Guidance on Implementation of Differentiated Service Delivery for HIV & TB Services - PowerPoint Presentation

1. Guidance on Implementation of Differentiated Service Delivery for HIV & TB Services in UgandaReference Desktop Job AideMarch 2020Introduction to DSD Pages: 2 - 4Clinical Pages: 5 - 56M&E Pages: 57 - 61Supply chain & QI Pages: 62 - 64Comm’n & HRHPages: 65 - 68

2. Differentiated Service Delivery (DSD): Definition, Core Principles and Building BlocksDSD refers to various ways of providing HIV prevention, care and treatment services that are tailored to the needs and preferences of PLHIV with the aim of maintaining good clinical outcomes and improving efficiency in service delivery.The core principles of differentiated care are: Client-centered careImproved health system efficiency2The 4 building blocks of DSD

3. Elements of Differentiation in UgandaIn Uganda, the 2 services for adopting differentiated models are:Differentiated HIV testing servicesDifferentiated HIV care and treatment servicesEach of these has further been differentiated based onLocation (facility, community) Clinical characteristics of the client (stable, unstable or complex)Specific populations (e.g., adults, children and adolescents, pregnant and breastfeeding women, key populations, men) Context (e.g., urban/rural, unstable context, epidemic type.) 3

4. How to Introduce DSDM in Your Health Facility 4

5. Recommended Differentiated HTS models and Approaches and Target Populations 5ALL communities are eligible for HTS. However, the HTS model depends on the population vulnerability and their unique needs.HIV self-testing (HIVST) is an additional approach to HTS but does not confirm a diagnosis for HIV. All reactive self-test results should be confirmed using the approved national HIV testing algorithm.

6. Population Groups that can be Accessed Through Facility-Based HTS ApproachesCLIENT POPULATION GROUPSWHOWHENWHEREWHATWHY? (Unique characteristics)LINKAGE STRATEGIES Patients with active TBHealth care workers at TB clinic/ward i.e. Physician, Clinical Officer, Nurse, Lab. Staff, RCT volunteerAt the time of diagnosisAt 4 weeks after initial testing (for those with initial HIV negative result)During contact tracingDuring sputum re-checksDuring TB treatment refills TB clinicTB wardRoutine HIV testing for HIV clientsDiagnostic HTSRe-test HIV as per HTS guidelines Very likely to have HIV co-infectionSame point/provider enrolment/initiationPatients with presumptive TBDepartment health care workers i.e. Physician, Clinical Officer, Nurse, Lab. Staff, RCT volunteerDuring TB screening During sputum-collection campaignsAll departments especially: MCH clinicYCCOPDRoutine HIV screening Very likely to have HIV infectionSame point/provider initiation/ enrolment in carePregnant and breastfeeding women and their partnersDepartment health care workers i.e. Physician, Clinical Officer, Nurse, Midwife, Lab. Staff, RCT volunteer, Vaccinator1st trimester/1st ANC visit3rd trimester/during labor and deliveryANC, L&D, PNCFP clinicsYCCMother baby care points Routine HIV screeningThese are sexually active and HTS will inform eMTCT interventionsSame point/provider initiation/ enrolment in careMentor mothers escort client to next point of careEvery 3 months until 3 months after cessation of breast feeding6

7. Population Groups that can be Accessed Through Facility-Based HTS Approaches (cont.)CLIENT POPULATION GROUPSWHOWHENWHEREWHATWHY? (Unique characteristics)LINKAGE STRATEGIES HIV exposed Infants and children below 18 monthsDepartment health care workers i.e. Physician, Clinical Officer, Nurse, Midwife, Lab. Staff, RCT volunteer, VaccinatorAt 6 weeks or at the earliest opportunity thereafter6 weeks after cessation of breastfeedingMother Baby Care PointOPDIPDImmunization YCCPNCRoutine early infant diagnosis through virological DNA/PCRHigh risk of morbidity and mortality if not diagnosed and initiated on ART earlyLikely to be severely ill and HIV infection could be the underlying cause of disease severityLikely to have delayed development milestonesMentor mothers Other expert clients at various entry pointsSame point/provider initiation/ enrolment in careChildren 18 months to below 10 yearsDepartment health care workers i.e. Physician, Clinical Officer, Nurse, Midwife, Lab. Staff, RCT volunteer, VaccinatorAdmittedMalnourished OVCSymptomatic Mother is HIV positiveHistory of hospitalization in the last 6 monthsDiagnosed with presumptive TBTB diagnosed History of TB treatmentSexually abused Accidental exposureIn-patient departmentOut-patient department Young Child Clinics TB ClinicsHIV care and treatment Clinics Nutrition ClinicsOVC ProgramsPITCKYCS (including holiday campaigns)Index client tracing and testingTo identify HIV infected children who were missed by the EID programLinkage facilitatorsSame point/provider initiation/ enrolment in care7

8. Population Groups that can be Accessed Through Facility-Based HTS Approaches (cont.)CLIENT POPULATION GROUPSWHOWHENWHEREWHATWHY? (Unique characteristics)LINKAGE STRATEGIES Adolescents (10-19 years) in and out of schoolDepartment health care workers i.e. Physician, Clinical Officer, Nurse, Midwife, Lab. Staff, RCT volunteer. Youth PeersDuring SMCAdmittedMalnourished OVCSymptomatic Mother is HIV positiveHistory of hospitalization in the last 6 monthsDiagnosed with presumptive TBTB diagnosed History of TB treatmentSexually abused Accidental exposureIPDOPDAdolescent friendly clinics/cornersANCFP clinicsSTI clinics Youth centersInstitutions of higher learning (if located within the health facility e.g. training schools) PITCIndex client tracing and testing KYCS (including holiday campaigns)Special facility campaignsSpecial/flexible hours, walk-ins or same-day appointmentsCharacterized with vulnerabilities which increase risk to HIV infection and yet they have a poor health seeking behaviorMay be sexually active and/or abusing drugsInadequate adolescent friendly services in facilities Adolescent peer educatorsLinkage facilitatorsAdolescent Health services focal personsYouth (20 – 24 years)Department health care workers i.e. Physician, Clinical Officer, Nurse, Midwife, Lab. Staff, RCT volunteer, Vaccinator, Youth Peers During SMCDuring sporting eventsWhen they meet the criteria as per the adult screening tool  IPDOPDANCFP clinicsSTI clinics Youth centersInstitutions of higher learning ((if located within the health facility e.g. training schools) PITCIndex client tracing and testing Special facility campaignsSpecial/flexible hours, walk-ins or same-day appointmentsHave a low risk perceptionThey have a need to experiment with sex and therefore engage in high risk sexual behavior  Youth Peer educatorsLinkage facilitatorsSame point/provider initiation/ enrolment in care8

9. Population Groups that can be Accessed Through Facility-Based HTS Approaches (cont.)CLIENT POPULATION GROUPSWHOWHENWHEREWHATWHY? (Unique characteristics)LINKAGE STRATEGIES MenDepartment health care workers i.e. Physician, Clinical Officer, Nurse, Midwife, Lab. Staff, RCT volunteer, VaccinatorDuring SMCRoutine care when they accompany their wives for ANC, L&D and PNCWhen they meet the criteria as per the adult screening toolMNCH clinicsSTI/MARPs clinics In non-communicable diseases’ clinics (DM, HT)IPD (male ward)OPDReproductive health clinicsVCTPITCIndex client contact tracingPartner notificationSelf-testing**Testing for men can be provided during evening/weekends/after work hoursPoor seeking health behaviorLeast likely to access HTS under routine health care due to fear, stigma, perception that health services are for femalesMale change AgentsSame point/provider initiation/ enrolment in careAdults Department health care workers i.e. Physician, Clinical Officer, Nurse, Midwife, Lab. Staff, RCT volunteerWhen they meet the criteria as per the adult screening toolIPDOPDNon-communicable diseases clinics (DM, HT, cancer)Rehabilitation units PITCVCTIf seeking care in HFs, are likely to be very sick and HIV could be the underlying infectionLinkage facilitatorsSame point/provider initiation/ enrolment in care PWDsDepartment health care workers i.e. Physician, Clinical Officer, Nurse, Midwife, Lab. Staff, RCT volunteerRoutine careWhen there is history of sexual abuseRehabilitation unitsPhysiotherapy clinicsIPDOPDOrthopedic Occupational therapy units PITCVCTMay not easily negotiate for safe sex, and often are sexually violatedMay have low literacy ratesCommunication of HIV and AIDS messages may be more difficultHTS may be physically inaccessiblePeer educators for PWDsLinkage facilitatorsSame point/provider initiation/ enrolment in care9

10. Population Groups that can be Accessed Through Facility-Based HTS Approaches (cont.)CLIENT POPULATION GROUPSWHOWHENWHEREWHATWHY? (Unique characteristics)LINKAGE STRATEGIES Health workers*Fellow health care workers i.e. Physician, Clinical Officer, Nurse, Midwife, Lab. Staff, RCT volunteerRoutine careWhen there is history of high risk exposureStaff clinics Work placesPITCVCTPEPHIV Self-testing** Likely to face self-stigma and may not access HTS easilyOccupational exposure/hazard at the workplace puts them at a higher riskSame point/provider initiation/ enrolment in careCouples and sexual partnersDepartment health care workers i.e. Physician, Clinical Officer, Nurse, Midwife, Lab. Staff, RCT volunteerDuring routine careDuring discordant couples’ meetingsMNCH clinicsCouple meetingsHIV care and treatment clinicsSTI and FP clinicsIPDOPDIndex client contact tracing and Partner NotificationVCTCouple and Partner HTSHave high incidence of HIV infectionMay be in discordant relationships, distant relationships and/or have multiple sexual partnersLinkage facilitatorsMentor motherMale change AgentsSame point/provider initiation/ enrolment in careInpatientsIPD HCWsRoutine patient care servicesIPDPITCLikely to have underlying HIV infectionSame point/provider initiation/ enrolment in care10

11. Population Groups that can be Accessed through Community-Based HTS Approaches CLIENT POPULATION GROUPWHOWHEN WHEREWHATWHY? (Unique characteristics)LINKAGE STRATEGYHousehold members of index clients with TB and/or HIV Health Care Workers i.e. Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteerDuring sputum-collection campaignsDuring contact tracingAt home Community-based stand-alone-testing pointsIn establishmentsIn high prevalence areasIndex client contact testing Targeted mobile outreachesThere may be at-risk individuals (e.g. sexual partners, partners in discordant relations, children of the index client) in that household who may not know their HIV status and are unlikely to attend the health facilityIndex clientLinkage facilitatorsHealth Care WorkersOVCs, adolescent girls, and young womenHealth Care Workers i.e. Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteer, Youth Peer During OVC-HTS integrated outreach campsDuring integrated immunization outreachesHome visits to OVC-headed household familiesHomesIn communitiesChurches OrphanagesIndex client contact testingOutreaches Have difficulty in accessing HIV services due to limited socio-economic capacityAdolescent peer educatorsLinkage facilitatorsHealth Care WorkersInfants and childrenHealth Care Workers i.e. Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteer, VaccinatorDuring integrated immunization outreachesDuring scheduled home visitsDuring contact tracing At homeCommunity EID through virological DNA/PCRIndex client contact tracing Integrated Immunization outreach campaignsHigh risk of morbidity and mortality if not diagnosed early and initiated on ART. To identify HIV infected children who were missed by the EID programSame point/provider initiation/ enrolment in careLinkage facilitatorsVHTs/CHEWS11

12. Population Groups that can be Accessed through Community-Based HTS Approaches (cont.)CLIENT POPULATION GROUPWHOWHEN WHEREWHATWHY? (Unique characteristics)LINKAGE STRATEGYLactating womenHealth Care Workers i.e. Nurse, Midwife, Lab. Staff, RCT volunteerDuring integrated immunization outreachesCommunitiesOutreaches Women and their partners are sexually activeHTS will inform PMTCT interventionsMentor mothersLinkage facilitatorsVHTs/CHEWSHealth Care WorkersPeople with limited access to HIV Testing Services (minorities, PWDs, elites)Health Care Workers i.e. Physician, Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteerDuring integrated HTS outreachesDuring index contact tracing When there is history of sexual abuseCommunity-based stand-alone testing points.In establishmentsUnderserved areas Homes Workplace Index contact tracing Outreaches to workplaces (camps)Stand-alone HTS Door-to-door outreach services in high prevalence geographical areasLimited access due to lack of confidentiality and privacySometimes criminalizedOften stigmatized due to their status Poor health seeking behavior (elites)May not easily negotiate for safe sex, and often are sexually violatedMay have low literacy ratesHTS may be physically inaccessibleIndex clientPeer educatorsChange agents/role modelsLinkage facilitatorsHealth Care Workers12

13. Population Groups that can be Accessed through Community-Based HTS Approaches (cont.)CLIENT POPULATION GROUPWHOWHEN WHEREWHATWHY? (Unique characteristics)LINKAGE STRATEGYRural communities Health Care Workers i.e. Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteerDuring mother and child health outreachesDuring SMCDuring events e.g. football matchesCommunity-based stand-alone testing pointsIn establishmentsIn underserved areasHomes In high prevalence geographical areasMobile testingIndex contact tracing Door-to-door outreach services Targeted integrated outreach services Limited access to HTS and other health care servicesVHTs/CHEWsLinkage facilitatorsHealth Care WorkersMenHealth Care Workers i.e. Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteerClientDuring VMMCDuring sports eventsDuring religious and other organization gatherings (Fathers union, Rotary club etc.)During index client contact tracing When they meet the criteria as per the adult screening toolCommunity based stand-alone testing pointsAt homeWork places – offices, boda boda stages, betting halls, brothels etc.Recreation places (sports venues, saunas, bars etc.)Index client contact tracingHIV self-testingTargeted HTS integrated within outreach servicesTargeted mobile outreaches Testing for men can be provided during evening/weekends/after work hoursLeast likely to access HTS under routine health care due to fear, stigma, and/or the perception that health services are for femalesChange agents/role modelsSame provider initiation/ enrolment in careIndex clientsLinkage facilitatorsHealth Care Workers13

14. Key Population and other High Risk population Specific Differentiated Approaches POPULATION CATEGORYWHOWHEN WHEREWHATWHY?(Unique characteristics) Linkage approachesMSM Health Care Workers i.e. Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteerClientRoutinely as part of healthcareEvery 3 month i.e. re-testing for the HIV negatives High prevalent areasSafe placesAt health facilitiesHot spotsDrop-in centresFriendly clinicsOrganized network meetingsCommunity-based stand-alone testing pointsMoonlight clinicsMobile clinicsSpecialized clinicsHIV self-testingOutreachesTargetedStand-alone Snow ball approach PITCVCTUnlikely to seek health services because of the unfavorable legal environment because they are not recognized Have stigma that may stop them from accessing HTSMSM Peer leaders KP focal personsSex workers and their clientsHealth Care Workers i.e. Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteerRoutinely as part of healthcareEvery 3 month i.e. re-testing for the HIV negativesHot spotsBrothels Drop-in centresSpecialized clinicsHIV and TB Index client contact tracingHTS outreaches Moonlight services Snow ball approach PITCVCT Highly mobileAre stigmatizedDrivers of the epidemicSW Peer educatorsKP focal personsPeople who use and inject Drugs (PWID) and transgender (TG) peopleHealth Care Workers i.e. Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteerRoutinely as part of healthcareEvery 3 month i.e. re-testing for the HIV negativesSpecialized clinics e.g. MARPISTI clinics Snowball approachPITCVCTIndex client contact tracing Are stigmatizedBecause of their high risky behaviorPWID Peer leadersKP focal persons14

15. Key Population and other High Risk population Specific Differentiated Approaches (cont.)POPULATION CATEGORYWHOWHEN WHEREWHATWHY?(Unique characteristics) Linkage approachesFisher FolkHealth Care Workers i.e. Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteerRoutinely as part of healthcareEvery 3 month i.e. re-testing for the HIV negativesLanding sitesBrothels Targeted community outreaches PITCVCTIndex client contact tracingBecause of their high risky behaviorTheir lifestyles keep them in water for long hoursMigratory nature Peer educatorsLinkage facilitatorsVHTs/CHEWsHealth Care WorkersLong distance track drivers Health Care Workers i.e. Physician, Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteerRoutinely as part of healthcareEvery 3 month i.e. re-testing for the HIV negativesHot spots – along major highwaysDrop-in centresSpecialized clinicsHIV and TB Index client contact tracingHTS outreaches Moonlight services Snow ball approach PITCVCT Highly mobileDrivers of the epidemicSame point/provider initiation/ enrolment in careLinkage facilitatorsSexual gender based violence (SGBV) survivorsHealth Care Workers i.e. Physician, Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteerRoutinely as part of healthcareAt first contact, then 1 month, 3 months and 6 months after completing PEP courseFacilities PITCVCTHave history of sexual abuseSGBV has the potential to increase the risk of acquiring HIVLinkage facilitatorsHealth Care WorkersUniformed personnel: Armed forces, Police, Prison Services and private guardsHealth Care Workers i.e. Physician, Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteerRoutinely as part of healthcareEvery 3 month i.e. re-testing for the HIV negativesInstitution health facilities e.g. Military barracks etc.Targeted HTS campaigns/testing eventsPITC at their health facilitiesWorkplace testing Migratory nature Because of their high risky behaviorPeer educatorsSame point/provider initiation/ enrolment in careLinkage facilitators15

16. Key Population and other High Risk population Specific Differentiated Approaches (cont.)POPULATION CATEGORYWHOWHEN WHEREWHATWHY?(Unique characteristics) Linkage approachesPeople in prisons and other closed settingsHealth Care Workers i.e. Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteerAt receptionEvery 3 month i.e. re-testing for the HIV negativesWithin prisonsAt refugee settlementsPITCTargeted outreaches Incarcerated and hence have restricted access to health facilitiesSame point/provider initiation/ enrolment in careRefugees and other persons of concern to UNHCRHealth Care Workers i.e. Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteerRoutinely as part of standard careHealth facilities within catchment areaRefugee settlementsPITCTargeted HTS outreaches in refugee settlements VCT Because of their refugee statusLack information about where to goFear travelling Have limited access to HTSMore susceptible to discrimination, violence, sexual abuse and abandonment upon disclosure of an HIV positive resultVHTs/CHEWsLinkage facilitatorsHealth Care WorkersPlantation workers e.g. sugar cane. Tea, palm treesHealth Care Workers i.e. Physician, Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteerRoutinely as part of healthcareInstitution health facilitiesAt Health facilitiesAt workplacesTargeted HTS campaigns/testing eventsPITC at their health facilitiesWorkplace testing Because of their high risky behaviorPeer educatorsSame point/provider initiation/ enrolment in careLinkage facilitators16

17. Key Population and other High Risk population Specific Differentiated Approaches (cont.)POPULATION CATEGORYWHOWHEN WHEREWHATWHY?(Unique characteristics) Linkage approachesPeople in mining industry e.g. petroleum, gold, sand etc. Health Care Workers i.e. Physician, Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteerRoutinely as part of healthcareInstitution health facilitiesAt Health facilitiesAt workplacesTargeted HTS campaigns/testing eventsPITC at their health facilitiesWorkplace testing Because of their high risky behaviorPeer educatorsSame point/provider initiation/ enrolment in careLinkage facilitatorsMigrant workers e.g. Road construction workersHealth Care Workers i.e. Physician, Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteerRoutinely as part of healthcareAt Health facilitiesAt workplacesTargeted HTS campaigns/testing eventsPITC at health facilitiesWorkplace testing Because of their high risky behaviorPeer educatorsSame point/provider initiation/ enrolment in careLinkage facilitatorsOther people in the transport industry e.g. Boda boda riders, Taxi drivers etc. Health Care Workers i.e. Physician, Clinical officer, Nurse, Midwife, Lab. Staff, RCT volunteerRoutinely as part of healthcareEvery 3 month i.e. re-testing for the HIV negativesAt Health facilitiesAt workplacesTargeted HTS campaigns/testing eventsPITC at health facilitiesWorkplace testing Because of their high risky behaviorPeer educatorsSame point/provider initiation/ enrolment in careLinkage facilitators17

18. There are two categories of clients (1) stable and (2) unstable/complexStable ClientsUnstable/Complex Clients PLHIV (Children, Adolescents, Pregnant and lactating women and adults) on current ART regimen for more than 6 months* On 1st or 2nd line ART regimens Virally suppressed: Most recent viral load result suppressed and still valid as per the viral load algorithmWHO stages 1 or 2 Demonstrated good adherence (over 95%) in the last 6 consecutive monthsTB clients who have completed 2 months intensive phase treatment and are sputum negative for PTBNOTE: A stable client must meet all the above criteria PLHIV (Children, Adolescents, Pregnant / lactating women and adults) on current ART regimen for less than 6 MonthsOn 3rd line ART regimenNot virally suppressed or with a valid suppressed viral load result.Has current or history of WHO stages 3 or 4 opportunistic infections within the past one yearPoor adherence (less than 95%)TB clients in intensive phase of treatment (< 2 months) or who are still sputum positive after intensive phase treatment for PTB.MDRTB/HIV co-infected clientsClient Categories for Differentiating HIV Care and Treatment (1) *All stable clients transitioned to new regimen due to policy changes (e.g. ART optimization) shall be retained in their current DSD approaches if all other factors stay constant however pharmacovigilance MUST be emphasized. See section on DSD implementation in the context of ART optimization for details. 18

19. Clients must first be categorized as either stable or unstable/complex. This will determine the model and approach that they will be differentiated to.KEY CONSIDERATIONS:For a client to be stable, must meet all the above criteria for stable clients.Clients with uncontrolled chronic co-morbidities (e.g. Hypertension, Diabetes, Cardiac diseases and renal diseases) should be considered unstable until control is achieved.Pregnant women can fall in either stable or unstable/complex categories, depending on their characteristics. They are, however, differentiated to only facility-based approaches. Health workers may take into consideration other issues not included in the lists above, e.g. psychosocial problems/issues, family support, etc. to determine whether a client is stable or not.Client Categories for Differentiating HIV Care and Treatment (2) 19

20. Recommended Differentiated HIV Care and Treatment Models and Approaches and Target Populations 20All PLHIV are eligible for differentiated Care and Treatment. However, the model and approach depends on many factors, including clinical stability

21. Clients Receiving Differentiated HIV Treatment and Care Under the Facility & Community-Based Models (1) 21

22. Clients Receiving Differentiated HIV Treatment and Care Under the Facility & Community-Based Models (2) 221 and 2, Stable children 2 - <10years can join FTDR or CDDP if their parents/care givers are stable and choose to join these approaches 3 and 4, Stable adolescents 10 – 14years can join CCLADs or CDDP if their parents/care givers are stable and choose to join these approaches3, Stable adolescents (10 – 14years) can be CCLAD members if their parents/care givers are stable and choose to join CCLADs but they cannot pick drugs on behalf of the other members. The responsibility of picking drugs will be for the parent/care giver in a given CCLAD group. 5 and 6, Stable adolescents 15 – 19years can join CCLADs or CDDPs if they choose to.5, Adolescents 15 – 19years can form an adolescent only group if they choose to.

23. Standard Operating Procedures for Facility-Based Individual Management (FBIM)FBIM is also referred to as Comprehensive Clinical Evaluation (CCE). It is an approach for all unstable/complex clients where an individual client is given a scheduled appointment for a thorough clinical assessment, review of blood tests and other services e.g. counselling. All stable clients will also undertake a clinical evaluation every six months.Categorization and Entry into Facility Based Individual Management (FBIM)Health worker uses the minimum characteristics for categorization to identify unstable patients prior to or during their routine clinic visitUnstable clients are sensitized about why they are categorized as ‘unstable’ and hence the need for facility-based individual management on a monthly basisClients who decline other approaches and prefer getting monthly ART refills are also differentiated into FBIMBefore Day of Appointment:The health worker/Lay provider reviews the Appointment Book to identify clients who are expected on the following day Files for expected clients are retrieved and temporarily stored in a designated place in preparation for the appointment visitOn Day of Appointment:Upon arrival at the facility, the patient goes to the reception/triage desk where registration, health education, weight, height, symptomatic OI screening, adherence assessment and documentation are doneThe client is then referred for clinical review and depending on findings, is referred according to the ART clinic client flowThe client receives a service package Follow-up AppointmentsAll FBIM clients are scheduled for one month appointmentsAt the end of the clinic day, the health workers review the appointment book(s) to establish if all expected clients came for the clinic visit. If any clients did not come for their review as expected, they should be entered into the facility’s Search List Form (Figure 16) for immediate follow-up23

24. Standard Operating Procedures for Facility Based Groups (FBGs)FBG is applicable for both stable and unstable/complex clients desiring peer support or needing special attention. The group sizes may range from 15-40 clients. The number of groups is dependent on the volume of clients in the facility. Stable clients attend FBG meetings quarterly while the unstable clients attend monthly to receive their ART refills and undergo basic screening for adherence, nutrition, TB and other OIs. For stable clients, Peer Leaders collect their drugs from the pharmacy, distribute, and account for them while for unstable clients, arrangements should be made to provide CCE and drug refills within these groups. Clients in the group who require an individual assessment or comprehensive evaluations (e.g. VL bleeding, poor adherence, OI management, post puerperal management, obstetric exam, nutritional assessment etc.) are sent to see a clinician after the group activities. Each health facility has to develop the meeting schedules for the groups as well as the health education sessions. Roles of the Health Care Worker Roles of the FBG Peer Leader Guide the clients in the process of identifying an appropriate Peer LeaderOrient Peers Leaders on their roles and responsibilitiesFollow up clients that miss appointmentsConduct health education talksAssess and categorize clientsProvide services to the clients Pre-pack ART and other medicinesUpdate records Leads the group as he/she works closely with the health care worker Identifies clients who need CCE and refers them to see the clinician Receives clients referred from the routine clinicsReviews appointment logs for group appointmentsReminds clients to come for their missed appointments and follows them up to ensure they attend the clinicEnsures clients attend the group visits as requiredTogether with (and under supervision of the clinic staff), pre-pack drugs for the groupsHelps in distributing ARVs to group members and documenting dispensed drugsARVs distributionCompleting records i.e. Appointment BookOrganizes and plans village savings and loan activities (VSLA)Sensitize group members24

25. Standard Operating Procedures for Facility Based Groups (FBGs) cont’dSelecting the FBG Peer LeaderHCW guides the process, however the group members have the right to select a peer leader of their choice. The selected person should be oriented on his/her roles. He/she should be one who;Will be most accepted by majority of clients in the clinicRegularly attends the clinicShould have good treatment outcomes (over 95% adherence, virally suppressed and healthy)Has disclosed to his/her partner, if anyHas no stigmaHas time to carry out the group activities and to coordinate the groupCan keep confidentialityCan read and write and communicateShould have gone through all the stages of the psychosocial support groupsServices received in the FBGsSharing experiences through testimoniesPsychosocial supportAdherence counselling by the health workerWeights and MUACRecords completionDrug refill (ART, Anti-TB, CTX, etc.)Saving and loans schemes activitiesOperational FBG initiatives at health facility levelBefore the meetingMobilizationSelection of speakers and topicsSourcing IEC materialsDuring the meeting Opening PrayerIntroductions - in any agreed methodReview the objectives of the group and the group’s expectationsReview key issues like: Adherence, retention in care, disclosure, confidentiality, viral load monitoring, nutrition, TB, etc.Educational talk – Speaker conducts an interactive learning session with group discussion NOT a lecture.Testimonies of the members (one or two testimonies are adequate)Share knowledge about available wrap around services i.e. income generating activities.Feedback of the Group meeting Provide clinical servicesEnd with a Prayer25

26. Standard Operating Procedures for Fast Track Drug Refill (FTDR)FTDR ensures that stable clients are fast-tracked to get their drug refills without having unnecessary clinical evaluations. The client passes through the triage desk where basic assessments are conducted. He/she returns to the health facility at three 3 months’ intervals, with every 6 month’s encounter consisting of a comprehensive clinical evaluation (CCE). i. Categorization and Entry into Fast Track Drug Refill (FTDR)Health worker uses the minimum characteristics for categorization (Table 8) to identify stable patients prior to or during their routine clinic visitThe Stable patient is sensitized about the fast track drug refill approach and enrolled if he/she agrees to itHe/she undergoes a comprehensive clinical evaluation and receives the service package of care Client receives a 3 months ART drug refill and is booked for an FTDR appointment in the appointment book ii. Before Day of Refill Appointment:The health worker/Lay provider reviews the Appointment Book to identify clients who are expected to on the following day Files for expected clients are retrieved and temporarily stored in a designated place in preparation for the appointment visitThe ARVs and other medicines (CPT, family planning, etc.) are pre-packed by the pharmacy staff and clearly labeled with the patient’s name and ART numberiii. On Day of ART Refill Appointment:Upon arrival at the facility, the client goes to the reception/triage desk where registration, health education, weight, height, symptomatic OI and TB screening, adherence assessment and documentation are done A client who has clinical signs and symptoms and/or is categorized as unstable is referred to the clinician for further evaluation A client who has no complaints and is categorized as stable has his/her next appointment dates recorded in his/her file, in the appointment book and in his/her client hand-held card or book. This next appointment will be for a comprehensive clinical evaluation. The client is then fast tracked to the pharmacy dispensing window or dispensing point to receive his/her three months ART refill and other medicationsThe dispenser records the dispensed drugs in the ARVs and medicines dispensing logAt the end of the clinic day, the health workers review the appointment book to establish if all expected clients came to pick their refills. If any clients did not come for their refill as expected, they should be entered into the facility’s Search List Form (Figure 16) for immediate follow-upiii. Day of Comprehensive Clinical Evaluation AppointmentEvery six months, the client comes for a comprehensive clinical evaluation and follows the standard client flow and receives the service package of care Re-categorization as a stable patient is confirmed26

27. Other Options for Facility-Based Differentiated HIV Treatment and Care ApproachesDifferentiated Schedules/Flexible TimeHealth workers can also dedicate specific time (early, late, weekends) to specific groups of clients such as the men, key populations, mobile populations etc. Clients attend the clinic at their convenient timeClients receive targeted counseling sessions as well as targeted health talks. Dedicated time depends on the size of the target client group.HCWs aim to see as many clients during the dedicated time as are seen in the regular schedule. Differentiated ClinicsHealth facilities can also dedicate specific clinic days for special populations e.g. children, adolescents, TB-HIV co-infected clients, Hepatitis etc.). Health facilities need to dedicate space for these populations Using temporary structures (such as tents)Providing dedicated space to specific groups on specific days or times of day, can be considered. Where the target group is small, Health workers may discuss with clients the possibility of transferring them to another preferred facility that has sufficient clients and is able to offer dedicated space and times for them This will require appropriate referral systems that allow the service provider to follow-up the referral to ensure that the client is receiving treatment at the referred facility.27

28. Facility-Based Models: Service Package for Stable ClientsClinical consultationsART refills(ART, CTX, Family Planning)Laboratory testsAdherence supportWhenEvery 6 months (twice a year) Every 3 months/ 4 times a yearVL annually At every visit WhereFacility or Community Facility or community Facility or community Facility or community Who Clinician (MO, CO Nursing Officer)Dispenser / nurse / trained lay providers (expert client) Laboratory staffCounsellor/ Nurse/ Trained Peer WhatHistory and physical examination (Vital signs including weight, blood pressure, mid upper arm circumference - MUAC, Nutritional Assessment Counselling and Support - NACs) Symptom screen (TB, sexually transmitted infections -STIs, other opportunistic infections)Referral for other conditions including non-communicable diseases (NCD) screening & management Adherence assessment (ART/cotrimoxazole - CTX)Update registerNew appointment – clinical or for viral load (VL)Through Facility Based Individual Management (FBIM) when the clinical evaluation is due for those who are in Fast Track, community client led ART distribution (CCLAD), and facility based groups (FBGs)Through Community Based Individual Management for the community drug distribution point (CDDP)Pre-packed ARVs (label)Dispense Fill dispensing log Fast Track (Pick-up from dispensing points or pharmacy after going via the triage desk)Longer appointment spacing and multi-month prescriptionsThrough peers (CCLAD)Through health care worker outreaches (CDDP)Viral load sample collectionTransport to hubFrom the facility laboratory following the FBIMClients are bled during the community outreaches and results communicated as soon as possibleAdherence support During the FBGsDuring the CDDPsDuring the monthly refill meetings for CCLADs28

29. Facility-Based Models: Service Package for Unstable/Complex/New Clients Clinical consultationsRefills(ART, CTX, Family Planning)Laboratory testsAdherence supportWhenClients already in care: Monthly New/naïve clients: Monthly Unstable/complex clients: Monthly New/naïve clients: MonthlyBaseline tests at initiationVL:First VL at 6 months (new clients) and then annuallyFor cases of VL non-suppression:Offer intensive adherence counselling (IAC) at least 3 consecutive sessions, 1 month apartRepeat VL 1 month after 3 consecutive IAC sessions with documented good adherenceAt every visit Where Facility Facility Facility Facility and community WhoClinician (MO, CO Nursing officer)Dispenser /nurse / Trained lay providers (expert client) Lab staff Counsellor/ Nurse/ Trained PeerWhatNew clients: Rapid initiation of ARTOI screening, e.g. CRAGNutrition screeningNon-communicable diseasesHistory and physical examination (vital signs including weight, blood pressure)Pre-packed ARVs (label) CD4; HBsAg; CrAg if CD4<100 or VL is not suppressed; VL test for pregnant women on ART at 1st ANC in that pregnancyOther tests as indicated: Complete blood count (if risk of anaemia)TB test (if presumed)HCG when indicated Renal function tests (for hypertension & diabetes mellitus)Liver function tests (HBV or HCV infection)Lipid profile & blood glucose HCV antibody testAdherence support 29

30. Facility-Based Models: Service Package for Children and AdolescentsClinical consultationsRefills(ART, CTX, FP)Laboratory testsAdherence supportWhenStable Children 2 yrs and above: QuarterlyChildren under 2 yrs: MonthlyAdolescents 10-19 years:Quarterly UnstableAll children and adolescents: Monthly  At every visit Baseline tests at initiationVL:First VL at 6 months and then every 6 months for children (up to 9 years) and annually for adolescents (10 years to 19 years)For cases of VL non-suppression:Offer intensive adherence counselling (IAC) at least 3 consecutive sessions, 1 month apartRepeat VL 1 month after 3 consecutive IAC sessions with documented good adherenceAt every visitWhere Facility - (adolescent corner, special clinic days, space for group meetings) Facility dispensingFacility laboratoryFacility 30

31. Facility-Based Models: Service Package for Children and Adolescents (continued)Clinical consultationsRefills(ART, CTX, Family Planning)Laboratory testsAdherence supportWhoClinician (MO, CO, Nursing officer)Dispenser/ nurseLab staffCounsellor/ nurse/ expert clients/ peerWhatChildren: ARV dose adjustmentdisclosure and adherence supportWeightRoutine care (CTX & ART refills, OI & screening nutritional assessment counselling and support (NACS), STI screening, Positive Health, Dignity, and Prevention (PHDP)Adolescents: More psychosocial support on stigma, disclosure, hormonal changesNeed FP, SRH, adolescent corner, STI care/ counseling; different clinic daysConsider school going; space for group meeting, entertainment; consider visits in holidays for adolescentsDispense Fill dispensing log Update the ART register and Open MRS  VL at 6 months, 12 monthsSTIs, such as syphilis (as indicated for others)Urine HCGOther tests as guided by clinical assessment   DisclosureAdherence supportPsychosocial support on stigma and discrimination reduction , disclosure, hormonal changes/sexual development, life skillsHealth education, counseling and provision of sexual reproductive health (SRH) – Family planning, sexually transmitted infections (STI) care, safe conceptionCareer development – schooling, vocational training, Income Generating Activities (IGAs) Entertainment and individual coping/stress management activities consider visits in holidays for adolescentsPHDP31

32. Facility-Based Models: Service Package for Pregnant and Breastfeeding Women and Their HIV-Exposed InfantsClinical consultations & screeningRefills(ART, CTX, Family Planning)Laboratory testsAdherence supportWhen Stable pregnant women** All ANC Visits (goal-oriented ANC)New/unstable pregnant women***2 weeks after initiation of ART and then monthly until delivery Follow routine maternal child health (MCH) schedule after delivery Stable breastfeeding mothersTogether with the exposed infant schedule 10 postnatal care (PNC) Visits:6 weeks, 10 weeks, 14 weeks, 6 months, 9 months, 12 months, 15 months, 18 months, 24 months Mothers At every ANC and PNC visit, clinical visitsHIV Exposed Infants (HEI)Low risk infant – Nevirapine syrup for 6 weeks after birthHigh risk infant – NVP syrup for 12 weeks after birthCTX at 6 weeks until confirmed HIV negative Pregnant /breastfeeding Mother:CD4 at enrollmentPregnant women on ART at 1st ANC: VL , then annually if suppressed For those newly initiated on ART: 1st VL done at 6 months after ART initiationSyphilis and CBC at ANC 1Blood chemistry as need arisesHEI:At 6 weeks: 1st DNA PCR2nd DNA PCR 6 weeks after stopping breastfeedingAt 18 months: Rapid HIV antibody test At every visitWhere Anténatal care (ANC) Clincs, Mother Baby Care Points (MBCP)*/PNC/Young Child clinic (YCC)MBCP/Maternal neonatal adolescent health (MNCAH), Maternity, PharmacyMBCP/MCH, LaboratoryANC, MBCP/PNC/YCC, pharmacy, in psychosocial (PSS) groupsWhoMidwives, MO/CO, Nurses, Counselors, Clinicians Counselors, Midwives, Nurses, dispensersMidwives, Nurses, Counselors, Lab personnelMidwives, Nurses, dispensers, counselors, MO/CO, mentor mothers & Family support groups (FSG)WhatANC, PNC & Immunizations, Rapid initiation of ART of new clientsScreening for OI e.g. TB, nutrition, & NCDsHistory and physical examination (Vital signs including weight, BP)Assessment and care for the HIV exposed infantDispense ARVs CTX & OI medsFP commoditiesNevirapine and CTX for the HEIRapid HIV testSyphilis testHIV viral load testDNA PCR for infant HIV diagnosisOther tests as per clinical assessment Adherence support Psychosocial support32

33. Facility-Based Models: Service Package for Stable Key Populations Clinical consultations & screeningRefills(ART, CTX, Family Planning)Laboratory testsAdherence supportWhenEvery 6 monthsEvery 3 monthsAnnual VL Quarterly STI screening testsAt every visitWhere Specialized Key Population clinics, general ART clinics, community outreachModified hours of operationOutreach service pointsFamily Planning servicesSpecialized Key Populations (KP) clinics, general ART clinics, pharmacy, community ARV refill pointsSpecialized KP clinics, laboratory Facility laboratory & community mobile lab pointsSpecialized KP clinics, general ART clinics, Pharmacy, Psychosocial groupsWhoMO/CO, NursesDispensers nurse/peerLab personnelCounsellor/ nurse/ expert clients/ peerWhatClinical assessmentManagement of OIs and other clinical problemsPrescribe ARVs and other medicines  Dispense ARVs, CTX and other medicinesFill the dispensing logUpdate the ART register/OpenMRS STIs, syphilis (as indicated for others)VLAdherence support33

34. Service Package for Patients with TBClinical consultationsART and TB drug refillsLaboratory testsAdherence support (ART and TBWhenNew TB Clients (already on ART): Fortnightly for 2 months Do repeat sputum at 2 months for PTBConsider Community DSDM if sputum conversion occurred for stable clientsNew TB patients (ART New/naïve clients): Fortnightly for 2 monthsThen monthly for 6 monthsClients in Intensive phase of TB treatment (Unstable): Fortnightly for 2 monthsDo repeat sputum at 2 monthsConsider community DSDM if sputum conversion occurred and client categorized as stableNew/naïve clients: ART initiation at 2 weeks of TB treatmentFortnightly for 2 monthsThen monthly for 6 monthsSputum at 2, 5, and 6 months Baseline testsVL:First VL at 6 months (new clients)Then annuallyFor cases of VL non-suppression:Offer IAC at least 3 sessions, 1 month apartRepeat VL 1 month after 3rd IAC sessionAt every visit Where Facility for 2 months and moves to community care model when stableFacility for 2 months and moves to community care model when stableFacilityFacility or community 34

35. Service Package for Patients with TB (continued)Clinical consultationsART and TB drug refillsLaboratory testsAdherence support (ART and TBWhoClinician (Medical Officer, Clinical Officer Nursing officer)Dispenser /nurse / Trained lay providers (expert clients) Laboratory staff Counsellor/ Nurse/ Trained PeerWhatRapid initiation of ARTClinical evaluation every 2 weeks for the first 2 months; thereafter at 2, 5 and 6 months. TB symptom screeningTB and other OI screening, e.g. CRAGNutrition screeningNon-communicable diseases (NCDs)History and physical examination (vital signs including weight, blood pressure) Pre-packed ARVs (label) and anti-TB medicationsFacility refills fortnightly in the first 2 months and then monthly or quarterly depending on stability Gene Xpert testSputum at 2, 5 and 6 months. Chest x-ray (CXR) at baseline Liver function tests if on multi-drug resistant (MDR) TB treatment or reacted to medicationThyroid function tests, monthly smear and culture for MDR patients. CD4, HBsAg, CrAg if CD4<100, VL test for pregnant women at 1st ANC and lactating mothersOther tests as indicated: Complete blood count (if at risk of anaemia)Test for TB (if suspected) Renal function tests (for hypertension & diabetes mellitus)Lipid profile & blood glucose HCV antibody testAdherence support (both TB and ART)TB and HIV Index Client Contact tracing and screening for TB 35

36. Service Package for CDDP Group Members36Clinical consultations & screeningRefills(ART, CTX, TB, FP)Laboratory testsAdherence supportWhenEvery 6 months 4 refills per year (quarterly)Annual VL Quarterly STI screeningsOther tests as neededAt every visitWhere Community Community Specialized KP clinic outreaches Community Specialized KP clinic outreachesCommunitySpecialized KP clinic outreachesWhoMO/CO, NursesNurses, Counselors, Expert Clients Lab personnelTrained nurse/clinician Counsellor/ nurse/ expert clients/ peersWhatOI & TB screeningNutrition assessment Adherence assessment STI screening & treatmentPHDPDispense ARVs and OI drugsSTI treatment TB treatment STIs, other tests as indicatedVL Sputum collectionPoint of care testingAdherence support

37. DSD implementation in the context of TB Preventive Therapy (TPT)37TPT is recommended for specific sub-populations who are at an increased risk of getting TB disease as per details in consolidated ART guidelines 2020. The following should be followed while providing TPT in the context of DSD;TPT to be initiated by a clinician regardless of which approach the client is in. Efforts should be undertaken to have baseline tests done (i.e. LFTs) prior to initiation of TPT.TPT should be initiated at the health facility for all clients receiving ART services through FBIM, FBG, FTDR and CCLAD.For clients enrolled onto CDDPs, TPT should be initiated from the CDDP during the clinicians visit. Efforts should be undertaken to have baseline tests done (i.e. LFTs) prior to initiation of TPT.Patient education about side effects and when to return to facility provided at the time of TPT initiation regardless of DSD approach.TPT and ART refills should be aligned. Clients in more intensive approaches (i.e. FBIM and FBG) should be reviewed every month for TPT and ART toxicities.Clients in less intensive approaches (i.e. FTDR, CDDP and CCLAD) should be reviewed at least once every three months. Review at 3 and 6 months post TPT initiation should happen at the facility for clients enrolled onto FTDR and CCLAD. Review at 3 and 6 months post TPT initiation for clients enrolled onto CDDP should happen at the CDDP.

38. Managing Special SituationsManaging transitions from PMTCT to ART and from pediatric/adolescent groups to adult clinicsThese clients should be automatically transitioned to the adult ART models/approaches and supported appropriatelyManaging clients who do not qualify for specific models and yet demand for themClients should be managed on individual basis.Managing clients who transfer in Transfers in clients should be managed as if they were new in care Managing clients who falter or drop out of a specific differentiated service delivery modelThese automatically revert to the comprehensive approach and are closely monitored until they become stableCouple enrolment into DSDMIf stable and disclosed to each other, they should receive care under the same model. This allows each one to alternately pick drugs for theManaging a TB/HIV co-infected clientTB/HIV co-infected clients are initially managed in the facility and can only join or re-join community care and treatment approaches if they have completed intensive phase and are sputum negative. Regardless of which HIV Care and Treatment approach they are receiving care from, their appointments for HIV and TB clinical reviews and ART and anti-TB medicine refills must be aligned.Managing clients whose regimen has been changed due to policy changesALL stable PLHIV transitioning to other regimens due to policy changes (e.g. ART optimization) shall still be considered stable if all other factors stay constant. Efforts should be made to strengthen pharmacovigilance through patient education and clinical review.38

39. Standard Operating Procedure for Community Client-Led ART Delivery (CCLAD)CCLAD are psychosocial community ART groups comprising of stable clients living in the same community/locality. Group members take turns to pick up ARVs at the health facility and distribute them to the rest in the community. They manage their own health and take action with the support of HCWs. It is recommended that the CCLAD groups comprise of 3 to 6 members. Organizing for CCLAD Step 1 – Preparations In The Health FacilityOrientation of health workers on the CCLAD approach Identify a Focal Person from the health workers to coordinate the following activities Identify and map clients by their locations Lead, promote and sensitize clients about CCLADOversee completeness of tools Train, monitor, supervise and follow up with CCLAD Group LeadersEnsure implementation and quality assurance of the groups’ functionality and operationsCoordinate the preparation for clinic visits for patients in CCLAD e.g. retrieval of files, prepacking medicines, ensure availability of blank CCLAD monitoring forms etc.Step 2 – CCLAD Group FormationConduct client mapping using the existing facility client data to categorize the clients into stable or unstable ART clients. Stable clients are listed in accordance to their locations, preferably villages. Sensitize all stable clients, one-on-one or as a group, explaining the implications and benefits of joining a CCLAD group. Schedule a meeting with clients coming from the same location Encourage stable clients to form groups on their own to foster ownership and belonging. These groups should be formed guided by;Locality of proposed group membersAbility to read and write for at least one of the proposed group membersGroup size i.e. 3 – 6 members per groupAssess each client’s readiness to join a group. In this assessment process, the following questions will be asked:Have you disclosed to anyone? If yes, to who? If not, why not?Would you like to know other clients who would like to form a group in your community? Are you willing to be known by them? Would you like to consent to join a group? If all answers are “Yes” then the client will be signed up for group formation. If “No” to any question the health worker should support the client accordingly. NB. Signed readiness forms should be kept in the client’s file 39

40. Standard Operating Procedure for Community Client-Led ART Delivery (CCLAD) cont’dOrient the newly formed groups in the approach about their roles and responsibilities (the do’s and don’ts of the group)Support the group to develop a visit plan that ensures that they all attend at six month’ intervals for comprehensive clinical evaluations and every twelve months for VL monitoring. Support the group to develop a drug refill schedule and appoint a group representative to collect ART from the health facility at three months intervals At three months’ intervals drug refills will be given to each individual during group drug refill meetings or during comprehensive clinical evaluationCommunicate the new group appointment dates to the members and record in the facility appointment book. VL monitoring will be done for all group members during the comprehensive clinical evaluation visits. The group members’ VL monitoring visits should be harmonized to ensure that all group members are bled at the same time. This will be guided by CPHL’s bleeding window of 10 – 12 months from the previous VL date and can be done over a period of 12 months.Support the CCLAD group members to select a leader to undergo additional training (e.g. TB screening, OI identification and referral, nutritional and adherence assessment). The leader must have basic reading/writing skills.Assign each group and group member a unique identifier (CCLAD Group Code) using the following format: Facility name 3 letter abbreviation/CL/group serial number/group member serial number in the group. E.g., “KWL/CL/001/01” i.e. KWL standing for Kawolo Hospital, CL for CCLAD, group serial number 001 and group member serial number 01. The CCLAD Group Code will exclude the group member serial number. NOTE: The group and group member serial numbers should never be given to another group or group member even if the group is dissolved or the group member leaves the group.Maintain a serial filing system based on client number (do not file according to CCLAD groups)Record all patients joining CCLAD groups in the appropriate registers and update registers as patients enroll into groups. Consider use of hand-held calendars (based on group size) or exercise books for appointment reminders Organizing CCLAD Groups In The CommunityGroup members will agree on the location of the group meeting and communicate to the health worker.Group members will agree on the mode of facilitation for the group member that will be selected to pick drugs on behalf of the group in a given month, e.g. group contributions or from their savingsGroup members will be encouraged to meet monthly to promote bonding, provide psychosocial support to each other and also conduct their other group activities e.g. Income generating activities, loans and saving activities. At the end of the three months after their comprehensive clinical evaluation, group members hold two meetings, 1 for community clinical assessment and the other for community ART delivery. The community clinical assessment will be conducted during the pre-drug pick-up meeting and the findings are filled on the CCLAD monitoring form using the codes to be discussed below.Pre-Drug Pick-Up Meeting (Assessment): This meeting takes place a day or 2 before the drug refillGroup Leader does pill count for each member and records the number of the remaining pills (i.e. ARVs, CTX and TB drugs) on CCLAD monitoring form against each member. 40

41. Standard Operating Procedure for Community Client-Led ART Delivery (CCLAD) cont’dGroup Leader assesses the health status of each member and records on the CCLAD monitoring form using the codes as indicated in the table below.Codes for health status during community clinical assessmentGroup Leader assesses the TB status of each member and records on the CCLAD monitoring form using the codes as indicated in the table below.Codes for TB status during community clinical assessmentGroup Leader assesses for pregnancy/Family planning status of each female member and records on the CCLAD monitoring form using the codes as indicated in the table below.Codes for pregnancy/family planning status during community clinical assessmentCodeWhat it stands forInstructions1Attended Community AssessmentThe group leader writes this number if the member came to attend the group meeting.2Missed Community AssessmentThe group leader writes this number if the member did not come to attend the group meeting.3DeadThe group leader writes this number if the member died prior to the group meeting.4Returned to health facilityThe group leader writes this number if the member has been referred back to the facility prior to the meeting.CodeWhat it stands forInstructions1No signsThe group leader writes this number if the member does not have cough, evening fevers, night sweats and weight loss2Presumptive TBThe group leader writes this number if the member has any of these symptoms i.e. cough, evening fevers, night sweats and weight loss3TB DiagnosedThe group leader writes this number if the member was diagnosed with TB prior to the meeting.4Currently on TB treatmentThe group leader writes this number if the member is receiving treatment for TB.CodeWhat it stands forInstructionsPPregnancyThe group leader writes this letter/code if the female member is pregnant.FPOn Family planningThe group leader writes this letter/code if the member is using family planning or condoms (specifically for men).No FPNot on Family planningThe group leader writes this letter/code if the member is not using family planning or condoms (specifically for men).41

42. Standard Operating Procedure for Community Client-Led ART Delivery (CCLAD) cont’dGroup Leader assesses nutritional status of each member and records on the CCLAD monitoring form using the codes as indicated in the table below.Codes for nutritional status during community clinical assessmentNOTE: The fully filled form is handed over to the person representing the group on the refill dayWhenever the group member feels or is sick (i.e. has fever, headache, cough etc...), he/she should go to a health facility any time for treatment and not wait for the routine ART refill visitPost-Drug Pick-Up Meeting (Drug Refill And Accountability): This happens on the day (or a day after) the member returns from the health facility with the drugs to distribute to other membersGroup members re-convene to collect their supply/refill The CCLAD monitoring form is handed over to the Group Leader The group members acknowledge receipt of their drugs on the CCLAD monitoring form The group shares observations, challenges and they discuss and agree on the way forward Communication is made about the next meeting dateNOTE: If there is a member who has not picked his/her drugs within two days, the group leader should immediately follow upIf the member cannot be traced within 7 days, the group leader should inform the health facility immediately. The drugs for these clients should be stored well and taken back to the facility within the next 7 days. The member can then pick his/her drugs from the health facility if he/she returns which will give an opportunity to the health workers to provide interventional adherence counselling.CCLAD group scheduling for visitsAt the initiation of the group, all the group members attend for a comprehensive clinical evaluation and receive their 3 months’ ART refill. At the next visit, which is three months later, one selected group member comes to the facility to pick drugs for him/herself and the other group membersAt the next visit, which is six months’ later, all the group members return to the facility for their comprehensive clinical evaluation and each receives his/her drugsThen at a subsequent visit which will be nine months later, one selected group member comes to the facility to pick drugs for him/herself and the rest of the group membersCodeWhat it stands forInstructionsGGreenThe group leader writes this letter/code if the member’s MUAC measurement falls under the green section of the tape.YYellowThe group leader writes this letter/code if the member’s MUAC measurement falls under the yellow section of the tape.RRedThe group leader writes this letter/code if the member’s MUAC measurement falls under the red section of the tape.42

43. Standard Operating Procedure for Community Client-Led ART Delivery (CCLAD) cont’dRoles of Key CCLAD Group ActorsGroup LeaderGroup MembersHealth Workers Ensure that each group member signs the CCLAD monitoring form for accountability of the drugs and store it until the next visitConduct monthly monitoring of groups membersInform the HCW about clients that have missed meetings and or drug refill pick upsConduct group counseling and education sessions and record health education topics/issues discussed in the groupCarry out clinical assessment of the group members i.e. symptomatic TB screening, adherence assessment, TB treatment support, TB treatment medications, and nutrition assessment (using MUAC tape)Facilitate referrals and linkages as well as provide the group psychotherapy sessionsIdentify and report any adverse outcomes or drug interactions (side effects) assess ability to perform simple tasks (functionality) etc. Ensure each group member undergoes a clinical consultation twice a year  Attend clinic on their appointment date for a clinical and laboratory reviewPick drug refills for all group members on their clinic appointment daysSign the CCLAD monitoring form as acknowledgement of receipt of his/her drugs Provide peer-to-peer adherence support and psychosocial supportReport to the facility, the status of other group membersTake his/her pill balances, if any, to the health facility during their turn to visit the clinicFinish the old supply of pills before starting the new refill, if there are any pill balances Bring a bag to the health facility to carry the pre-packed drugs to membersAttend meetings with the other group members Orient CCLAD Group Leaders as one-on-one or as a groupSupervise the CCLAD groups under their care at least once every 6 months (a minimum of twice a year) Track and follow up missed appointments of individual group members as reported by the group leader Link CCLAD members to other services at the facility, including FP, cervical and breast cancer screening, etc.Provide comprehensive ART clinical evaluation for clients coming to the facility for drug pick upReview information in the CCLAD monitoring form to ascertain community clinical assessment findings (TB status, adherence, family planning status, nutritional status) and take appropriate actionTransfer the information from the CCLAD monitoring form & TB Treatment Card to the HIV Care Card and the registers (ART and TB)Review the list of appointments of CCLAD members prior to clinic appointment, retrieve their files, and pre-pack and label the drugs (the latter can be delegated to expert clients/lay counselors)Dispense the correct drugs to the CCLAD membersReceive and file the CCLAD monitoring forms and supply new onesGive and document the next appointment in the appointment book and the client hand-held card 43

44. CCLAD Monitoring Form44

45. Guidance on completion of the Community Client Led ART Delivery (CCLAD) FormDescription and InstructionsObjective: Facilitate documentation of HIV care and treatment data for clients that are self-managed within the Community Client Led ART Delivery groupsCopies: Two Copies. Original stays in the booklet, a copy is kept at the health facilityResponsibility: At the community level, CCLAD group leader while at the health facility, DSD Focal personProcedureInitial visit as CCLAD Group at the health facilityClinician conducts a clinical assessment for each of the group member and documents/completes their respective HIV care/ART cards for this particular visitClinician/triage nurse completes Sections A, B, C and D of the CCLAD form for each of the CCLAD group memberDESCRIPTION OF SECTIONS: Section A: Write the facility name, level, district, sub-county and parishSection B:CCLAD group code: Write the group unique identifier (CCLAD Group Code) using the following format: Facility name 3 letter abbreviation/CD/group serial number. E.g. KWL/CL/001 i.e. KWL standing for Kawolo Hospital, CL for CCLAD and group serial number 001.Unique identifier for group member who picked drugs: Write serial number for the group member picking drugs e.g. 01.Name of attending Health worker: Refers to the name of the health worker attending to the CCLAD group member(s). One who updates the files, fills the CCLAD form and prescribes drugs.Next Appointment Date: Refers to the date when the group members will be due for ART refill +/- a comprehensive clinical evaluation. Section C: Group member unique identifier (Serial #): Write serial number for each group member.Patient clinic # (ART #): Write patient clinic number/ART number as recorded on the HIV care/ART card.Patient Initials: Write the first letters of the first (Given) and last (Surname) name of the patient. E.g. for a patient called Gertrude Nakacwa, write GN.Sex: Write patient’ sex. F for Female or M for Male.Age: Write age of patient as per records on the HIV care/ART card45

46. Guidance on completion of the Community Client Led ART Delivery (CCLAD) Form cont’d Section D:Date: Write the drug refill dateDrugs given: Write details of the dispensed drugs i.e. ARV regimen codes for ARVs, CTX or DAP for Cotrimoxazole or Dapsone and TB regimen for TB drugs.# of pills: Write number of pills dispensed# of days: Write number of days for which drugs have been dispensedAfter receipt of the drugs at the dispensing window, All group members acknowledge receipt by completing Section E.DESCRIPTION OF SECTION: Section E:Date drugs received by patient: Patient or CCLAD leader or any other designated group member writes the date when each group member received his or her drugs.Patient signature: Patient acknowledges receipt of his or her drugs by appending his or her signature or thumb print here.Dispenser records the dispensed drugs into the ARV Consumption logClinician/dispenser hands over the CCLAD booklet to the CCLAD team leader, drugs to each member, while the group HIV care/ART cards are kept at the health facility.Community Pre drug Pick up Meeting/AssessmentCCLAD group leader assesses each group member and completes Section F for each DESCRIPTION OF SECTION:Section F:Patient status: Group leader fills in one of the following codes as appropriate;1 - Attended Community Assessment2 - Missed Community Assessment3 - Dead4 - Returned to health facilityTB status: Group leader fills in one of the following codes as appropriate;1 - No signs2 - Presumptive TB3 - TB Diagnosed4 - Currently on TB treatment46

47. Guidance on completion of the Community Client Led ART Delivery (CCLAD) Form cont’d# of Pills returned: Group leader fills in the number of pills returned after a pill count. Preg/FP status (P, FP, No FP): Group leader fills in one of the following codes as appropriate.P - Pregnant FP - On Family Planning No FP - Not on Family Planning MUAC: Group leader fills in one of the following codes as read off the MUAC tape.G - GreenY - YellowR - RedDrug re-fill visit at the Health FacilityA CCLAD group member reports to the Triage nurse desk at the health facility with the booklet containing a fully completed CCLAD formTriage nurse updates each CCLAD group member’s HIV care/ART card using the data in Section F of the completed CCLAD form: Calculates adherence score, based on the number of pill returned data and completes the ARV and Septrin/Dapsone Adherence columns for the previous visit when the drugs were dispensedThe rest of data under Section F are recorded on the HIV care/ART card under a new visit.Under the new visit, Triage nurse records drug refills for each of the CCLAD group members on the HIV care/ART cardTriage nurse retains a copy of the completed CCLAD formTriage nurse initiates a new CCLAD form and completes Sections A, B, C & DDispenser records the dispensed drugs into the ARV Consumption logClinician/dispenser hands over the CCLAD booklet and packs of drugs for each member to the CCLAD group representative, while the group HIV care/ART cards are kept at the health facility.Individual Drug Refill at the CommunityUpon return from the health facility CCLAD group representative distributes to each member, their respective consignment of drugs and they each acknowledge receipt by completing Section E of the newly issued CCLAD formCCLAD booklet is handed over to the team leader for safe custody until the time of the next Community Pre drug Pick up Meeting/Assessment47

48. Standard Operating Procedures For Community Drug Distribution Point (CDDP) ApproachThe CDDP approach is an outreach that targets clients in remote/underserved areas with poor access to health facilities for ART such as hard to reach areas (islands, landing sites, pastoral areas, etc.), districts with few facilities accredited to offer ART, etc. The groups range from 10-50 clients who come from a common area/location distant from the health facility. Additional eligible clients can join the group at any point. Only clients stable on ART are eligible to receive care under this approach. Steps in Establishing a CDDPStep 1. Identify need for CDDP The facility should have identified it as a priority approach Step 2. Form the CDDP group and orient members The HCW reviews all files of all clients coming from that community or location to establish their eligibility status (Stable/Unstable) All eligible members at an opportune time are called upon by a HCW to discuss about CDDP and informed consent is obtained from those interestedA minimum of 10 members will be grouped together to form a CDDP group. If more than 50 are interested, another group must be formed. Enrollment into the CDDP model is strictly voluntary. A CDDP group list is generated and a code is given to the group using the following format: Facility name 3 letter abbreviation/CD/group serial number/group member serial number in the group. E.g., KWL/CD/001/01 i.e. KWL standing for Kawolo Hospital, CD for CDDP, group serial number 001 and group member serial number 01. The CDDP Group Code excludes the group member serial numberNOTE: The group and group member serial numbers should never be given to another group or group member even if the group is dissolved or the group member leaves the group.The health facility will organize a two-day workshop for all the CASAs/Group leaders for orientation on the CDDP approach and sensitization about roles and responsibilities. Assessment for group formation and group re-assignment in this approach will be an on-going process.Step 3. Agree on the distribution pointThe group decides where they will regularly meet (drug distribution point) with the guidance of the health worker.The health worker then maps and visits the site and seeks the consent of the stakeholders and local authorities. The minimum requirements for the distribution point include;A public place e.g. Health Centre II, church, mosque, school, CBO premises etc.Offers some kind of privacyHas a room to be used for safe blood sample collection48

49. Standard Operating Procedures For Community Drug Distribution Point (CDDP) Approach cont’dStep 4. Implement the CDDPHealth workers retrieve files of the CDDP members and put them together in one big file folder that they will take to the community when services are deliveredThe first refill for the CDDP group will be at the facility and members will receive a 3-month supply of ARVs. Subsequent members who join the group will be given drugs up to the next appointment date.Thereafter, members are given an appointment at the CDDP for subsequent ART refills, consultation and ART monitoring by the clinical team.The Group Leader of HCW mobilizes group members to come for their appointments.ARV drugs are pre-packed for the CDDP members. Additional supplies to be pre-packed include FP supplies, OI drugs, condoms, etc.Transportation is organized.The facility agrees on the health team to visit the CDDP.NOTE: VL monitoring should be synchronized for all clients on one date (The date when the CDDP outreach is held).Logistics needs – CDDPLocationLogistics Needs Facility Enough stock of drugs for all clientsMarkers for labelingPortable scales, MUAC tapesBig file folders (box files)Tools (HMIS tools—data collection/reporting, registers, patient cards, ICF forms)Health education, job aids, client flyers, etc.Transport means to deliver drugs to the CDDP groupCool box with ice packs, sputum containers, triple packagingCommunity Appropriate venue for the group meetings where members feel free (safe zone/meeting point)Health education job aids, client flyers, etc.49

50. Multi- month prescriptions50Multi-month prescriptions may apply to stable clients in all models. This is defined as prescriptions for 3- or 6-months. Previous guidelines have recommended 3 months prescriptions for stable clients on stable approaches i.e. FTDR, CDDP and CCLAD. These guidelines recommend the introduction of 6 months prescription for clients in whom frequent drug pickups may compromise their adherence to ART. Clients will be assessed against the following criteria prior to considering a 6-month refill of ART:Stable client≥15 yearsNot pregnant or breastfeedingRepeat VL not due in less than 6 monthsNot TB/HIV co-infectedNo regimen switch or substitution in the last 6 monthsCompleted INH prophylaxis

51. DSD implementation in the context of ART optimization51ALL stable PLHIV transitioning to other regimens due to policy changes (e.g. ART optimization) shall be retained in their current DSD approaches if all other factors stay constant. Efforts should be made to strengthen pharmacovigilance. The following are recommended;Providing one-month refill at regimen changeProviding patient education about side effects and when to return to the facilityScheduling a clinical review one-month post regimen change. If no major concerns are identified, stable clients should resume multi-month refills (MMRs)Clients enrolled Community Drug Distribution Point (CDDP) approach shall have their regimen optimization done as follows;Regimen change done by clinician at the CDDPPatient education about side effects and when to return to facility provided at the CDDP3-months refill providedClinical review scheduled at 1 month later at the facility. If no major concerns identified the client is referred back to the CDDP for the next scheduled visit.

52. ART Clinic Flow Chart52Lab investigation1. Counseling2. Appointment recordingDispenser, nurse, midwife, expert clientDrug refillHomePharmacy/DispensaryLab assistantLay counselor, nurse, midwife, expert client.Come to see counselorReception/Triage Area:Registration, health education, weight & height taken, symptomatic OI screening, adherence assessment, documentation Clinical review/ lab services neededClinical Review Medical officer, clinical officer, nurse, midwifeNurse, midwife, expert client, counselorAll Arrivals Those who don’t need labThose who need lab

53. SOP for differentiating clients into careAll HIV positive clients will need to be categorized and allocated an appropriate care and treatment approach53

54. Flow Chart for Clients Already Differentiated into CareAll HIV positive clients already differentiated into care need regular/continuous assessment to determine stability. This is done at the triage point.54

55. SOP: Client tracking and follow up55

56. SOP on How to Manage Clients Identified for Differentiation Talk to each of these clients individually at their next appointment:Explain to each of them that they are eligible to get HIV services under the DSD approach either at the facility or in the communityDiscuss and answer any questions or concerns the client hasAgree on and document the model the client has chosen in his file (e.g., sticker on file)For clients who choose to receive care at the facility:Discuss and help them choose the best approach for them and schedule their next appointment If client is due for a clinical evaluation:Provide a complete evaluation during the visitIf still stable, dispense 3 months drugs and scheduled an appointment for the next drug refill (under fast track)If client is due for a drug refill:Provide all the basic services detailed in the client flow chartSend to the pharmacy for drug re-fill Schedule the next appointmentFor clients who choose to receive care at the community:Discuss and help them to form groups in the communityFill in the community group formation formsChoose their group leaderArrange for their orientation on DSDM56

57. HTS Data Flow Chart57

58. HTS Data Elements, Data Sources and Disaggregation Levels54Data ElementData sourceDisaggregation levelsNumber of clients testedALL entry points except MCHHMIS ACP 020: HIV Testing Services (HTS) RegisterMCH entry pointsHMIS MCH 005: Integrated Antenatal RegisterHMIS MCH 006: Integrated Maternity RegisterHMIS MCH 008: Integrated Postnatal RegisterHTS models (Facility, Community)HTS approaches (PITC, VCT)Entry points for Facility-based testing and testing points for community-based testingAge groups (<1, 1-4, 5-9, 10-14, 15-19, 20-24, 25 – 29, 30-34, 35-39, 40-44, 45-49 and 50+)Sex (Male, Female)Number of clients tested HIV PositiveALL entry points except MCHHMIS ACP 020: HIV Testing Services (HTS) RegisterMCH entry pointsHMIS MCH 005: Integrated Antenatal RegisterHMIS MCH 006: Integrated Maternity RegisterHMIS MCH 008: Integrated Postnatal RegisterNumber of identified HIV positive clients linked to careHMIS Form 080: Linkages and Pre-ART Register

59. HIV Treatment and Care Data Flow Chart 59

60. HIV Treatment and Care Data Elements, Data Sources and Disaggregation Levels56Data ElementData sourceDisaggregation levelsNumber of clients newly enrolled in each DSD model during the reporting quarterART Register (HMIS ACP 005)DSD approachesAge groups (<1, 1-4, 5-9, 10-14, 15-19, 20-24, 25 – 29, 30-34, 35-39, 40-44, 45-49 and 50+)Sex: Male, FemaleNumber active on ART by DSD approachNumber active on ART achieving viral suppression by DSD approach during the reporting quarter

61. Drugs (ARVs) Data Flow Chart61

62. Logistics Implications for DSDGuidance for Managing Supplies and Logistics for DSDSites should continue to QUANTIFY and order supplies based on their consumption or client volumesThe DISTRIBUTION mechanism for ARVs under DSD will remain the same as it has been under the routine system Health facilities should submit all HIV COMMODITY ORDERS and reports to the appropriate warehouse in line with their delivery schedules. Health facilities should observe the FEFO/FIFO PRINCIPLES and all good storage and record keeping PRACTICESHealth facilities are expected to have a functional open MRS or appointment books to allow generation of the drug pick-up lists to be used for drug pre-packaging PRE-PACKAGING should be done for each of the clients ensuring that they receive a full supply to cover the period to the next drug refill. Facility REPORTING into WAOD/TWOS/DHIS2 will remain the same 62

63. Using QI to Improve Client Outcomes Under DSDArrange a “kickoff” meeting for the entire site staffs to sensitize them on DSDUse QI theory and practice to identify problems in care Apply the Plan/Do/Study/Act cycles to continuously implement, measure, and refine changes.Routinely, preferably on monthly basis, focus on improving specific aspects of differentiated HTS and HIV treatment and care and exchange ideas.Develop an information infrastructure to track progress (opening a documentation for each QI project)Submit monthly reports of site team improvements, which include charts tracking key measures.Prepare reports on activities, methods, and results for learning sessions.63

64. Steps for Implementing a QI Project Part 1: Fill in the facility name, district and region. Fill in the team leader and list other team members working on proposed QI project. Time frame: 3 months period and review if the change/”solution” or intervention introduced works.Improvement objective: Should be SMART and answer the team’s question – Why it is important to start that project. E.g. “To reduce on the number of ineligible HIV +ve clients enrolled into community based differentiated HIV care and treatment approaches from 45% to <5% within the next six months.”Indicator: Expressed as percentage or proportion. E.g. “Percentage/proportion of ineligible HIV +ve clients enrolled into community based differentiated HIV care and treatment approaches during the past month.”Problem description: Start by quoting the average performance for the given period. E.g. 45% ineligible HIV +ve clients were enrolled into community based differentiated care and treatment approaches yet MoH recommends 0%. Managing ineligible clients from the community compromises on the quality of services and hence increases the chance of getting undesirable clinical outcomes. State the possible/probable causes: E.g. Possible causes include; 1) Staff knowledge gaps 2) Failure to use SOPs 3) Poor documentation.Part 2: Brainstorm on the possible changes (solutions/interventions) for the identified problem and prioritize one that is within your means to implement and fill in the column of the tested changes. State the period, preferably an action period of not less than three (3) months. In the subsequent months, the team should comment whether the change/solution works or not and give reasons why so.Part 3: Provision for showing measurements for tracked performance over a period of time. In case the team fills that they still want to document the progress of the improvement effort for a selected improvement aim, please open the subsequent pages 3b and 3c with the words “Title continued” even when you started focus on other QI projects. This is intended to institutionalize QI efforts. The Y-axis scale is a 1o-units per interval, minimum is 0 and maximum being 100%. The X-axis is for month/year, preferably fill month abbreviation/last two digits of the year e.g. Jan 18. When plotting the points, use a dot or x against the corresponding percentage and place this in the middle of bar. Join the plots to generate a run series chart. Use shapes to annotate the changes/interventions/reasons for the fall in the run chart. Remember to put the title and label the axes (Y with percentage and X with the period).Part 4: Just read off from the graph annotations one best change evidenced by an upward trend which worked and comment in this part. Also make a general observation.64

65. Communicating to Stakeholders65

66. HCW Roles and Responsibilities66

67. Cadres and the Designated Services they can Provide Doctor/ Clinical OfficerNurse/ MidwivesTrained Nursing AssistantsPharmacists/ Pharm Technicians/ Dispensers/ Nurses/ storekeepersLab Technicians/ Lab Assistants/Lay providers (Expert Clients, VHTs, CHEWS, Mentor Mothers), CBOs and CSOs working with PLHIV VHT Health Information Assistants/ Data ClerkComprehensive clinical services including, NACS, symptom screening for NCD’s, TB, STIs and hepatitisXX     Prescription of ART, initiation and follow up for adults, adolescents and childrenXX     Switching and substituting ART regimens by a multidisciplinary ‘switch team’X      Management of complicated case (e.g. CCM; second line treatment failure etc.)X      TB initiation of smear or gene X-pert positive cases for adults, adolescents and children XX     TB initiation for adults and adolescents requiring CXR interpretation, and for children where no sputum is availableX      HIV testing services XXXXXXXHealth EducationXXX  X Registration and filling of appointment diaries XXXX  Performing vital signs (triage)XXX    DBS, VL sample collection, testing and results deliveryXXX XX Coordinating and supervising the community groupsXXX    Linkage facilitationXXX  X 67

68. Cadres and the Designated Services they can Provide cont’d Doctor/ Clinical OfficerNurse/ MidwivesTrained Nursing AssistantsPharmacists/ Pharm Technicians/ Dispensers/ Nurses/ storekeepersLab Technicians/ Lab Assistants/Lay providers (Expert Clients, VHTs, CHEWS, Mentor Mothers), CBOs and CSOs working with PLHIV VHT Health Information Assistants/ Data ClerkPre-packing medicines, Picking drug refills, distribution of refills, Forecasting and ordering of commodities from the warehouses, Dispensing, Filling/updating the dispensing log and tracking tools XXX X*XART preparation and adherence counselling for adults, adolescents, children and pregnant women including treatment failureXXX XXXDefaulter tracing XX XXXClient records management/data entry & updating registers (for area of service) XX XXXPhlebotomyXX  X  Reporting on community activities/client groups, support; coordinate and supervise their peers      X Community – facility referrals and vice versa      X *These service providers must be supervised while undertaking the listed/designated tasks 68