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close this bookNational Guidelines for the Clinical Management of HIV/AIDS - Tanzania (NACP; 2005; 131 pages)
View the documentLIST OF ABBREVIATIONS
View the documentACKNOWLEDGEMENTS
View the documentFOREWORD
Open this folder and view contentsCHAPTER 1: INTRODUCTION
Open this folder and view contentsCHAPTER 2: ORGANIZATION OF HIV/AIDS CARE AND TREATMENT
Open this folder and view contentsCHAPTER 3: HIV/AIDS PREVENTION
Open this folder and view contentsCHAPTER 4: PROTECTIVE MEASURES AGAINST HIV TRANSMISSION
Open this folder and view contentsCHAPTER 5: LABORATORY TESTS IN HIV/AIDS
Open this folder and view contentsCHAPTER 6: HIV/AIDS AND PREGNANCY
Open this folder and view contentsCHAPTER 7: PEDIATRIC HIV/AIDS AND RELATED CONDITIONS
Open this folder and view contentsCHAPTER 8: COMMUNITY AND HOME BASED CARE FOR PEOPLE LIVING WITH HIV/AIDS (PLHA)
Open this folder and view contentsCHAPTER 9: COUNSELLING RELATED TO HIV-TESTING AND TREATMENT ADHERENCE
Open this folder and view contentsCHAPTER 10: MANAGEMENT OF COMMON SYMPTOMS AND OPPORTUNISTIC INFECTIONS IN HIV/AIDS
Open this folder and view contentsCHAPTER 11: MANAGEMENT OF MENTAL HEALTH PROBLEMS IN HIV/AIDS
Open this folder and view contentsCHAPTER 12: MANAGEMENT OF HIV INFECTED PATIENTS USING ANTIRETROVIRAL DRUGS
Open this folder and view contentsCHAPTER 13: ARV THERAPY IN INFANTS AND CHILDREN
Open this folder and view contentsCHAPTER 14: USE OF ARVS IN SPECIAL CIRCUMSTANCES
Open this folder and view contentsCHAPTER 15: HIV/AIDS AND NUTRITION
Open this folder and view contentsCHAPTER 16: MANAGEMENT OF ANTIRETROVIRAL MEDICINES
close this folderCHAPTER 17: CERTIFICATION OF HEALTHCARE FACILITIES AS CARE AND TREATMENT SITES
View the document17.1 Overview
 

17.1 Overview

In order to be able to reach the more than half million HIV+ people who are expected to require treatment as described in the National HIV/AIDS Care and Treatment plan (NCTP), it will be necessary to have hundreds of healthcare facilities, public and private, of various sizes and capabilities spread equitably throughout the country. These facilities will each have to meet a minimum set of criteria in order to provide quality care and treatment services for People Living with HIV/AIDS (PLHA). As the large-scale provision of ART has yet to start in Tanzania, not all health facilities will currently meet the minimum standards needed for quality HIV/AIDS care and treatment. This implies that health facilities need to be strengthened before they can start and/or expand ART-services.

In order to have as many health facilities as possible qualify for the provision of ART to HIV/AIDS patients the National AIDS Control Programme (NACP) has developed a strengthening and certification procedure.

The objectives of this procedure are to:

Determine the availability and quality of the essential elements to start and/or expand ART

Identify areas for strengthening and improvement to upgrade health facilities to be able to provide comprehensive care to PLHA

Issue certification to health facilities to enable them to start/expand ART, once they have met a minimum set of criteria

It is important to keep in mind that the need for the minimum standard requirements is not to limit the number of institutions that can deliver care and treatment to PLHA. It instead has the dual role of not only assuring that care and treatment services are delivered, they are done so at an appropriate quality and standard, but also becomes a key way in which hospital needs can be identified and resources channelled to meet these needs. A rigorous certification process is therefore beneficial to all.

Selection and Strengthening Process

The Care and Treatment Unit has developed a system to identify facilities as potential ARV providers and to manage the strengthening process. The objective is to establish clinics to prescribe ARVs, monitor patient condition, and provide other care and treatment services for HIV+ patients.


Figure 11. Preparing facilities for certification

In conjunction with other divisions of the MoH, the Care and Treatment Unit will target on an annual basis the public facilities where ARV therapy will be administered. This targeting will be undertaken in full consultation with authorities at the local and regional levels.

It will be important to plan sufficiently far in advance to ensure that facilities can be strengthened to be full participants in the programme in time to meet the goals of the scaling-up plan. This is especially true in the case of ensuring sufficient personnel will be available at the proper time and for facilities which cannot participate without major construction work.

The targeted health facilities will be assessed by a multidisciplinary assessment team, composed of clinical, nursing, laboratory and pharmaceutical experts, in which representatives of the MoH and of the Region and/or District Council will participate. During the assessment visit a comprehensive assessment tool will be completed as well as a check list with minimum criteria for starting ART. These forms will contain the basic information for the preparation of a strengthening Plan.

The Strengthening Plan will be the key tool in preparing facilities for participation in the ARV programme. It will be jointly prepared and agreed upon by representatives of the Care and Treatment Unit, the Region/Council and managers of the target facility, to ensure the needs and remedies for each facility are correctly identified and prescribed. Over time as the program expands, it is planned that Regional Medical Officers, working as extensions of the Care and Treatment Unit, will play a major role in the targeting of facilities as well as in the preparation of Strengthening Plans. The RMO’s office will be given additional resources to carry out this function, as explained in Section 11.3 of The National Care and Treatment Plan 2003-2008.

Each Strengthening Plan will develop detailed strategies for dealing with issues such as:

Designation of a facility leader to take responsibility for preparation of the strengthening plan and supervision of the facility’s participation in the HIV/AIDS Care and Treatment Programme.

The recruitment of personnel for the Care and Treatment Team and other supporting units of the facility.

Training of Care and Treatment Team members.

Orientation and training of other healthcare workers at the facility and in nearby facilities to support the CTC

Establishing appropriate clinic space.

Development of a laboratory plan.

Inventory of existing equipment, and ordering of new equipment.

Maintenance plan for equipment.

Building secure pharmacy.

Participation in PMTCT programme.

Preparation for linking with NTLP, ante natal, and STI clinics.

Linkages with other facility operations (wards, other clinics, support units etc.).

Linkages with community resources (VCT, social support, etc.).

Participation in locally based continuous care and IEC activities.

Preparation of a facility-specific Operations Manual for HIV/AIDS Treatment and Care.

It is important to note that planning for strengthening should not be limited only to looking at the facility itself. For example, an analysis of the availability of VCT services in the area must be undertaken and preparations made for increasing the number (or effectiveness) of sites if necessary. These activities will require coordination with other sections of the MoH, community leaders and resources, NGOs and other providers of VCT services.

Other important activities outside the facility might include:

Briefing local officials and leaders and liaising with district or lower level Multisectoral AIDS Committees.

Cataloguing available continuous care activities in the community, and making plans to increase where necessary.

Enlisting resources to help educate families and communities about the basics of HIV/AIDS medicine, particularly the role that treatment can play and the difficulties inherent in lifelong treatment for infected individuals and their families.

The Strengthening Plan will spell out in detail the implementation steps which are necessary for bringing the facility to the point where it can be certified as ready to receive, prescribe and distribute ARVs. The plan will also assign responsibility for each implementation step and develop a time line that will show when the strengthening process will be completed.

The Care and Treatment Unit will be responsible, again working closely with the Regional Medical Officer as its representative, to monitor progress in implementing the Strengthening Plan and ensuring adherence to the approved timeline.

The Certification Process

A major challenge for the Care and Treatment Unit will be to design a certification process that is rigorous enough to ensure quality care for patients at all levels, and yet is flexible enough to allow for creativity, initiative and reflection of unique local conditions on the part of the target institutions.

The key values the Care and Treatment Unit will look for in considering an application will include:

Quality - Does the facility have a treatment system in place that will ensure quality health care for HIV/AIDS patients?

Quantity - Is the facility prepared to treat a significant number of HIV+ individuals upon certification, and to increase the patient load as the staff gains experience?

Accessibility - Will treatment be made available on an equitable basis to all Tanzanians regardless of ability to pay?

Accountability - Are procedures and safeguards in place to ensure that funds, equipment, supplies, and medicines are properly used and accounted for?

With these values in mind, the strengthening plan should help prepare a facility to meet the minimum criteria outlined below. The Care and Treatment Unit should encourage flexibility and maximum integration with existing healthcare resources in the methods for meeting the minimum criteria. Target facilities should feel free to tailor the way they propose to meet a specific requirement in a manner which reflects the facility’s individual needs and characteristics. In this way, best practices can be developed to aid in the scaling up efforts.

The target facilities for the first year will be primarily Regional and District Hospitals. The check list with minimum criteria highlights what each facility should have in place as a minimum at District and Regional levels.

Minimum criteria to start/expand ART:

1. Organisation of HIV/AIDS care services within facility

1. Space for registration of HIV/AIDS patients

2. Clearly described a functioning patient flow plan (including referral within the facility)

3. Project manager to coordinate the HIV/AIDS care and treatment services at the facility (this can be a member of the C&T team).

2. Human resource capacity, training and continuous education

1. Dedicated Care and Treatment team consisting of

 

- 1 assessing/prescribing clinician (MD/MO or AMO)
- 1 ARV-evaluating clinician (AMO or CO)
- 1 nurse-counsellor (treatment counselling)
- 1 laboratory technician
- 1 pharmaceutical technician
- 1 data-clerk

2. Above team has been trained according to approved national curricula

3. Guidelines available: National HIV/AIDS care and treatment guidelines-revised 2004, pMTCT guidelines, Laboratory guidelines Dec 2003, Pharmacy guidelines, HBC-guidelines 1999, VCT guidelines

3. Clinical HIV/AIDS care and treatment services

1. Confidential consultation room

2. TB-diagnosis and treatment services

3. STI-diagnosis and treatment services

4. Patient records and reporting systems

1. An established and working medical record system

2. Locked area with limited access for medical records

5. Continuum of Care: Organisation of HIV/AIDS care services with and between facility units, outside referral sites and community support services

1. A functional referral system from health facilities to the community and vice versa (linkage with HBC, NGO’s, CBO’s, FBO’s and other community-based organisations), and to specialised referral facilities.

2. System for patient tracking in place

 

6. Counselling and Testing services

1. 1 confidential room

2. 1 VCT-counsellor

7. Laboratory services

District level

1. Adequate facilities (enough space, 2-4 rooms)

2. HIV-testing (rapid)

3. Manual haematology

4. Manual biochemistry

5. Routine testing stool and urine

6. Malaria blood smears

7. TB sputum smears

8. Pregnancy testing

9. Screening for blood safety

10. Refrigerator including freezer compartment

11. Lockable room or cabinet for record storage

12. Lockable inventoried store

13. Use of SOPs

14. Internal quality system

15. External quality system

16. Reliability of transportation

Regional level (criteria for District level plus below criteria)

1. Emergency water reserve

2. Electricity supply back up (generator, solar)

3. Automated haematology (low volume)

4. Automated biochemistry (low volume)

5. ELISA testing

6. CD4-testing (low volume)

7. Refrigerator including freezer compartment for samples

8. Refrigerator including freezer compartment for reagents

9. Freezer, -20oC

8. Pharmacy services

1. Storage space for 1 month supply of ARVs

2. Key policy in place (limited access)

3. Functional ARV-tracking system

4. Use of SOPs (national ARV-pharmacy instructions)

5. Refrigerator

9. Finances

1. Budget earmarked for strengthening clinical HIV/AIDS services

2. External quality control arrangement in place

3. Internal quality control arrangement in place

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