially among the
high risk groups, blood safety, and injection safety.

In the area of Care, the focus is on Home Based Care.

In the area of Treatment, the focus is on Anti Retroviral Therapy (ART) and the management of
opportunistic infections.

Invite questions from the participants and make clarifications. (24 Minutes)


Module III: Overview of HIV/AIDS
Part 2: The ART Programme in Kenya
PURPOSE: To introduce participants to the ART programme in Kenya
Introduce participants to organisation of ART services in Kenya


• The ART Programme in Kenya
• The main goal of the ART Programme
• Specific goals of ARV therapy
• Resource limitations affecting ARV therapy

METHOD: Lecture

MATERIALS: LCD or overhead projector white board or flip chart, markers and
handouts.

PREPARATION: Ensure that all materials i.e. LCD or Overhead projector are
working and white board or flip chart is available including
markers.

LEARNING ACTIVITIES 1 hour


Show Module III Part 2 Slide 1 with objectives

Explain the purpose and the objectives of the module.

Ask participants about objectives of the ART programme. List down their responses on a flip
chart or white board. Then…

Show Module III Part 2 Slide 2 and;

Summarise that the main goal for any ART programme is to increase accessibility to
antiretroviral therapy with a view of prolonging the lives of the patients infected with HIV.

Lecture: ART Programme in Kenya (8 min)

Introduce the lecture by giving an overview of the ART programme.

Show Module III Part 2 Slide 3.


Explain that in Kenya, the plan by NASCOP is to scale up to all 72 districts in the country. It
also aims at building capacity of regional centres to act as referral sites and priority will be
given to high disease burden areas.

The ART program is expected among other things to;
• Reduce mortality and morbidity resulting from HIV/AIDS
• Reduce escalating burden of AIDS orphans
• Enhance national prevention efforts
• Reduce HIV/AIDS related hospital admissions by 60%.

Other programmes related to ART programme include PMTCT, VCT, and treatment of
Opportunistic Infections.

Lecture: Target of HIV/AIDS Patients to be on ART (10 mins)

Show Module III Part 2 Slide 4 and explain generally the targets set.

Explain that globally, the target set for HIV/AIDS patients to be on ARVs is 3,000,000 by
the end of the year 2005. The number of ART patients in Kenya has increased 10-fold from
3,000 in 2000 to more than 30,000 in 2004. The Kenyan government’s goal was to reach 50%
(95,000) of the eligible people by 2005 and 78% by 2010. Currently over 200 public health
facilities, mission and private facilities are providing comprehensive HIV care. There are
currently over 70,000 patients on ART and thousands waiting to start treatment.

Hint: To effectively measure the progress towards attaining such local and international ART
goals, it is imperative that a monitoring and evaluation system is put in place. This system
must answer and meet these different demands at various levels.


Explain to the participants that the provision of ART in the country faces several challenges.
Among them are;
• Cost of drugs, for instance in 2000 the cost of drugs was prohibitively high for the
majority of people at $10,000 per year. Currently, the first line-regimen costs between
$77 per year in the public sector and $700 in the private sector.
• Integrating ART services into the existing health programs
• Limited work force of health workers in the health sector
• The labs need to be equipped with new equipment to provide new services to monitor
HIV treatment

Invite questions from participants and make clarifications. (30 mins)


Module IV: Introduction to ART-A Conceptual
Framework

PURPOSE: To introduce participants to ART programme in Kenya by looking at its
conceptual framework.
Explain to participants the progression of the clinical manifestation and the
General management of the cases.

• Procedures for commencing someone on ART
• Key stages for data collection.

METHOD: Lecture

PREPARATION: Ensure that all materials i.e. LCD or Overhead projector are
working and white board or flip chart is available.

LEARNING ACTIVITIES 45 Minutes

Introduction (2 Minutes)

Show Module IV Slide 1.

Explain the purpose of the module with emphasis that it is not designed to equip participants
with skills to provide clinical ART services. It is meant to highlight standard procedures for
commencing a patient on ART and their management thereafter. A direct relationship exists
between the clinical processes and data collection, hence this module.

Emphasise to the participants that this module must be well understood if modules V, VI and
VII have to be appreciated.

Lecture: The ART Conceptual Framework (18 Minutes).

Show Module IV Slide 2

Ask participants to locate the generic ART flow diagram in the Participant's Notes and let
them turn to section 1.2 of the procedures manual and read through with them while module
IV slide 2 is still showing

Explain that the diagram presented is very generic and may not be representative of
individual facilities. The principle on which it is based can be used at all levels.

Turn to section 1.2.2 of the procedures manual for additional explanations on chart. Ensure
that before moving to section (b) participants are clear with what takes place while in
Pre-ART as explained in section (a).


Explain the following terms:

• New in HIV Care B These are patients coming into HIV care without prior
records of ever having been in HIV care including ART.
• Transfer-Ins B These are patients who were enrolled in HIV Care from other
facilities but have been officially transferred to this facility. An official transfer is
that which is accompanied by referral documents with minimum data required for
continuity of care.

Show Module IV Slide 3.

Explain that assessment for eligibility is done either clinically or via lab results of CD4 or
Viral Load or a combination of clinical and lab investigations. Below is the eligibility criteria
set by the Ministry of Health (NASCOP) in collaboration with stakeholders:

• WHO clinical stage 1 and 2, with a CD4 count < 200/mm3
• WHO stage 3 with CD4 cell count < 350/mm3
• WHO stage 4 regardless of CD4 cell count
• TLC less than 1200/mm3

Explain that in August 2002, standard treatment guidelines were developed in order to
standardise care. These guidelines included standard regimens that simplify ART delivery
and commodity management and minimize procurement costs.

Put back Module IV Slide 2 and continue explaining the following terms.

• Not Eligible: This applies when a patient does not meet the criteria shown in
module IV Slide 3.
• Eligible for ART: If a patient meets the criteria outlined earlier.
• Start Treatment: This means that the patient has started taking ARV drugs for
the first time. Patients are commenced on first line drug combination of the first
choice by the clinician.
• Substitution: This involves changing one drug or two but still keeping a patient
on the same family of drugs.
• Switch: This involves taking a patients to a new line of drugs e.g. from 1st line to
2nd line.
• Pre-ART: This is a stage in HIV care when a patient has not commenced on
ART. This can be as a result of pending tests, assessment for readiness or the
assessment has revealed that the patient is not eligible to commence ART.


Module V: Introduction to ART Data Collection System.

PURPOSE: To introduce participants to the ART programme in Kenya
Introduce participants to organization of ART services in Kenya.

OBJECTIVES: At the end of the module, participants will be able to understand the
rationale behind the ART Data Collection System

METHOD: Lecture and group exercises

PREPARATION: Ensure that all materials i.e. LCD or Overhead projector is working
and white board or flip chart is available.


Introduction (3 Minutes)

Show Module V Slide 1 with objectives.

Go over the objectives of this module.

Lecture: Rationale of the ART/HMIS (10 Minutes)

Show Module V Slide 2

Explain that the design and development of the Kenya ART/HMIS, was in response to

• The need for a monitoring and evaluation framework as outlined in the national
scale-up plan for ART.
• Lack of an ART information system during scale-up of antiretroviral treatment to all
provinces created a chaotic environment resulting in a weak and fragmented reporting
structure for the government ART programme.
• Standardized data capture tools to allow for patient and facility comparisons.
• Response to the international reporting responsibilities such as the 3 by 5, PEPFAR
etc. All these demanded for a need to develop an M&E system for public and private
sector.

Lecture: The Architecture of ART/HMIS (30 Minutes)

Introduction


Explain that ART/HMIS is a paper-first-based system with an option for computerisation. It
is designed to collect bare minimum data elements for both patient management and


programme management. It is not a clinic system designed to improve the quality of care in
individual facilities but assists in providing minimum standards of care.

Data Flow Structures


Explain that ART/HMIS uses several data tools.
It uses registers/cards and aggregation forms
• Registers: There are two registers used in ART/HMIS. One used during Pre-ART
and the other used as a monthly event summary sheet for ART events.
• Aggregation Forms: Monthly Summary Sheet and Cohort Summary Sheet

Scope of ART Data Collection System


Explain that ART/HMIS is not designed to answer all aspects of ART. Among others, it is
meant to do the following:

• Provide history of patient visits to the facility
• Provide basis for monitoring patient progress
• Provide information on adverse drug events
• Assists in tracking adherence to treatment
• Provides information on:
(i) Patients outcomes (Deaths, Lost, Stop, Substitutions, Switches, etc)
A (ii) General programme performance against set goals at all levels.


Explain that although ART/HMIS is scalable, in its current form, cannot provide information
on:
• Drug resistance but only warning signs of the potential or apparent resistance
through drug line switches and adherence.
• Staff availability
• Laboratory or Pharmacy capacities or
• Patient moving intra or inter facility.


Module VI: Data Collection
Part 1: Overview of Data Collection Tools
PURPOSE: To introduce participants to data collection
To introduce participants to the ART data collection tools

OBJECTIVE: At the end of the module, participants should be able to understand the
importance of data collection and correct completion of ART/HMIS data
collection tools.

METHOD: Lecture

MATERIALS: LCD or Overhead projector and white board or Flip chart
Handout

flip chart is available



Show Module VI Slide 1 with objectives

Explain the objectives of the module.

Lecture: Data Collection Tools (10 minutes)

Show Module VI Slide 2 and explain the three general purposes of data collection which
include:
• to provide a record of care given to specific clients
• to provide information on health status and service delivery
• to provide data for planning eg drug ordering and quality improvement

Show Module VI Slide 3

Explain to the participants that there are three data collection tools: two register and one
patient card. Remind them that this section only presents an overview; the sections that
follow will explain each tool in greater detail.

Comprehensive Care Clinic Card

Ask participants to locate the CCC card in appendix I of the Procedures Manual.

Explain that this card serves as a patient’s detailed record of clinical diagnosis and treatment.
It is opened when a patient enrolls into chronic HIV Care and continues to be used for


patients who enroll on ART. However where resources may not permit, these cards are only
opened for patients at commencement of ART to avoid wastages.

Pre ART Register

Ask participants to locate the Pre-ART register in appendix I of the Procedures Manual.

Explain that details for all patients who enroll for HIV Care are entered here. This includes
patients identified within the facility and those that are referred or received from other
facilities. The purpose of the Pre-ART Register is to provide:-

(i) Information the medical status of a patient on entry into HIV Care
(ii) Provide a record of patient outcome while on Pre-ART and
(iii) Provide a basis for facility-level self-assessment and supervision

Show Module VI Slide 4

Explain the ART register is an event-based register meant to record key monthly outcomes
for individual patients and consequently interval cohort outcome. Its specific purposes
include

(i) providing a record of patient outcome
(ii) providing a track record of patients from initiation to follow up monthly visits
(iii)Serving as a source of information on patient drug mix

Show Module VI Slide 5 and explain the ART document flow:

Explain the stages, processes, decisions and documentation used at each stage of service
provision. This flow is closely linked to the generic ART conceptual framework presented in
module IV and key stages that demand data collection are highlighted on this flow chart.

Follow the direction of the arrow in running through the document flow chart.


Part 2: Comprehensive Care Clinic Card
PURPOSE: To introduce participants to the Comprehensive Care Clinic Card

OBJECTIVE: At the end of the module, participants should be able to understand the
use and correct completion of the Comprehensive Care Clinic Card.

METHOD: Lecture, demonstration on how to complete the card and exercises

MATERIALS: LCD or Overhead projector and white board or Flip chart;
Handouts:
Participant's Workbook pages 1-9
Facilitator’s Workbook pages 1-9
Procedures Manual section 2.2.1

PREPARATION: Ensure that LCD or Overhead projector is working and white board
or flip chart is available


Lecture: Comprehensive Care Clinic Card (20 minutes)

Refer participants to the blank samples of the Comprehensive Care Clinic Card on page 4-9
of the Participant's Workbook

Ask them to turn to section 2.2.1 of the ART/HMIS Procedures Manual and;
Explain the following points.

• Purpose of the Comprehensive Care Clinic Card
• Who completes
• When to completed

Explain to the participants step by step the data elements required for completing the
Comprehensive Care Clinic Card in each part and when it is filled in.

Exercise: Completing the Comprehensive Care Clinic Card (13 Minutes)

Ask the participants to turn to page 1 of the Participant's Workbook and do exercise 6-1.

Ask participants to return to the large group. The rapporteur from each group should report
the group’s experiences according to instructions # 4 and # 5 on page 3 of the Participant's
Workbook

Summarise the comments and allow participants to add anything they may have forgotten to
mention (40 Minutes). Ask them to use the space under each of the questions in their
Workbooks to write down the interesting contributions of other group members.


Part 3: Pre-ART Register
PURPOSE: To introduce participants to the Pre-ART Register

OBJECTIVE: At the end of the module, participants should be able to understand the use
and correct completion of the Pre-ART Register
METHOD: Lecture, demonstration on how to complete the register through exercises

MATERIALS: LCD or Overhead projector and white board or Flip chart
Handout

PREPARATION:
Ensure that LCD or Overhead projector is working and white board or flip
chart is available


Lecture: Pre-ART Register (18 min)

Refer participants to page 11-12 of the Participants Workbook for a blank Pre-ART Register
Refer participants to ART/HMIS Procedure Manual section 2.2.2 and;


• Purpose of the Pre-ART Register
• Who completes
• When to complete

Explain to the participants step by step the data elements required for completing the
Pre-ART Register in each column and when it is filled in.

Exercise: Completing the Pre-ART Register (20 Minutes)

Ask participants to turn to page 10 of the Participant's Workbook and do exercise 6-2.

Ask participants to return to the large group. Ask the rapporteur of each group to report the
group’s experiences according to instruction # 4 on page 10 of the Participant's Workbook

Summarise the comments and give chance to participants so they can add anything they may
have forgotten to mention. Ask them to use the space under each of the questions in their
Workbooks to write down the interesting contributions from other members (30 Minutes)


Part 4: ART Register
PURPOSE: To introduce participants to the ART Register

OBJECTIVE: At the end of the module, participants should be able to understand the use
and correct completion of the ART Register

METHOD: Lecture, demonstration on how to complete the Register and exercises

Handout:

or flip chart is available.

LEARNING ACTIVITIES

1. Lecture: ART Register (10 min)

Refer participants to page 14-16 of the Participants Workbook for a blank ART Register

Refer participants to ART/HMIS Procedures Manual section 2.2.3 and explain the following
points.

• Purpose of the ART Register
• Who completes
• When to complete

Explain to the participants step by step the data elements required in completing the ART
Register in each column and when it is filled in.

Exercise: Completing the ART Register

Ask the participants to turn to page 13 of the Participant's Workbook and do exercise 6-3.


mention. Ask the participants to use the space under each of the questions in their Workbooks
to write down the interesting contributions of other group members.


Module VII: Aggregation and Reporting
Part 1: Completing the Monthly Summary Sheet

PURPOSE: To introduce Aggregation and Reporting forms to participants

OBJECTIVE: Upon completion of this module, participants will be able to recognise and
correctly fill in the reporting forms

METHOD: Lecture, group discussions, demonstration on how to complete the
documents and exercises

Handout:
Procedures Manual section 3.2

or flip chart is available

LEARNING ACTIVITIES


Show the Module VIII Slide 1.

Explain the purpose and the objectives of the module and explain that there are two data
aggregation and report forms:

• Comprehensive Care Clinic Monthly Summary Sheet
• Comprehensive Care Clinic Cohort Summary Sheet

These forms provide a summary of information on Pre-ART and ART services provided by
the institutions.

Lecture: Comprehensive Care Clinic Monthly Summary Sheet (30 min)


Purpose of the aggregation and reporting forms
Who completes
When to complete


Explain to the participants step by step the data elements required from the registers to
complete the reporting forms.

Ask participants to locate the two blank CCC Monthly Summary Sheets on page 24 of the
Participants workbook and let them turn to section 3.2 of the ART/HMIS Procedures
Manual.

Read with them on each of the measures on the CCC Monthly Summary Sheet
• New patients enrolled within the month for HIV Care by entry point
• Persons ever enrolled in HIV Care at this facility by end of this month
• Patients starting ARVs within the month by WHO stage
• Patients ever started on ART at this facility by end of this month
• Patients currently on ARVs
• Persons enrolled and eligible for ART but not yet started on ART
• Patients currently on Post Exposure Prophylaxis (PEP)
• Patients currently on prophylaxis

Note: Before moving on to another measure, ensure that all the participants have understood.
Pause after each measure and allow for questions.

Exercise: Completing the Comprehensive Care Clinic Monthly Summary Sheet


group’s experiences according to instruction # 5 on pages 18-19 of the Participant's
Workbook

mention. Ask participants to use the space under each of the questions in their Workbooks to
write down the interesting contributions from other member


Module VII: Aggregation and Reporting
Part 2: Completing the Cohort Summary Sheet

Lecture: Comprehensive Care Clinic Cohort Summary Sheet (10 min)

Ask participants to locate the two blank pages of the CCC Cohort Summary Sheets pages
27-28 in the Participants Workbook and let them turn to section 3.3 of ART/HMIS
Procedures Manual.

Read with them section 3.3 on CCC Cohort Summary Sheet with focus on the following data
elements:
• Started on ART in this clinic- original cohort
• Transfers in
• Transfers out
• Net current cohort
• On original 1st-line regimen
• On alternate 1st-line regimen (substituted)
• On 2nd-line regimen (switched)
• Stopped
• Died
• Lost to follow-up (DROP)
• Percent of cohort alive and on ART
• CD4 median or fraction ≥ 200 [of those with available CD4] (optional)
• Number of persons who picked up ARVs each month for 6 months
• Number of persons who picked up ARVs each month for 12 months

Ensure that all the participants understand each of the measures discussed.

Explain to the participants that this is an interval analysis form, for cohorts of patients that
have completed 6 months, 12 months, 24 months on therapy.

Exercise: Completing the Comprehensive Care Clinic Cohort Summary Sheet



mention. Ask participants to use the space under each of the questions in their Workbooks to
write down the interesting contributions from other member.


Module VIII: ART Programme Measures

PURPOSE: To familiarize participants with the ART/HMIS Indicators and to provide
examples of analysis and action based on information
To emphasize the need for local action, using locally available knowledge

OBJECTIVE: After completion of this module, participants should be able to:

• Calculate the ART/HMIS indicators
• Interpret the ART/HMIS indicators

METHOD: Lecture, demonstration on how to calculate the indicators, and exercises

MATERIALS: LCD or Overhead projector, white board or Flip chart, markers, Handout

flip chart is available including markers.

LEARNING ACTIVITIES 30 MINUTES

1. Introduction (2 minutes)

Show Module VIII Slide 1 with objectives.

Explain the purpose and the objectives of the module and explain generally that there are
several indicators in ART/HMIS for patient management, patient monitoring and monitoring
the ART programme.

Show Module VIII: Overhead/Slide 2.

Explain that the ART Indicators are selected based on the following:

• The NASCOP Strategic Plan 2005-2010: In this plan, ART indicators are required so
as to monitor the ART program.
• International obligations: There are international obligation to report ART indicators
by WHO, UNAIDS, or PEPFAR.
• Efficiency, exclusiveness, feasibility, cost implications: Indicators are selected based
on the cost to provide those indicators, how efficient it is to provide those indicators,
and how feasible it is to provide those indicators

Invite for questions and make clarifications


2. Lecture: ART Indicator categories (10 min)

Show Module VIII Slide 3

Explain that the data to calculate these indicators are obtained from registers summarised on
tally sheets and transferred to aggregation and reporting forms.

Indicators are expressed in many formats. They can be absolute numbers, rates, ratios or
proportions. There are three main categories of ART indicators namely: -

• Measures of accessibility to HIV Care and ART
• Measures of programme success
• Measures of adequacy in programme support areas at all levels
• Measures of HIV drugs resistance early warning

Briefly describe the types and examples of the measures. Explain, step by step how to
calculate and interpret the indicators.

Access to HIV Care or ART

The following indicators relate to patients accessing HIV care or ART.

a. Number enrolled in HIV care
b. Number started on ART
c. Number currently on ART
d. Number, Proportion of persons who are enrolled and eligible for ART but have
not been started on ART.
e. Number, proportion of patients on both TB treatment and ART.
f. Percentage of those eligible for ART in the clinic who has been started on ART.

ART Programme Success

The following indicators measure ART Programme Success.

a. Survival at 6, 12, 24, 36 months etc after initiation of ART.
b. Continuation on first-line ARV regimen at 12 and 24 months after initiating
treatment.
c. Median CD4 at 6 and at 12 months on ART compared to baseline.

HIV Drug Resistance Early Warning

The following indicators may provide a flag for potential or apparent resistance towards a
specific line of drugs (mostly first line) or towards a given combination in given family of
drugs. It is desired that as long as it takes, patients should remain on the original 1st line drug.
Below are some indicators that may point to drug resistance.


a. Percentage of patients who started ART 6 or 12 months ago who picked up ARV
medications 6/6 or 12/12 months.
b. Percentage of patients with (good) adherence to ART

3. Exercise: Calculating ART Indicators

Ask participants to turn to pages 29 of the Participant's Workbook and do exercise 8-1

groups experiences.

Confirm their answer with the ones provided on pages 30-36 of the Facilitator’s Workbook

Summarise the comments and give participants to add anything they may have forgotten to
mention. Ask the participants to use the space under each of the questions in their Workbooks
to write down the interesting contributions of other member


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