This describes the Nyaya Health HIV voluntary counseling and testing (VCT) and antiretroviral treatment (ARV) treatment program.

Nyaya is initiating a comprensive HIV testing and treatment program including highly-active antiretroviral therapy.

Framework:

-ARVs are obtained from the government and stocked through mSupply as per other meds

-CHWs will provide directly-observed therapy, DOT-HAART with weekly follow-up

-patients will receive VCT and be initiated on therapy in the Saphe Bagar clinic, then followed by home-visits with a CHW

Training:

-the PIH accompagnateurs training system will be initiated, starting trainings in Jan 2009

-these will take place as a series of 7 days of training for CHWs, under resident supervision

-training for VCT must be found (search in progress for ongoing government training programs)

-Patients and their family members should undergo a several part education program to learn about HIV, transmission, opportunistic infections, and antiretroviral therapy.  Ideally these are done in groups with several patients starting at the same time, but due to low numbers of HIV patients initiating ART at a given time, it will likely be individual training sessions.  The patient must bring a family member to participate in the education session.

The CHWs will be trained to recognize the side effects of ARVs and know the warning signs that an HIV or TB patient is getting sicker. The health workers tell the nurse at the clinic that their patient needs help. The clinical staff arranges to have the patient brought to the clinic for follow up.

Implementation:

-as HIV patients are diagnosed, they will be assigned a CHW

-medical therapy and follow-up will follow the PIH manual for HIV treatment, 2nd edition

CD4 Counts

We do not have a CD4 counter on site, and the nearest one is in Dhangadi, which is about 10 hours away by jeep/bus.

Blood should be drawn in K3EDTA or K2EDTA tubes.

Specimens should not be refrigerated. They are stable for 30 hours at room temperature.  They should be packed in a leak-proof bag and kept at room temperature (20-25 degrees), avoiding extreme heat (>37 degrees) that does occur in this environment.  They should be packed in an insulated container.

Role of Community Health Workers

Our existing CHWs will serve as treatment supporters for patients on ART.  In wards where we do not have CHWs, we will hire a CHW.  For some wards, it could be >1 hour walk each way for CHWs to visit patients.  For these patients, we can consider every other day visits.  The frequency of visits should be more intensive in the earlier weeks-months.  

We will leave a one day dose with the patient and tell them to only take if the CHW does not show up and come the very same day to the clinic. We will allow for if the CHW is going out of town to leave the medicines with another CHW, or if no one is available, with the patient. We will try to be flexible and let the patient know that if he or she needs to leave the village that they can also take medicines with them. We will give them a few extra tablets in case the are delayed for any reason. We will be strict that if a CHW does not show up, and does not send word why they can not show up, they could lose their job. We will stress the patient depends on them being on time every day. But we will also try to be flexible to let CHW plan ahead when circumstance prevent a daily visit. We will be up front with the patient and the CHW that the CHWs role is not to be the patients own personal worker. We will try to reimburse patients for travel to the clinic. Every month the CHWs will get together and discuss problems. Similarly, patients will come together every month so that we can improve the program.

Oversight:

-a full case description will be provided over team@nyaya for each newly diagnosed HIV case

-a full case description and treatment plan as well as lab statistics wll be provided weekly for the first month for each case

-a full case description and treatment plan as well as lab statistics will be provided monthly after the first month

-an HIV database will be implemented, modeled off of existing OpenMRS or related databases for EMR follow-up

Indicators to be recorded and reported on a quarterly basis by our program:

drug possession ratio  = doses dispensed/doses prescribed on a bi-monthly basis (see notes about pharmacy refill adherence)

interruptions in supply of meds - dates and reasons for us to follow-up with gov't

pharmacy stock-outs - dates and reasons to follow-up with pharmacy staff

treatment adherence = number of doses taken/number of doses prescribed on a bi-monthly basis

visit adherence = percent of scheduled visits that are attended

treatment failure = virologic failure and will be investigated for incomplete adherence, suboptimal pharmacokinetics related to medication absorption and metabolism, and possibly overwhelming disease

Both treatment and visit adherence will be investigated to detect economic/structural barriers of transportation, transfer of care to a different clinic, mortality between visits, and less commonly behavioral-social factors

Outstanding Questions 

1. Where will we send patients for CXR for TB screening prior to starting therapy? (Is the CXR at Doti hospital operational?)

2. Need to make arrangement with lab in Dhangadi to send CD4 counts there. Could be sent on the buses from Sanfe to Dhangadi.

3. Need to send a staff member(s), preferably midwives, for VCT training session.

4. How to ensure clinical quality of CD4 specimens; independent assay to ensure time-to-analysis is sufficiently low? and to check for lab accuracy?