Clinical Mentorship in Public Health Settings

Documented and Designed by
SAATHII
in association with
New Concept Information Systems Pvt. Ltd.
Website: www.newconceptinfo.com
Copyright: 2009 TANSACS & SAATHII
ACKNOWLEDGEMENTS
1. I-TECH team
2. ART medical ofcers
3. TNFCC programme partners
4. TNFCC clients
5. TANSACS and SAATHII team
In the ght against HIV/AIDS, Tamil Nadu has achieved a signicant reduction in the prevalence,
providing an example to other states of how well-planned and comprehensive programmes can
help control the epidemic. One such effort is the Clinical Mentorship Programme implemented by
Tamil Nadu AIDS Control Society (TANSACS) as part of the 3-year (2005-08) Tamil Nadu Family
Care Continuum Programme, in three government hospitals.
The technical assistance and capacity building inputs from SAATHII were crucial to the success
of the programme. I-TECH, added to the quality of the training and mentorship component.
The aim of the clinical mentorship programme was to signicantly increase the skills of medical
ofcers in the management of HIV/AIDS; the approach was participatory, based on the principles
of adult learning. Highly skilled and experienced clinicians were designated as mentors to guide
the ART medical ofcers. Programme components which ensured effectiveness were needs
assessment, training, both face-to-face and distance mentoring, and on-going monitoring and
evaluation.
The programme has been remarkably successful in ensuring the mentees improved skills.
Evaluation has demonstrated improved learnings, improved clinical outcomes and improved
documentation. Successful clinical mentorship has been followed by three other programmes:
counseling mentorship for hospital and eld counselors; home-based care mentorship for
outreach workers; and child services mentorship for child counselors.
TANSACS acknowledges SAATHII for its technical assistance to the program, Duke University for
monitoring and evaluation, The Childrens Investment Fund Foundation for funding support, and all
the TNFCC-associated ART centers, eld NGOs and hospital NGOs for effective implementation.
On behalf of TANSACS, I take this opportunity to express our appreciation of hospitals and the
Medical Ofcers contribution to the success of the clinical mentorship programme.
Dr S. Vijayakumar, IAS
Project Director
FOREWORD
1. HIV Prevention, Care and Support in India 1
2. Tamil Nadu Family Care Continuum (TNFCC) Programme 4
3. TNFCC - Technical Assistance and Capacity Building 7
4. The Clinical Mentorship Programme - Overview 9
5. The Clinical Mentorship Programme - Training Needs Assessment 12
6. The Clinical Mentorship Programme - Learning Methodology 15
7. The Clinical Mentorship Programme Findings, Feedback and Outcomes 19
Annexure I - I-TECH Clinical Mentors Training Curriculum 24
Annexure II - Tool for Mentorship Assessment 25
Annexure III - Sample Mentorship Report 43
Annexure IV - Case Sheet Documentation for treatment failure 48
CONTENTS
HIV Clinical Mentorship - In a public health context 1
Overview
The revised estimate of people living with HIV in
India (July 2007) puts India in third place in the list
of countries with the largest number of people living
with HIV. Of the estimated 2-3.1 million people
with HIV in India 39% are women and 3.8 % are
children.
The transmission route is predominantly sexual
(87.4%) from high-risk groups to bridge populations
(clients of sex workers, truckers) and then to the
general population.
Globally, the availability of new resources has
accompanied a push for greater access to treatment,
care and support. Never before has the world
attempted, on such a large scale, to bring broad-based
chronic disease management to resource-limited
settings. India, like other countries, has embarked
on aggressive campaigns to control the epidemic.
National response to the AIDS epidemic has been to
decentralize the programme to the state and district
levels to enhance commitment, coverage, and
effectiveness. The goal is to reverse the HIV epidemic
by 2015, and to improve quality of life for people
living with HIV/AIDS (PLHIV) through increased
access to care and support services and, in particular,
Anti Retroviral Therapy (ART).
The national response also recognizes the importance
of maintaining strong prevention efforts. Prevention is
critical in countries, like India, where HIV prevalence
remains low in the wider population and where
opportunities still exist to prevent an exponential rise
in transmission. Where transmission occurs mainly
through risky behaviors, it is critical to continue to
employ robust behavior change intervention efforts
to stem the epidemic.
Care and Treatment Models
Family-centered and comprehensive care models are
recognized as appropriate strategies for mitigating
the impact of AIDS. Access to therapy, nutrition
assistance, and treatment for Opportunistic Infections
(OI) and other health issues that complicate or
exacerbate HIV infection are all integral components
of a comprehensive care model.
It is thus recognized that medical treatment alone is
not sufcient. Programmes offering care and support
to HIV-affected families should integrate psychosocial
services in the treatment process, as well as supportive
services such as nancial support, family counselling,
nutritional aids, and palliative care where necessary.
ART programmes should also address the mental
health-related aspects of disease management, and
HIV Prevention, Care and
Support in India
1
2 HIV Clinical Mentorship - In a public health context
provide access to psychotropic medications where
possible. Palliative carein combination with and as
an adjunct to home-based care also has a role to
play in improving medical care, symptom control, and
mortality from the disease. Appropriate palliative care
also addresses psychosocial issues experienced by
families and surviving children, supports care givers
and communities, and encourages future patients to
come forward earlier in the disease.
National Strategy
Following the detection of the rst case of AIDS in
India in 1986, several measures, both governmental
and non-governmental, were taken throughout the
country to curtail the spread of HIV and protect
the rights of People Living with HIV/AIDS (PLHIV).
At present, the National AIDS Control Organisation
(NACO) provides leadership to HIV/AIDS control
programmes in India through 35 HIV/AIDS Prevention
and Control Societies.
The overall goals of NACP-III (National AIDS Control
Programme) is to halt and reverse the epidemic
in India over the next ve years by integrating
programmes for prevention, care and support, and
treatment [2]. This will be achieved through a four-
pronged strategy:
l Prevent infections through saturation of coverage
of high-risk groups with targeted interventions
(TIs) and scaled up interventions in the general
population.
l Provide greater care, support, and treatment to
larger numbers of PWLHA.
l Strengthen the infrastructure, systems, and
human resources in prevention, care, support,
and treatment programmes at district, state, and
national levels.
l Strengthen the nationwide Strategic Information
Management System.
The specic target of NACP-III is to reduce the rate
of incidence by 60 percent in the rst year of the
programme in high prevalence states to obtain the
reversal of the epidemic, and by 40 percent in the
vulnerable states to stabilise the epidemic.
Care, Support, and Treatment
under NACP-III
NACPIII seeks to implement HIV services across the
continuum of care. Accordingly, prevention will go
hand-in-hand with access to prophylaxis, management
of opportunistic infections, and ART. Given the low
levels of coverage, focus will also be on assuring
universal access to rst line Anti Retroviral drugs
(ARVs) in the rst instance. To ensure drug adherence,
the Community Care Centers will be recongured as a
bridge between the patient and the ART centers and
provide psychosocial support, counselling through
strong outreach services, referrals, and palliative
care. Home-based care will be an integral part of this
strategy.
Care, support, and treatment services include
management of opportunistic infections including
control of TB in PLHIV, ART, safety measures, positive
prevention, and impact mitigation. By 2011, the
programme will be able to treat 320,000 OI episodes
in a year, provide TB referrals to 2.8 million PLHIV,
and ART treatment to 300,000 PLHIV, including
39,000 children. The component related to Care,
Support, and Treatment is proposed to be allocated
an amount of Rs. 1953 crores accounting for 16.9%
of the total project outlay.
Overview
Tamil Nadu Family Care Continuum (TNFCC) Programme
for HIV+ Families is a 3-year programme (September
2005 to August 2008) being implemented by Tamil
Nadu State AIDS Control Society (TANSACS) in
partnership with Solidarity and Action Against the
HIV Infection in India (SAATHII). SAATHII, a non-
prot agency headquartered in Chennai, India,
provides technical assistance and capacity-building
to government and non-government HIV service
providers, and has been helping strengthen and scale
up services in the country since 2000.
In 2005, The Childrens Investment Fund Foundation,
UK (CIFF, UK) awarded funding to TANSACS to expand
ART, with SAATHII designated as the provider of
technical, operational, and logistical assistance.
Tamil Nadu Family Care
Continuum (TNFCC) Programme
2
Clinical Mentorship is being carried out in partnership
with International Training and Education Center on
HIV/AIDS (I-TECH). External Monitoring and Evaluation
is being conducted by Duke University, USA.
TNFCC is one of the rst and largest public-
private partnerships for HIV care in India. It
serves approximately 14,178 PLHIV, 9,393 families
with children, 13,104 adults, and 1,074 infected
and 10,253 affected children at the end of three
years (September 2005 to August 2008). It has
demonstrated success in reducing HIV-related
morbidity and mortality, and improving quality-
of-life, by providing ART to children and families
infected and affected by HIV/AIDS in the urban and
rural areas of Tamil Nadu.
Of particular note is the fact that TNFCC is one of the
rst government programmes to give free 2
nd
line ART
drugs. Out of the 65,000 PLHIV in Tamil Nadu, around
35% requires 2
nd
line ART. Second line ART is more
expensive (Rs. 6,00012,000, averaging 10,000 per
month) than 1
st
line ART (Rs. 6502,000, depending
on regimen, government procurement rates may
be between Rs. 5001,500). One of the biggest
achievements of the TNFCC clinical mentorship
programme is streamlined 2
nd
line initiation. This
process will be discussed later in the document.
TNFCC Programme Objectives:
l To develop and evaluate a multi-sectoral model
involving government hospitals, NGOs, CBOs, and
positive networks in providing a comprehensive
continuum of care and treatment to include
medical, psychosocial and nutrition services,
treatment of opportunistic infections, and
provision of ART.
l To develop and evaluate an integrated family-
centred continuum of care and treatment model
for HIV positive families.
l To develop successful linkages through
partnerships among various stakeholders
including government, NGOs, CBOs, and PLHIV.
l To integrate community-led treatment
preparedness and literacy programmes with care,
support, and services.
l To evaluate the impact of nutrition support and
counselling on morbidity and mortality in children
and adults.
Expected Outcomes:
l Prevent children being orphaned.
l Reduce HIV related mortality and morbidity
among families.
l Achieve 90% adherence among adults receiving
ARV therapy.
l Improve quality of life among families.
Programme Overview
Sites
Three hospital sites cater to ten districts:
l Kilpauk Medical College Hospital (Chennai
cluster) - Chennai, Tiruvallur, Kanchipuram and
Villupuram.
l Govt. Mohan Kumaramangalam Medical College
Hospital (Salem cluster) - Salem, Erode,
Dharmapuri, and Perambalur.
l Govt. Medical College Hospital (Tirunelveli
cluster) - Tirunelveli, and Tuticorin.
Hospital Activities
The three government medical college hospitals
function as hospital programme sites and are responsible
for coordinating and providing comprehensive care,
support, and treatment services.
The hospital-based services are provided by
hospital staff, government appointed doctors, and
representatives of community based organizations.
Hospital and NGO Partners of the TNFCC programme
Hospital Districts covered Hospital NGO Field NGOs, CBOs and
Positive Networks
Government Kilpauk
Medical College
Hospital, Chennai
Chennai, Tiruvallur,
Kanchipuram, and
Villupuram
Community Health
Education Society (CHES)
SIP+, MSDS, and ACD
Government Mohan
Kumaramangalam
Medical College
Hospital, Salem
Salem, Erode,
Dharmapuri, and
Perambalur
Young Women
Christian Association
(YWCA), Salem
YWCA, HILLS,
SEARCH, and INDO
Government Medical
College Hospital,
Tirunelveli
Tirunelveli, Tuticorin,
and Kanniyakumari
Gramodhaya Social
Service Society
PWST+, St. Joseph
Leprosy Hospital
For each ART Center, TANSACS has recruited and
trained 2 ART medical ofcers, 12 counsellors,
1 lab technician, 1 pharmacist, 1 community care
coordinator, and 1 data entry operator. While this
stafng pattern is similar to that of ART Centers
across the country, TNFCC sites were established with
supplemental stafng in the form of a trained NGO
support team, consisting of the following personnel:
l 1 Project Coordinator
l 12 Counsellors
l 12 Nutritionists
l 12 Nurse Case Mangers
l 2 Nursing Aides
l 1 Pharmacist
l 1 Accountant/Data Entry Operator
l 1 Sanitary Worker
After the second year of operation, the NGO staff were
slowly phased out once the ART staff were added, as
per the revisions in national ART centre operational
guidelines. The NGO staff numbers have varied across
the three centers, in accordance with the prevailing
client load.
Field Activities
Community services provided by NGOs in each of
these ten districts are as follows:
l Identication of HIV clients and motivation of
patients for hospital registration and monthly
follow-up visits
l Conducting support groups near the patients
residence
l Identication and training of peer educators and
care givers
l Provision of home-based care that includes
opportunistic infections diagnosis and referrals,
as well as ongoing adherence counselling
l Referrals and linkages to various services like
housing, income generation, legal services, etc.
l Child counselling and related services
All services are provided by the Project Coordinator,
Child Counsellor, Community Health Nurse, and 810
Outreach Workers of the eld NGOs afliated with the
respective ART Centers.
SAATHI (Solidarity and Action Against The HIV
Infection in India) has served as technical assistance
partner for TNFCC, providing training, support visits,
coordination, networking, ongoing technical updates,
and mentorship.
Training
TANSACS and SAATHII conducted training for various
stakeholders on the following topics (target trainee
population shown in parentheses):
l Clinical Management of HIV/AIDS (counsellors, lab
technicians, nutritionists, pharmacists, sanitary
workers, project coordinators, community health
nurses, child counsellors, and outreach workers)
l Home-based Care (nurses, counsellors, project
coordinators, nutritionists, outreach workers,
community health nurses)
l Adherence Counselling (hospital and eld
counsellors and coordinators, community health
nurses, and outreach workers)
l Child Counselling (ART counsellors and eld child
counsellors)
l Life-skills Training (eld project coordinators,
child counsellors)
l Financial Management (project head, project
coordinators, accountants)
l Training on Organization Development/
Management, Leadership, and Communication
(NGO heads and project coordinators)
l Induction and advanced training for
nutritionists
l Training and mentorship to hospital and eld
counsellors and outreach workers on general
counselling with a component on HIV/AIDS
(disclosure, safe sex, and stigma)
TNFCC - Technical
Assistance and Capacity Building
3
l Home-based care mentorship training for
community project coordinator, child counsellors,
and community health nurse for mentoring
outreach workers
l Child Services training for the community child
counsellors
l Training for ART medical ofcers (see below).
ART medical ofcers were trained at the start of the
TNFCC programmefour days in Tambaram Sanatorium
and six days in YRG Care. The Tambaram training
complied with NACO Guidelines and covered OI, ART,
side effects, documentation and reporting, monitoring,
clinical rounds, and pediatric HIV care. The training
at YRG covered second line drugs, system-wide HIV
clinical management, hospital-waste management,
universal work precautions, clinical rounds, and case
studies. Tools were adapted from the Clinical Mentoring
Toolkit developed by the International Training and
Education Center on HIV (I-TECH).
The contents of induction training were repeated
during Years II and III because of high staff
turnover. The training was made specic and target-
focused in order to ensure that participants attained
the necessary level of competence. All training
programmes were conducted within the rst three
years since TNFCCs inception.
SAATHII provides technical updates during support
visits and programme coordination meetings at ART
centers where hospital ART team and community
NGO teams interface. Discussions focus on the issues
arising out of the daily work of programme staff,
especially outreach workers. Technical assistance
to NGOs helps in identifying eld-based solutions
through monthly monitoring visits and ongoing need-
based support. For instance, several outreach workers
have difculties in talking about sex, ART treatment,
and disclosure so SAATHII conducts regular follow-up
on the trainings provided.
Mentorship Initiatives
There are four Mentorship programmes under the
TNFCC:
l Clinical Mentorship to ART medical ofcers
(provided by SAATHII and I-TECH)
l Counselling Mentorship to hospital and eld
counsellors (SAATHII)
l Home-based Care Mentorship to outreach workers
(SAATHII and Field NGO Core Team: Project
Coordinator, Child Counsellor, Community Health
Nurse)
l Child Services Mentorship to child counsellors
(SAATHII)
The clinical mentorship programme was the rst
of its kind in the programme, and in the country,
and its success resulted in launching of mentorship
initiatives in the other domains listed above. The
clinical mentorship programme will be presented in
detail in the following section.
For the counselling mentorship programme, four days
of training were provided (two days each, in two
rounds from January to March 2008). In addition,
one-day visits were made twice to the hospitals.
These visits involved counselling and observations
in the morning, and case study discussions among
hospital and eld counsellors, in the afternoon. The
mentorship activities were implemented by SAATHII
with initial assistance from external experts.
Initial home-based care mentorship was provided by
SAATHII. However, due to an increased number of
outreach workers in the third year (around 100), a
mentorship training was conducted by SAATHII for
selected eld staff (2025 total, two to three from
each community NGO) who then constituted the core
eld team. This helped broaden and decentralize the
pool of mentors.
The child services mentorship was provided by SAATHII
to the community NGO-based child counsellors.
Training covered life skills education, recreation,
education and referrals, and linkages to additional
services.
Background and Partners
A signicant need addressed through the TNFCC
programme was capacity enhancement of the local
health institutions in HIV care and treatment,
especially in management of complicated and
challenging cases in relation to OIs, and ART (rst
and second line drugs). SAATHII identied clinical
mentoring as an appropriate strategy to develop
this expertise among local health care providers.
Structured clinical mentoring, using adult learning
principles, helped bridge the training gap between
traditional didactic trainings and practice in the
clinical setting.
SAATHII identied the International Training and
Education Center on HIV/AIDS (I-TECH) as the
technical partner to develop the Clinical Mentorship
Programme for TNFCC. I-TECH is a global AIDS training
programme working at the invitation of ministries of
health and the U.S. government to increase human
and institutional capacity for care and treatment in
countries hardest hit by the HIV and AIDS epidemic.
The Clinical Mentorship
Programme Overview
4
I-TECH is collaboration between the University of
Washington, Seattle, and University of California,
San Francisco.
I-TECHs model of Clinical Mentorship
I-TECHs primary objectives for clinical
mentoring are consistent with the World Health
Organizations public health approach to scaling
up HIV care and ART. These objectives include:
l Supporting decentralized delivery of HIV care,
ART and prevention, as well as continuous
improvement of patient outcomes at all ART
delivery sites.
l Promoting application of classroom learning
to clinical settings.
l Improving the quality of clinical care and
patient outcomes in resource-constrained
settings.
l Building capacity of primary care providers
to provide comprehensive and integrated
care using on-site clinical collaboration,
consultation, and directed support
SAATHII collaborated with I-TECH in curriculum
adaptation, mentor programme design and
implementation.
Geographical Sites
The Clinical Mentorship Programme has been implemented
in ART centers in three districtsGovernment Kilpauk
Medical College Hospital in Chennai, Government Mohan
Kumaramangalam Medical College Hospital in Salem,
and Government Medical College Hospital in Tirunelveli.
These three sites cater to families from three focal and
seven surrounding districts.
Who is a Clinical Mentor?
As dened by WHO: A clinical mentor in the
antiretroviral therapy context is a clinician with
substantial expertise in antiretroviral therapy and
opportunistic infections who can provide ongoing
mentoring to less-experienced HIV clinical providers
by responding to questions, reviewing clinical cases,
providing feedback and assisting in case management.
This mentoring occurs during site visits as well as
via ongoing phone and e-mail consultation. Clinical
mentoring is critical to building successful district
networks of trained health care workers for HIV care
and treatment in resource-constrained settings.
The Clinical Mentorship Programme involves two mentors
from I-TECH, one mentor from SAATHII, and seven
mentees, who are medical ofcers at the ART Centers
that were included in the TNFCC programme. When
mentorship was initiated in April 2007, the mentees
already had a case load of around 12,000 HIV/AIDS
patients altogether at three sites, including over 4,000
patients on ART, of whom 80 are on 2
nd
line drugs.
The mentors possess clinical knowledge, training and
interpersonal communication skills. Key mentoring
strategies included building rapport, giving feedback
effectively, identifying teaching moments, teaching
at the bedside, and addressing systemic issues.
For greater details on the Clinical Mentors Training
Curriculum, refer to www.go2itech.org
Mentorship Methodology
Mentorship is an ongoing process whereby the
mentor assists and assesses the patients condition
and line of treatment both directly during visits and
through distance mentorship to ART medical ofcers
based on details provided via email or telephone.
Mentorship includes, at a minimum, the following
components:
l Orientation of external mentor by SAATHI
mentor
l Planning and tool development by mentors
l Training and needs assessment of the ART medical
ofcers by SAATHII mentor
l Reliance on adult learning principles
l On-site two-day hospital visits by mentors to
each of the hospitals every three months
l Long-distance mentorship
Onsite Mentorship
The mentor makes quarterly visits to the hospitals
and engages directly with the doctors and the
patients identied by the mentee as case studies. In
addition, the mentor examines individual patients as
requested by the mentee. Onsite mentorship entails
the following:
l Onsite review of medical practices at the hospitals
with the doctors
l Identifying training needs and areas for
strengthening
l Mentoring the doctors by the various methods
elaborated below:
l Modeling
l Facilitation of various case studies and
discussions
l Hands-on training
l Additional clinical training using adult learning
principles
l Sharing of supplementary reading materials from
peer-reviewed journals.
l Advocacy with mentees for systematized case-
management, laboratory investigations and
documentation
l Facilitating data collection, best practices
sharing, and clinical research
Distance Mentorship
This component of the mentorship programme is
probably the most pragmatic, as it ensures continuous
and adaptive learning. The mentees call or email
the mentors periodically, enabling timely treatment
of patients, and establishing open communication
between mentor and mentee.
Distance Mentorship entails the following:
l Ongoing consultation with doctors by phone and
email
l Exchange of case sheets, scans, and other relevant
documents
l Sharing of reference material to enhance
learning
Focus Areas of Mentor Involvement
l Routine clinical care for HIV and associated
medical conditions
Mentoring Strategies
Modeling Facilitate Discussions Additional Clinical
Training
Support
l Greeting patients
warmly
l Sensitive patient
examination
l Multidisciplinary
team approach
l Shadow/observe
l Difcult and
complex cases
l Ethical issues
l Patient ow
l Clinic set-up
l Patient triage
l Quality of Care
l Case Studies
l Mini-Teaches based
on needs of clinic
l Serve as an advocate
l Cheerlead
l Listen/validate
work of doctors
l Coach
communication
techniques
(source: www.go2itech.org)
l Progress assessment of patients on ART (side-
effects, toxicities, management)
l OI management of non-ART patients
l HIV-TB co-infection management
l Second line initiation, regimen selection, and
monitoring
l Improving doctor-patient interaction through
effective communication
l Post-Exposure Prophylaxis (PEP)
Results
Findings and outcomes of the mentorship programme
were gathered through initial training needs
assessment, personal observations by the mentors,
patient interviews, and focus group discussions with
the hospital staff and through mentees self reporting.
Results are presented in the following sections.
The Mentees
A needs-assessment of the seven mentees was conducted
at the beginning of the mentorship. The following
synopsis reects the experience in all three centers:
1. Prior experience in the HIV/AIDS eld
Work experience varied among doctors, with two
having less than two years of experience, and the
rest ve either 24 years, 46 years, or 810 years.
All but one had previous AIDS-related work experience
in hospitals, private clinics, or with NGOs.
2. Patients treated per month
Hospital PLHIV PLHIV on ART
Tirunelveli 1,000 250300
Kilpauk Medical
College Hospital
2,100 530
Salem 4,500 1,500
Average 2,533 768
3. Previous trainings
All of the doctors had attended previous HIV-related
trainings. These include:
l GHTM NACO 4 attendees
l YRG Care 4 attendees
l HIV-TB/ATT-RNTCP 4 attendees
l Dr. MGR Medical University 1 attendee
l International Conference, University of
Hyderabad 1 attendee
l CME, Karigiri 1 attendee
l CME, YRG 2 attendees
l WHO IMAI training, St. Johns Bangalore
1 attendee
l Clinton Foundation IMA doctors training
1 attendee
Clinical Mentorship Programme
Training Needs Assessment
5
4. Training formats
l The most preferred training formats were:
t Conferences
t Printed materials (journals, newsletters, etc.)
t Skill building workshops
t Case presentation seminars
l The least preferred training format was weekend
case discussions.
l Each doctor listed a separate preference for
frequency of ongoing trainings.
l Most of the doctors agreed that one working day
a month could be dedicated to training, either as
four hours each day for two days, or one day of
eight hours.
l Internet access: Tirunelveli and Salem had
unrestricted access to internet use, but KMCH
only received access towards the mid-mentorship
period.
5. Barriers to training
l The most commonly cited barrier to training was
long travel times to Chennai.
Suggested solutions:
t Make Madurai or Tiruchi the centre for
trainings
t Conduct trainings at all three sites, on a
rotating basis
l Salem indicated that both ART medical ofcers
could not attend at the same time.
Suggested solution: Assign an alternate/additional
ART medical ofcer
l KMCH cited lack of access to internet as a
barrier.
Suggested solution: Printed materials and CDs
Training Needs Assessment
Doctors were presented with a set of HIV-related
topics, and asked to indicate their level of skill in
each and their learning interest (as high, medium
or low).
The doctors expressed the highest learning interest in
topics listed below. Items that are starred are those
in which they also indicated low levels of skill.
1. Lab Diagnosis of HIV Infection Therapeutic
diagnoses
l HIV RNA PCR
l CD4 Count testing
l Other markers*
l Culture and resistance*
2. Opportunistic Infections and Co-Infections
l Clinical presentation
l Lab and clinical diagnosis of OIs
l Differential diagnosis
l Treatment
l GIT manifestations
l Dental manifestations*
l Ophthalmic manifestations*
l Neurological manifestations
l Tuberculosis*
3. Pediatric HIV
l Growth and development parameters
l Lab diagnosis (<18 months)
l ART
l Second line regimen
l ART and ATT
l ART in women (pregnancy and PMTCT)
l Immune Reconstitution Syndrome
l When to change treatment (resistance and
treatment failures)
5. HIV and Psychiatry
6. HIV Virology
l Mechanism of resistance
7. HIV and Gynecology*
8. HIV and Wasting*
9. HIV and Nutrition*
l Nutritional counselling
10. Legal, Ethical, Cultural Issues*
The doctors expressed low skill but only moderate
learning interest in the following:
l Economic, health care, and socio-cultural issues
impacting patients.
l Current trends in epidemiology India, Global
l Palliative care
l Structured treatment interruptions
Site-specic needs
Tirunelveli KMCH Salem
Clinical Topics
l Radiotherapy in HIV patients
l HIV/TB
l Role of Immuno-
Modulators in HIV
l Natural Medicines/Herbs/
Ayurveda/Siddha and HIV
l Neurological case presentation
other than common CNS OI
l Immunity: Innate, Acquired,
and HIV Pathogenesis
Other Topics
l Need for separate
e-forum for ART MO
l Legal implications
and advocacy
l Administration skill
development and leadership
qualities improvement
l Financial management
of ART centers
Clinical Topics
l Resistance testing methods
l Mutations (diagnostic,
prevention, treatment
2nd line) and dry selection
according to mutations
l Algorithms for specic
toxic effects of ARVs
l Psychosocial assessment
scales for specic conditions,
adult scales, child scales
l Prevention: breast feeding,
education of adolescents,
ARV eligibility
l ART: second lines, integrase
inhibitors, maturation
inhibitors, any viricidals?
l Vaccines: trials, types
l Recent research studies
l HIV and other elds
Clinical Topics
l Non-HIVrelated
co-infection
l Management of chronic and
recurrent diarrhoea
l Technical update on ART
initiation and re-initiation
l Management of OI
in ART patient like
Immune Reconstitution
Inammatory Syndrome
l Changing patient attitudes
and positive prevention
(i.e., more women
getting pregnant)
As described in Section IV, Overview, the TNFCC
Clinical Mentorship Programme incorporates three
primary learning components use of adult learning
principles, onsite and Distance Mentorship. Training
tools were adapted from the Clinical Mentoring
Toolkit developed by I-TECH. (For additional
information on the I-TECH training curriculum, see
Annexure - I)
The following section explores these components in
greater detail.
Adult Learning as Basic Approach
The clinical mentorship programme is designed
on the premise that adult learning techniques are
the most effective in skills transfer. Adult learning
principles emphasize that adults come to learning
environments with:
l their own experience and expertise
l an expectation that they will be respected and
guided
l and a focused motivation to learn based on
specic needs to accomplish job-related tasks
more effectively
The experience at Tirunelveli provides a case study on
the use of these learning principles within the clinical
mentorship programme. Dr. Narayana Srinivasan,
Senior Medical Ofcer at the Government Medical
College Hospital, Tirunelveli, calls this a unique
programme because it was developed in response to a
personal needs-assessment. The mentors rst question
was what are your expectations? The mentor seeks
to identify strengths and weaknesses and provides
assistance accordingly. The mentors work beside the
doctors and not above them. The center has a case
load of 250 patients a day. The mentor recognizes the
The Clinical Mentorship Programme
Learning Methodology
6
challenges faced by the doctors and the staff, as well
as the demands made upon them.
The mentors have been very willing to share
information. The doctor calls the mentor everyday on
the I-TECH hotline to discuss any problems or doubts
he may have. These conversations cover a range of
issues including drug adjustment, availability of
drugs, and drug dosage. A recent example is that
of a patient with renal failure the mentee sought
guidance regarding on how to assess changing levels
of kidney functions, and the need to adjust ARV
dosages accordingly.
Moreover, the mentorship is not purely clinical -- the
mentors urge the doctors to use interpersonal skills
which enhance their role as a doctor, such as how to
elicit information from reluctant/hesitant patients or
how to counsel them on behavior change.
Mentorship through On-Site Visits
The rst round of On-site Mentorship for the ART medical
ofcers of three TNFCC centers was implemented during
the rst quarter of the grant period. This round followed
a tools development for mentors and training needs
assessment of the ART medical ofcers (mentees). On-
site visits proceeded as follows:
(a) The mentor outlined the objectives/purpose of
the visit to the medical ofcer: to improve the
skills of the ART medical ofcer. The mentor also
reviewed the principles of mentorship and the
specics of the two-day schedule.
(b) On the rst days morning session, observation
was used to assess the medical ofcers clinical
knowledge, skills, attitudes, and practices. Mentors
sat with the medical ofcers at the ART clinic.
(c) In the afternoon, discussions/trainings were
conducted to share observations, explore
challenging cases, review national guidelines,
and discuss the feasibility of implementation.
Mentors also shared their work experiences in
other settings as a way to discuss best practices.
In addition, the following issues were covered in
detail: ART toxicities, substitution of ARVs, privacy
of examination, ow of patients at the ART centre,
the role of the nurse case manager at the ART
centre, and HIV/TB co-infection management.
(d) On the second day, apart from mentoring in the
outpatient department, the mentor:
l Performed ward rounds and hands-on-training
on the wards
l led detailed case discussions on second line
drugs using actual case studies from the ART
centre
l addressed gaps in case management and in
the documentations of second line cases;
and, made suggestions as to how to rectify
the problems using the check list, a draft
copy of which was handed out
l demonstrated how to use the Stanford guide
in interpreting the genotype resistance study
results using the appropriate web site
l using case records, stressed how important it
is for the medical ofcer to examine patients
on second line drugs
l explained the importance of documentation
related to death and other interesting cases
l gave the medical ofcers important web sites
for reference, and shared articles related to
areas of interest
Recommendations were made to all three sites based
on the rst round of visits. See box below. The tool for
mentorship assessment is provided in Annexure - II
Distance Mentorship
Distance Mentorship in this programme has been
actively encouraged and a hotline between the
doctors and the mentor allows for open and regular
communication. Several doctors said that they would
call the mentors 34 times a day. Distance Mentorship
included:
(e) Ongoing consultation with the doctors through
various communication modes like phone calls
and e-mails
(f) Monthly follow-up meetings with Technical
Assistance (TA) and Implementer
(g) Quarterly eld visits by the mentor. On these
occasions, special cases are directly presented
to the mentor. In addition, observations and
discussions with mentees give the mentor an
opportunity to observe any other infrastructure
needs doctors may have. (See more about On-Site
mentorship above).
Mentor Recommendations at the end of initial visits, from all three centers -
l Appropriate instruments and logistics for systematic clinical examination to be provided to improve
clinical examination.
l Appropriate laboratory tests for better clinical care to be made available at all the centers for testing
selected and needed cases.
l The doctors shall follow the NACO guidelines in care and treatment.
l There is a need to arrange experience-sharing and review meetings and update sessions with interesting
and difcult case studies.
l The ART medical ofcers of three centers should rotate for experience sharing and case discussions. They
can also visit other centers during mentorship visits (cross-mentorship).
l Documentation should be improved in case sheets and ART card.
To improve the documentation practices in the case sheets:
l Medical Ofcers shall conduct audit of the reported deaths among the ART team to discuss and identify
the probable cause and also use it for programme improvement
l Death
(a) Doctors shall mention the associated conditions that led to patients death and document in the case sheets
(b) Doctors shall mention the probable cause of death if outreach workers are giving the details of the
patients either by discussions with the doctor or in a form of short note.
(c) Field staff should convey information to doctors during their visit to hospital during information-
sharing days like Write a note on the patients condition during his/her last visit and discuss with
the doctor based on the same.
l SECOND LINE DRUGS:
(a) Appropriate initiation of second line drugs A committee consisting of TA team, I-TECH and TANSACS
should decide on the appropriate regimen to be chosen. Other technical members shall be included
in the committee as required by TANSACS.
(b) The ART medical ofcers should ll the second line case sheet attached as annexure and send the
same to the committee for deciding the second line.
(c) ART medical ofcers should collect all the details from the referral doctors regarding previous
treatment before starting second line drugs.
(d) Doctors need second line drugs training sooner as there are around 75 patients on second line therapy.
(e) Doctors shall document all the second line cases in the case sheet attached (Annex 5) for improving
the quality of services as per the mentors feedback.
(f) The basic lab tests for management of HIV including second line drugs as per the NACO guidelines
are available. The lists of unavailable lab tests are shown below.
l All the basic lab tests for management of HIV including second line drugs as per the NACO guidelines are
available. Below is the list of lab tests not available:

Tirunelveli KMC Salem
HBsAg Anti- HCV HBsAg
Anti-HCV S.Lipase Anti-HCV
S.Amylase S.Triglycerides
S.Lipase
S.Triglycerides

TANSACS shall suggest TA and ART medical ofcers to follow-up on the above lab tests.
l The pharmacy assessment report shows majority of the basic drugs especially Cotrimoxazole (Septran)
and Fluconazole are available for treatment and the drugs not available are listed with the reasons below.
The starred drugs are not available under regular hospital supply, and hence will be purchased using the
OI drug funds. At present, all the drugs needed for the opportunistic infections treatment are procured
centrally by TANSACS for distribution to all ART centres.
Tirunelveli Reasons
Azithromycin 500 mg Inadequate hospital supply
Clarithromycin 500 mg No request made due to no need so far
Clindamycin 300 mg OI drugs purchase can be done *
Fluconazole-T. and Inj. OI drugs purchase can be done*
Nitazoxanide 500 mg OI drugs purchase can be done*
Inj. Amphotericin B 50 mg OI drugs purchase can be done*
Inj. Acyclovir 250 mg No request made
Inj. Gancyclovir 500 mg OI drugs purchase can be done*
Cap.Gancyclovir 250 mg OI drugs purchase can be done*
Dapsone OI drugs purchase can be done*
Sulphadiazine, Sulphadoxine OI drugs purchase can be done*
Pyrimethamine OI drugs purchase can be done*
Folinic acid No request made
Salem Reasons
Clindamycin 300 mg OI drugs purchase can be done*
Folinic acid OI drugs purchase can be done*
Inj. Acyclovir 250 mg OI drugs purchase can be done*
Cap. Gancyclovir 250 mg OI drugs purchase can be done*
KMC Reasons
Azithromycin 500 mg OI drugs purchase can be done*
Clarithromycin 500 mg OI drugs purchase can be done*
Clindamycin 300 mg OI drugs purchase can be done*
Inj. Fluconazole OI drugs purchase can be done*
Inj. Amphotericin B 50 mg OI drugs purchase can be done*
Inj. Acyclovir 250 mg OI drugs purchase can be done*
Cap. Gancyclovir 250 mg OI drugs purchase can be done*
Folinic acid OI drugs purchase can be done*
The Clinical Mentorship Programme, implemented by
I-TECH and SAATHII, in partnership with TANSACS,
has demonstrated success in
1. Improved learning;
2. Improved clinical outcomes;
3. Improved documentation.
1. Improved Learning
The most signicant emerging practice in the Clinical
Mentorship Programme is the culture of new and
continued learning for the entire team of health care
professionals in the three hospitals:
(a) Government Kilpauk Medical College Hospital,
Chennai
(b) Government Mohan Kumaramangalam Medical
College Hospital, Salem
(c) Government Medical College Hospital, Tirunelveli
Based on the pedagogical principles of adult learning,
the programme has made a signicant impact on
the approach to HIV care and treatment, and laid a
strong foundation for continuous and renewed adult
learning.
Dr.Thennarasu from Kilpauk Medical Hospital afrms,
The Clinical Mentorship has shaped me! The
mentorship programme has brought him in contact
with senior professionals and has improved his
knowledge and skills in dealing with patients. A
focus group discussion with the project coordinator,
nutritionist, nurse, and lab technician at Government
Mohan Kumaramangalam Medical College Hospital
in Salem revealed that even though they have not
interacted with Dr. Manoharan (the mentor) directly,
they are aware of his expertise and knowledge. The
process of continuous learning has had a ripple
The Clinical Mentorship Programme
Findings, Feedback and Outcomes
7
effect. They have learnt when to change the regimen
and are more comfortable with preparing nutrients
for special cases, and making home visits. Health care
professionals in Salem indicate that their knowledge
of HIV has increased not only in care and treatment,
but in counselling as well.
Mentorship programme enhances the mentees
existing expertise
This enhanced expertise translates into higher job
satisfaction for doctors and, ultimately, into higher
patient satisfaction rates. For example, Mr.Rajan
(name changed)a 35-year-old lorry driver who has
been coming to Tirunelveli since 2005was aware
that when the new drug prescribed did not agree
with him, it was changed in consultation with an
external doctor.
This alternative route to learning has set a precedent
in the programme to foster an open environment
where there is easy access to information and
enhanced communication and collaboration at all
levels. Besides this, the process of continued learning
is a new experience for the doctors who are used to
attending trainings that are either too didactic or
too short to address the complexities of HIV care and
treatment. Simple standardized guidelines for care
do not t in many cases. The nuances of managing
drug interactions and toxicities against the backdrop
of underlying liver disease and co-infections are
challenges the medical world is trying to meet at
every turn. It requires expertise and a progressive
approach, which a mentorship programme provides
for both the mentor and the mentee.
Clinical mentors help the mentees translate
theoretical knowledge into practical clinical skills
Dr. Thennarasu at Kilpauk Medical Hospital admits
that his knowledge of HIV/AIDS prior to the launch of
mentorship was quite limited. His specialization is in
ophthalmology, and there was no component of HIV/
AIDS in his medical curriculum. It was only through
the Clinical Mentorship programme that he became
aware of diagnostic challenges and other clinical
considerations that steer the line of treatment. The
mentor advises him on when to run viral load and
resistance tests, and when to start 2
nd
line ART. Dr.
Sentha Krishna from Salem Government Hospital
explains, I am more condent about handling cases
now. She now treats complications like Cryptococcal
meningitis and Zidovudine anemia (caused by ART
toxicity) because of the knowledge she gained
through mentorship.
The mentors have been very willing to share
information, and they give the doctor tips on how to
elicit information from reticent patients. The doctors
call the mentors regularly on the I-TECH hotline for
advice on drug adjustment, dosage, and availability.
Detailed case histories are sent through email, while
X-rays, CT scans, and photographs are couriered at
least 23 times a month.
2. Improved Clinical Outcomes
Key outcomes of the clinical mentorship programme
have included streamlining of 2
nd
line ART initiation
and improved management of complicated cases
including kidney, liver and CNS issues.
TNFCC was one of the rst initiatives in the country to
make 2
nd
line ART drugs available. Out of the 65,000
PLHIV in Tamil Nadu, around 5% require 2
nd
line ART.
NACO started 2nd line ART recently.
As Dr Sathish puts it, one of the biggest
achievements of clinical mentorship is streamlined
2
nd
line initiation. The complexity of managing
difcult cases means that standard protocols and
straightforward algorithms cannot always be applied.
Individual clinical judgment needs to be supported
through mentoring, referral, and consultation support
until clinicians become comfortable in knowing when
to start, stop or change therapies. The mentorship
programme enhances the quality of both short-term
and long-term patient care and health outcomes.
Prior to the mentorship programme, complicated
cases were referred to other hospitals or sent to
larger towns. Dr Sentha Krishna, from Salem, says
that referrals to Tambaram have come down and the
patients reiterate it, Tambaram care is available
here! The programme has also raised the hospitals
prole in the eyes of patients. Patients from other
districts have also started visiting these hospitals
because of accessibility and quality treatment.
Complicated cases are treated in the hospital either
through electronic or telephonic consultations or
the case is presented to the mentor on the day of
his visit.
Another signicant clinical outcome of this programme
is the timely intervention in peripheral and symptomatic
conditions like kidney and liver malfunction, central
nervous system problems. Earlier these cases were
referred to other departments or hospitals causing
delays in the patients treatment, which in some cases
were fatal. For instance, a patient with Zidovudine
anemia in Salem hospital showed no improvement
even after eight bottles of blood transfusion. On
mentors suggestion, an erythropoietin injection was
administered and the patient, who had severe anemia
with heart failure, improved dramatically and his
hemoglobin, is now 12%.
3. Documentation
In many healthcare programmes implemented by the
government and NGOs, documentation processes and
quality are compromised due to a high patient load,
lack of documenting skills, and a single-minded focus
on care and treatment. Although doctors are fully
aware that documentation is a critical contributor
to assessment and follow-up in patient care, the
documents they produce are usually perfunctory and
sketchy. The mentorship programme is based on long
distance communication and quarterly visits, making
accurate and detailed case studies imperative in order
to determine the line of treatment and follow-up.
The programmes well-dened documentation processes
are now being followed by all the staff. Reports,
detailed records, maintaining registers, death analysis,
2
nd
line ART documentation, and pediatric records
have improved and mentors have been extremely
encouraging in teaching new documentation skills.
In addition, the mentors have introduced the doctors
to some online learning models to expose them to
international formats and even shared a model of the
Stanford Guide from their curriculum.
Bridging Gaps in the
Mentorship Programme
Though there has been a signicant scaling up of HIV
care and treatment through the clinical mentorship
programme, there are still some gaps that need to be
addressed.
The mentors are well respected doctors and their
commitment to the programme has helped make it a
success. But the mentees did not have exposure to all
the mentors because there was no rotation, and some
of the doctors felt that they would have benetted from
other mentors. Successful mentoring involves a dynamic
process and it is often wise to consider establishing
a discrete time period as a trial basis to determine
whether the mentoring relationship is working. This
may help minimize any misunderstandings. It is
important to match the mentees expectations in order
to foster an effective mentoring relationship. There
were cases where a mentee would have preferred a
more senior mentor who better matched his own
considerable experience and knowledge.
The mentorship programme needs to focus beyond
clinical management of HIV. The spectrum of HIV
related care is much broader and the patient load in
some of these centers is very high (the doctors are
treating around 12,75013,000 HIV/AIDS patients
at three sites, more than 4,300 of whom are on
ART, including 100 on 2
nd
line drugs). Counselling,
stigmatization, and behavioral changes are some of
the issues that need to be addressed.
The mentorship programme is too focused on clinical
care and management of HIV/AIDS. It should include
counselling, nutrition and home based care.
Some doctors felt that the mentors quarterly visits
were not enough, especially if they delayed/missed a
visit. A more exible itinerary may be more effective.
Most doctors felt that it would be a good idea to
institutionalize the mentorship programme.
Mentorship outcomes and ndings
Mentorships Positive Impact on Care as per
MentorsOobservations
l Comprehensive medical assessment
l Improved safer sex education and family
counselling
l Privacy during medical examination and
counselling
l Diagnosis and treatment of complex medical
conditions including crypotococcal meningitis,
TB meningitis, TB pleural effusion, AZT-induced
chronic diarrhoea and ascites among others
l Timely initiation of ART for TB co-infected
patients
l Use of correct dosages of ART for children
l Diagnosis and treatment of co-morbidities such
as diabetes, hypercholesterolemia, and liver
disease
l Accurate identication and treatment of failure
cases
l Referral to appropriate medical services which are
available onsite
l Frequent referencing to national guidelines and
protocols
l Quality of care documentation
l Reduction of overcrowding at the clinics by
shifting certain tasks to nurse managers
l Diagnosis of various medical conditions through
use of medical equipment that was previously not
available onsite
In the course of a focus group discussion with
ART team other than doctors, to share and analyze
outcomes of the mentorship programme, points
discussed included:
l Paramedical staff (excluding the Project
Coordinator) knew about the mentors visits.
l There is not enough space and time to control the
high patient turn over. Given the opportunity, they
would like to spend more time on counselling.
l Improvement in infrastructure, like provision
of generators, would facilitate the free ow of
services, especially in the labs.
l To help practice universal precautions, coats,
shoes, and gloves have been provided and are
available.
Feedback from Different Stakeholders:
The clinical mentorship programme has been received
favourably in all the centers and feedback reects
this. Its reach has, in some cases, extended to
persons not directly participating in the programme.
For example, at one ART centre, staff who had not
interacted directly with the mentor was familiar with
his work in the hospital.
Direct feedback obtained from the different groups
reects a generally favorable reaction to the
mentorship programme.
23 HIV Clinical Mentorship - In a public health context 23
Mentors From the implementation point of view, the following challenges need to be addressed:
l To plan and execute the mentorship as per the plan
l Retain the same medical ofcers at the ART centers
l Advocate for more, but appropriate, lab tests and drugs at the ART centers
l Advocate for more collaboration between hospital departments
Mentees l The clinical mentorship programme is very useful for doctors, especially in centers with only
one doctor, who would otherwise not have the chance to discuss patients with colleagues
l Helpful for those recently graduated from medical schools
l Need for an intensive training on 2
nd
line ART and annual refresher/orientation programmes
Paramedical l Pre-ART care is also an essential feature of the programme
l Rapid patient turnover presents many challenges. Space is inadequate and limited
staff capacity does not allow for patients to receive the desired care and attention.
l For example, counsellors are forced to keep counselling sessions to 510 minutes
because the patients who are waiting become impatient. Given that these sessions
usually address health and hygiene, micro/macro nutrition, and other positive living
topics, more time is required to discuss these essential matters.
l Doctors are also not able to spend enough time with patients due to the need for fast
patient turnover.
Patients l Overall, quality of treatment is good.
l Waiting hours are too long because of high client load. Long waiting times interrupt
family obligations such as childrens attendance at school.
l Few patients prefer counsellors to make home visits
l Would like to see more services and education on wound care and treatment.
l In comparison to other centers (those not under TNFCC), the process moves faster.
Care and support facilities are provided efciently and a months supply of OI drugs is
available. In addition, concerned hospital staff provides patients with information and
answers their questions in detail. For these reasons, patients dont mind spending the
whole day at the hospital.
Reference:
To equip the mentors with mentoring skills the three-
day training focuses on:
Relationship Building
A trusting, two-way relationship between the mentor
and mentee is the foundation of effective mentoring
practice. This section includes suggestions on how
to initiate and build a strong relationship of mutual
respect between the mentor and the mentee, and how
to provide constructive feedback and encouragement
within the mentoring relationship.
Strategies for Mentoring
Mentors work in a variety of settings in which they
face a wide range of constraints and challenges.
Developing strategies and approaches to effectively
carry out mentoring activities within different settings
presents a unique set of challenges. The documents
in this section provide mentors with suggestions and
ideas on various approaches to mentoring, including
how to conduct bedside teaching, conduct site visits,
mentoring in the face of heavy patient loads, and
strategies for addressing a wide range of systems
issues.
Monitoring and Evaluation Tools
This section includes tools and resources for a
mentor to use to assess the skills of providers and
to assess facility issues. Observation checklists
in this section help the mentor to track providers
I-TECH Clinical Mentors
Training Curriculum
Annexure - I
improvement in their delivery of clinical care over
time. Facility checklists enable monitoring of systems
improvements at a site. The tools included have been
developed by I-TECH projects around the world, and
can be adapted to t a mentors particular situation
and area of focus.
Training Health Care Workers
The ultimate goal of a clinical mentoring programme is
to build the skills of local clinicians. Clinical mentors
may provide one-on-one mentoring to a health care
provider during a patient consultation, conduct stand-
alone sessions for clinical staff on various clinical
topics, lead discussions highlighting the management
of complex cases, and accompany staff on rounds.
This section includes resources for mentors on how to
use case studies and clinical vignettes to guide the
training of health care workers.
I-TECH Curricula
This section contains I-TECH training curricula on a
variety of topics related to HIV and AIDS that can
be used by a clinical mentor to conduct more formal,
classroom-based training of health care workers.
Each curriculum includes sets of PowerPoint slides,
facilitator guides, and participant handbooks. Clinical
mentors are free to adapt and change these materials
as needed. This section includes twelve complete
curricula (multiday trainings with several slide sets)
and four workshops (shorter sessions appropriate for
an hour or two of training on a focused topic). All of
the curricula included here have been pilot tested by
I-TECH country programmes.
Tool for mentoship
assessment
Annexure - II
Clinical Mentorship - Assessment Questionnaire
Date: ______________________________________________
Site: _______________________________________________
Site Reviewer: ________________________________________
I. STAFFING
What types and numbers of providers do you have at this clinic?
Number Number
Physician ______
Nurse case manager ______
Lab technician ______
Nurse aid/assistant ______
Pharmacist ______
Nutritionist ______
Councelor ______
Project coordinator ______
Data entry operator ______
Sanitary worker ______
Pharmacist ______
Other (specify) ______
1. How would you describe your overall stafng
level?
Very well staffed
Adequately staffed
Understaffed
2. How much staff turnover do you experience? High turnover
Moderate turnover
Low turnover
Where among your staff is the greatest turnover? Comments:
II. SPACE AND EQUIPMENT
How many consulting or counseling rooms are present in the centre? _____
Facilities and supplies (Tick all that apply)
1. Injection material:
1.1 Multiple use needles provided
1.2 Single use disposable needles
provided
If YES
1.2.1 Needles recapped before disposal
1.2.2 Needles recapped one handed
1.2.3 Needles deposited directly
1.2.4 Needle cutter used
1.2.5 Sharps containers available
2. Methods for disinfecting reusable
medical equipment:
2.1 Autoclave
2.2 Steam sterilization
2.3 Boiling and chemicals
2.4 Chemicals only
2.5 Boiling only
2.6 Other ____________________
2.7 Use disposables only
3. Disposal of contaminated items:
3.1 Burned in incinerator
3.2 Burned in open pit
3.3 Burned and buried
3.4 Thrown in trash/open pit
3.5 Thrown in pit latrines
3.6 Removed off site
3.7 Other ______________________________
4. Record keeping:
4.1 Record HIV-related illnesses in register
4.2 Patient medical records kept by patient
4.3 Paper patient medical records kept on-site
4.4 Electronic medical records
5. Availability of written material/posters on HIV/
AIDS/STDs to educate patients:
Yes
No
6. Material/internet access for doctors on:
6.1 NACO ART adult guidelines
6.2 Paediatric guidelines
6.3 OI guidelines
6.4 PEP
6.5 PPTCT guidelines
6.6 Second line drugs
6.7 Others
Category Capability
(Yes/No)
Currently
functioning
(Yes/No)
Last used /
available
(Date)
Reasons for
not using/non
availability on
day of visit
(*see codes
below)
Final code
(To be coded
later)
Electricity
Running water
Communication
facilities (phone, fax,
internet access)
Private room for
condential consults
Seating for patients
while waiting
Disp. gloves
Disp. masks
Stethoscope
Disinfectants
Appropriate
examining table
Adequate lighting
BP cuff
Reex hammer
Speculum
Microscopy
*Codes: 1. Equipment failure 2. Lack of or inadequate supplies
3. Absence or non-availability 4. No request made
of trained staff 5. Other (specify)_______________
Do you also have the following available for use in the clinic?
1. Weighing scale (tick) Yes No Maybe
2. Furniture (tick) Yes No Maybe
3. Lockable ling cabinet (tick) Yes No Maybe
4. Thermometer (tick) Yes No Maybe
5. Waiting benches (tick) Yes No Maybe
6. Computer (tick) Yes No Maybe
Comments: ______________________________________________________________________
III. PATIENT DEMOGRAPHICS
Number of HIV/AIDS patients seen/day in OPD: Number of patients on ART:
1. What percentage of your HIV+ patients also
consults a traditional and/or alternative healer?
%
Dont know
Providers dont ask
2. What are the general characteristics of your
patient/client population?
Race
Ethnicity
Gender
Age
Health priorities
Sexual orientation
Other
What have you observed among your patients/
clients as the most common mode(s) of HIV
transmission?
IV. CLINIC SERVICES
1. What types of services do you have at your clinic site and hospital setting?
Mental Health Care
Alcohol/Substance Abuse
Treatment
Pharmacy Services
Family Planning Services
Dental Care
Patient Education
HIV/STD/Hepatitis B& C
Screening
HIV/AIDS Care and Treatment
reatment
Pharmacy Services
Family Planning Services
Dental Care
Patient Education
HIV/STD/Hepatitis B& C
Screening
HIV/AIDS Care
2. Does the clinic perform blood draws? Yes
No
3. Does your lab have the capacity to keep blood
specimens frozen at 20-70
o
C below
Yes
No
4. Where do you send blood specimen to run the following tests?
Viral load testing
Resistance assays
CD4 counts
Hepatitis screening
5. Which of the following immunizations do you
provide?
Inuenza
Pneumococcus
Hepatitis A and B
6. What barriers do you experience in providing
care to HIV-infected patients/clients?
Limited resources
Inadequate reimbursement
Inadequate access to HIV medications
Lack of provider expertise
Lack of provider interest
Patients/clients not aware of services
Issues of condentiality
Issues of cultural competency
Other (specify) ____________________

V. PRACTICE SET-UP
1. Physical space to accommodate and patient privacy (tick one):
Inadequate, major barrier 1.
Minimal 2.
Adequate 3.
2. Does triage promote efciency and patient safety?
None, totally ad hoc 1.
Some effort at triage (no guidelines in place) 2.
Triage occurs (guidelines in place) 3.
Efcient triage system practiced 4.
3. Communication among HIV/ART team
None 1.
Minimal discussion among some team members 2.
Some regular discussion of information shared by team members 3.
Regular information sharing about most key things occur 4.
Highly functioning team communication practiced regularly 5.
4. Patient ow between members of the team is effective and efcient:
Patients movement among providers is inefcient 1.
Patient spends time with different team members makes some sense 2.
Patients receive maximum benet from moving among providers 3.
Is patient education incorporated into patient care?
Physician Nurse Councellor Nutriotionist
No Yes No Yes No Yes No Yes
General Health
Adherence
Risk reduction
Is continuum of care routinely practiced?
No Rarely Sometimes Routinely
OI prophylaxis
OI treatment
TB treated/monitored
STIs treated
Pain reduction methods offered
Is continuum of care routinely practiced?
Yes No Yes No
Data capturing forms/registers
Case sheets - initial (Yes/No)
Report forms (Yes/No)
Clinical document forms
Patient connection with community
Yes No Comments
Adherence
CD4
Viral load
Patient functioning (QOL)
Decrease in patient suffering
Weight gain
OI prophylaxis given
To the best of your knowledge, how often do patients
follow through on care and/or service referrals?
Always
Almost always
Sometimes
Never
What is the most common reason patients cite for lack of
follow through on referrals?
Medical Care Yes
Who provides this service?
No
Where are people referred for medical care?
Pharmacy services Yes
Who provides this service?
No
Where are people referred for medical care?
Under what circumstances--and to whom--do you refer HIV+ patients?
VI. SAFETY & HYGIENE
Universal precautions practiced
Yes No Yes No
Data capturing forms/registers
Case sheets - initial (Yes/No)
Report forms (Yes/No)
Clinical document forms
Hand hygiene
Available Reported
available,
not seen
Not Available Notes
Sink or basin with
running water
Bucket of water
with cup next to
sink or basin
Antibacterial soap
is available in
ward/on site
Alcohol-based
solution for hand
washing available
Dry Soap in dish
near sink/basin
Comments:
Aseptic technique
Equipment/
Supply
Available Reported available,
not seen
Not Available Notes
Supply of sterile
tubes for ICD
procedure available
Alcohol rub (i.e.
antiseptics) available
for sterilization
of patient
Disposable sterile
syringes available
Other sterile
equipment (please
specify)
Number of intravenous lines inserted using aseptic technique:
Doctors: Nurses: Nursing Assistants:
Sanitary Workers: Other (please specify): No procedure observed
Number of sterile syringes used during a procedure: No procedure observed
Patient placement related to UP
Methods Observed Reported available,
not seen
Not Available Notes
MDRTB+ patients
placed separately
from HIV+ patients
TB- patients
separated from TB+
Comments
Immunization and exposure management
Methods Observed Reported done,
not seen
No procedure
conducted/observed
with needle
Notes
MDRTB+ patients
placed separately
from HIV+ patients
Health care staff
used needle destroyer
immediately after
use (i.e. did not
recap needle)
Comments
Number of doctors reporting completing Hepatitis B vaccine course:
Doctors:
VII. LABORATORY
Can your laboratory perform the following tests?
Lab tests
recommended
by NACO
Yes No Maybe Remarks
Haemogram:
Hb%
TC
DC
ESR
Platelet count
TLC
Urine tests:
Sugar
Albumin
Deposits
Other tests
Liver function tests:
S.Bilirubin
SGOT
SGPT
SAP
Total protein
Albumin
Renal function tests:
Blood urea
Sputum for AFB
Mantoux test
Chest X ray
Blood sugar
Blood VDRL
TPHA
HBsAg
Anti-HCV
CD4 count/CD4%
CD8 count, ratio
Viral load

S.Amylase
S.Lipase

Culture
Sputum
Urine
Blood
CSF
Stool
Fluid analysis CSF,
pleural, peritoneal
etc.
CSF India ink

S.Cholesterol prole
S.Total cholesterol
Triglycerides
LDL,VLDL
HDL

S.Lactate
LDH
Stool examination
Motion ova, cyst
Stool for AFB

Toxoplasma serology

Stains
Leishmans
Methenamine silver
ZN
Gram
Giemsa
Modied acid fast
FNAC

USG scan
CT scan
MRI scan
VIII. PHARMACY
Category Currently available/
not available
(A/NA)
Last used/ available
(if currently not
available)
Whether available in
the OP or hospital
Reasons for
not using/non
availability on
day of visit
Antibiotics
Ciprooxacin
Noroxacin
Co-trimoxazole
Erythromycin
Doxycycline
Azithromycin
Amoxicillin
Naladixic acid
Clarithromycin
Spectinomycin
Aqueous
Penicillin (Inj)
Clindamycin 300 mg
Sulphadiazine
500 mg
Levooxacin
Antifungals
Fluconazole.T
Fluconazole. Inj
Nystatin
Ketoconazole
Amphotericin B
Itraconazole
5-Flucytosine
Clotrimazole topical
Antivirals:
Acyclovir .T
Acyclovir.Inj
Gancyclovir
Antiamoebics:
Metronidazole
Antihelminths:
Albendazole
Mebendazole
Nitazoxanide
Antidiarrheals:
ORS
Loperamide

Antiemetics:
Metoclopramide
Domperidone

Dermatological
preparations:
Gentian violet
Whiteeld ointment
Topical antifungals
Liquid parafn
Other drugs:
Nitrofurantoin
Dapsone
T. Sulfadiazine
Pyrimethamine
Folinic acid
Paracetamol
Aspirin
Ibuprofen
Codeine
Chlorpheniramine
Dexamethasone
Hydrocortisone
Amitriptyline
Carbamazepine
ATT
Isoniazid
Rifampin
Ethambutol
Pyrazinamide
Streptomycin

Others - specify
IX. Physician assessment: QUALITY CARE ASSESSMENT
PATIENT CHARACTERISTICS
1. Sex (male=1; female=2) |__|
2. Type of visit (initial=1; follow-up=2) |__|
2. A. If follow-up visit date of previous visit to facility ) ___________
3. HIV status (positive=1; negative=2; unknown=3) |__|
[Note to interviewer Q2 and Q3 can be lled in after the observation]
Known HIV-positive person
1. Chief complaints (check all that apply)
Skin lesions
Difculty breathing
Cough
Weight loss
Fever
Oral ulcers
Persistent diarrhea
Night sweats
Difculty swallowing
Fatigue
Mental status change
PID
Genital discharge
Genital ulcer
Lower abdominal pain
Abnormal test
Pregnancy
Other (specify)_________________
2. Symptoms (check all that apply)
2.1 Determined if they were recurrent
2.2 Asked about duration
2.3 Asked about severity
2.4 Probed further about other symptoms
3. Risk factors (for new cases)(check all that apply)
3.1 Asked patients occupation
3.2 Asked about unprotected sex
3.3 Asked about IV drug abuse
3.4 Asked about sex with men (men only)
3.5 Asked about previous STIs
3.6 Asked about alcohol use
3.7 Asked about spouse/family symptoms
3.8 Asked about spouse/family risk behavior
3.9 Asked if previously tested for HIV
4. Physical exam (check all that apply)
4.1 Vitals measured or reviewed
4.2 Weighed or reviewed patient wt.
4.3 Visually inspected eyes
4.4 Visually inspected mouth
4.5 Visually inspected skin
4.6 Listened to chest
4.7 Palpated abdomen
4.8 Referred-gynec/STD exam
4.9 Pelvic examination
4.10 Speculum examination
4.11 External genital examination
4.12 No exam performed
5. Diagnostic tests available to physician for review
5.1 Chest x-ray
5.2 Culture results (bacterial/viral infections)
5.3 AFB smear (TB test)
5.4 VDRL/RPR results
5.5 Pregnancy test result
5.6 HIV test results
5.7 CD4 count
5.8 Viral load
5.9 Other ___________________
5.10 None
6. Diagnostic tests ordered
6.1 Chest x-ray
6.2 Culture (bacterial/viral infections)
6.3 AFB smear (TB test)
6.4 VDRL/RPR
6.5. Haemogram
6.6 CD4 count
6.7 LFT
6.8 RFT
6.9 Others _____________
6.9 None
7. Presumptive diagnosis (check all that apply)
Skin infection
Malaria
Diarrhoeal illness
Cold/u
Oral candida
TB
Herpes zoster
PID
Cryptococcal meningitis
Syphilis
Pneumonia (non-specic)
Gonorrhea
Pneumonia (PCP)
Chlamydia
Herpes simplex virus
Depression
AIDS stage
Other ________________________
No presumptive diagnosis made
Dont know
8. Treatment prescribed
8.1 Yes
8.2 No
8.3 Dont know
9. Conditions of consultation
9.1 Private consultation with doctor
9.2 Hands washed/gloves changed
9.3 Time spent with patient ____ mins
10. Partner notication
11.1 Partner notication recommended
11.2 Partner notication not discussed
11. Staging
Stage I
Stage II
Stage III
Stage IV
Patient not staged
12. Patient is on ART
12.1. Yes
12.2 No
12.1 For patients on ART
12.1.1 __________(regimen)
12.1.2 Asked about adherence
12.1.3 Asked about side-effects
12.1.4 Ordered ART follow-up labs
12.1.5. ART adherence counselling
12. Patients not on ART
12.2.1 ART not discussed
12.2.2 OI prophylaxis prescribed
12.2.3 OI drugs adherence counseling provided
12.2.4 OI drug side effects discussed
13. Patient referred to a support group/+
Persons network?
13.1 Yes
13.2 No
13. 3 Already involved with group
14. Counseling
14.1 Provided counseling-living w/HIV
14.2 Referred to counseling [family/VCT]
14.3 Provided counseling on safe sex
14.4 Provided counseling on nutrition
14.5 None mentioned

Comments:
Patient medical history
Component (Did physician obtain
the following information?)
Check those observed Where not observed, provide
explanation where possible
When/how was DX of HIV
rst established
Current symptoms and
concerns of patient
Past illnesses and treatment given
Symptoms of TB and/
or treatment for TB
Past or present symptoms of STI
Possibility of Pregnancy
Immunizations
Social habits & sexual history
Patient exam
Component Check those observed Comments
Weight
Temperature
Oropharyngeal mucosa
Lymph nodes
Chest (incl. x-ray)
Cardiovascular system
Abdomen
Genitourinary system
Skin
CNS
Accuracy of diagnosis Comments on those that apply
WHO staging
OI
Temperature
Appropriateness of labs ordered Comments on those that apply
What lab tests were ordered?
What lab tests were not ordered
(although available) that should
have been?
Accuracy of treatment Comments on those that apply
ARV Rx
OI Rx
Other
Follow up recommended
Accuracy of treatment Comments on those that apply
ARV Rx
OI Rx
Other
Follow up recommended
General Observations
Were universal precautions respected?
Basic privacy/condentiality practices followed?
Is a team approach being used to treat and monitor patient progress?
Demonstrated knowledge/skills Comments
ART doctor conducts focused, thorough discussion with
patient of pertinent omissions or errors
Doctor emphasizes team approach (shares information
with nurse, efcient interaction, lack of duplication of
effort)
Doctor underscores need for adequate physical exam (in
relation to history and current complaint)
Doctor comments on accuracy of assessment and diagnoses
(including WHO staging) of patient
ART adherence, tolerance, side-effects addressed
Appropriateness of recommended drug treatment (ART
& OI)
Appropriate involvement of patient in development of a
focused management plan
Appropriateness of recommended labs
Patient education on sexual and other risk behaviors
(including secondary infection)
Emotional/social support needs/possibilities discussed
Develops appropriate follow-up schedule
Introduced self and objective appropriately
(name, where from, credentials, what this is all about )
Negotiated interaction in the presence of the patient
Doctor made the patient comfortable (no tension,
preceptee not defensive)
Listens and observes patiently
(avoids unnecessary interruptions)
Recommendations to improve this doctors skills to mentor independently
Examples of information shared that might improve this doctors skills to mentor independently
Clinical Mentor Scale for individual doctor 1 2 3 4 5
Puts patient at ease and makes patient comfortable

Respects patient

Assesses complaints/symptoms/risk factors

Reviews necessary medical history

Ensures that vital signs are taken

Complete physical exam completed

Orders appropriate lab tests

Provides correct/appropriate diagnosis

Appropriate follow-up for ART
(appropriateness of prescription,
description of side effects,
importance of adherence stressed)

Safe sex education

Provides patient education as needed

Appropriate referrals were made

Develops follow-up schedule

Involves patient in decision-making and medical care

Team approach was used

Privacy and condentiality measures were followed

Universal precautions were taken
First Visit
Recommendations based
on the initial assessment
Second Onsite mentorship
visit-October 2007
Third visit - February 2008 Fourth Visit -April 2008
"1. Needs to be provided
with an examination table
and a
private room for thorough
physical examination
including examination
of abdomen and
sensitive parts."
Both the doctors are
examining patients in 2
separate rooms, thereby
privacy is ensured. The
examination table will
be provided soon.
Now there are 3 doctors
and one senior doctor is
having a separate room
and other 2 doctors are
examining patients in
the other room. But
the privacy is taken
care of. The exmination
table is available and
being put to use.
"Same practice is being
followed. If there is one
more room for third
medical ofcer, privacy
for patients may be
appropriate."
"2. Needs more medical
personnel to take thorough
history especially sensitive
and sexual histories
counselling regarding
safe sex, family
counselling etc."
Medical ofcers need
to complement the
counselling done by
counsellors by providing
safe sex and family
counselling.This was
also highlighted during
the discussions
"Now there is one more
new Medical Ofcer. The
presence of an additional
doctor has really improved
the time spent in case
management. All three
doctors also participated in
the 'basics of counselling'
training.
All the doctors are
observed providing safe
sex counselling and
family counselling for
appropriate cases."
Same practice is
being followed.
Note: Counsellors provide
safe sex counselling
Sample Mentorship Report
Annexure - III
"3. Doctor needs training
on second line drugs
and ongoing updates in
managing HIV patients
with CNS manifestations.
( Training on the topic
is given during the
afternoon hours)"
"It was noticed that the
Medical ofcers' knowledge
and skills in managing
patients with rst line
treatment failure has
increased. They were able
to prescribe appropriate
second line drugs, identify
toxicities correctly and also
maintain appropriate case
records for second line
patients.
There were lot of
discussions related to CNS
opportunistic infections
during the mentorship B1"
"It was observed that
during the interval
between second and third
visits, the senior ART
medical ofcer (SMO)
was able to identify
treatment failure cases
and also made correct
interpretations using the
checklists and Stanford
website on genotypic
resistance testing analysis.
C3The second doctor was
also found to identify
treatment failure cases
but her involvement in the
interpretation on second
line options, was not
observed by the mentor.
Discussions on CNS
opportunistic infections
happened during the
mentorship and it was
observed that the CNS
OI cases were managed
appropriately. (One case
of Toxoplasmosis was
presented to the mentor
at the time of mentorship
which demonstrated
their skills in correct
diagnosis and management
of the case)+C1"
"The knowledge and skill
of senior ART Medical
Ofcer (SMO) on managing
treatment failure cases and
providing second line drugs
has improved. If further
training on second line
drugs is given to him, he
will become an asset to
the ART centre.
The other two doctors
need to learn from senior
medical ofcer about
treatment failure and
initiation of second line
patients.
OIs involving CNS were
discussed and the doctors
knowledge seem to have
improved compared to
the last visit.D8"
4. The two medical ofcers
are examining around
200 patients a day. The
SMO is also involved in
administrative help to
other staff of ART centre
and coordination with
hospital departments and
management. Both of
them are taking care of 21
inpatients also. If support
is provided in this regard,
his skills in ART care and
support will improve.
The Nurse case
man+B3ager (supportive
role) was involved in
active patient care along
with the Medical Ofcers.
It was noticed that the
Nurse case manager,
under the supervision of
ART Medical Ofcer was
able to manage this task
reasonably well. Because
of her involvement the
doctors were able to spend
more time with difcult
cases. The supervision shall
continue until the Nurse
is adequately trained.
"There was a third Medical
Ofcer now and this has
improved not only the
patient care but also
the counselling aspect.
The third Medical ofcer
though not attended
NACO training, was able
to manage cases through
support from other 2
Medical Ofcers.
The nurse case
manager still assist
in providing care. "
The three Medical Ofcers
work in unison so that the
care and support activities
are appropriate. It was
observed that one doctor
is taking care of inpatients
and other 2 doctors are
taking care of OP patients.
All the 3 doctors discuss
the problem cases among
themselves and arrive at
a consensus of opinion
regarding the management.
5. Both the doctors
can communicate with
mentors and other experts
in the eld to improve
their knowledge.
Both the doctors used
to communicate with
mentor regularly
Both the doctors used
to communicate with
mentor regularly
All the 3 doctors
communicate with the
mentor regularly.
6. Frequent references to
NACO guidelines, keep
the guidelines handy
"The NACO guidelines were
seen on the doctors' table
and it was referred to
whenever necessary
The WHO clinical staging
posters ( adults and
children) and the ART
dosage charts for adults
and children were provided
for their reference during
this mentorship"
Now the doctors were
able to manage cases
appropriately without
looking into the guidelines
which showed their
understanding of the
guideline components.
Doctors were able
to manage the cases
appropriately. They were
referring to the guidelines
whenever necessary. .
During the mentorship they
were observed looking at
the growth chart in the
Paediatric guidelines for
managing a child with
growth retardation.
7. I-TECH handbook
reference
"The I-TECH Handbook
seen on the doctors' table
and it was referred to
whenever necessary.
The doctors were using a
small handbook on ART
and other drug interactions
also . If they are provided
with the small pocketbook
on all drug interactions
related to HIV , it will be
very useful.
Several other materials,
study articles of relevance
are given to the doctors
by mail and hard copies
during the visit e.g.. ART
drug interactions, drug
dosing in various medical
conditions, second line
paediatric dosage etc."
They are referring
for appropriate case
management whenever
necessary (during the
mentorship, the doctors
were observed referring a
case of chronic myeloid
leukemia and another
case of lymphoma to the
appropriate higher centres
for further treatment)
Frequent references
were made
8. Need based calls
and mails to I-TECH
During the period between
rst and second onsite
mentorship, TA was
provided in managing 5
difcult cases and brief
follow-up calls were made
second and third onsite
mentorship, TA was
provided in managing
6 difcult cases and
follow-up calls and email
discussions were made
third and fourth onsite
mentorship, TA was
provided in managing
3 difcult cases and
follow-up calls and email
discussions were made
9. Tongue depressor, knee
hammer, tuning fork, X-Ray
lobby to be provided for
better clinical examination.
To be provided To be provided Orders had been placed
for X-Ray lobby and by the
end of mentorship, the
X-ray lobby was purchased
and doctors started using
them. The other logistics
were made available.
10. Doctor shall start
referring for special
tests like HBsAg and
HCVTo initiate with
few patients and then
increase to more numbers.
Steps taken for the
purchase of kits by
the Microbiology
department/discuss
with the blood bank
To discuss with the
implementers for necessary
steps and check with
the follow-up steps.
Appropriate advocacy
measures have to be taken
by the authorities for the
provision of these facilities
11. Patient ow needs to
be studied and streamlined
to avoid overcrowding in
front of doctors room.
Because of the usage of
separate rooms for each
doctor and also because of
the assistance provided by
Nurse case manager, the
patient ow was smooth.
Patient ow is smooth Though the patient ow
is smooth the available
space was not sufcient
during morning hours
especially between 9.30
to 11.30. The ART centre
was overcrowded. More
space is needed for
the appropriate service
providers and patients.
12. During the feedback
session on the second
day, the doctors
mentioned more training
related to Non-HIV co-
morbid conditions.
Discussed during
mentorship and it will be
covered during future case
discussions and conference
call once in 15 days
It was observed that the
team manages the co-
morbid medical conditions
appropriately but they
need still more training
on managing the co-
morbid conditions. They
were able to diagnose
the co-morbid conditions
but need support in the
management. Appropriate
referrals were made. (a
case of cirrhosis liver with
portal hypertension on
ART was diagnosed and
managed appropriately)
"The co-morbid conditions
were discussed during
mentorship. The Medical
Ofcers were also looking
for general medical
conditions like Diabetes
Mellitus, Congestive
cardiac failure,anaemia and
others.
The Medical Ofcers
made appropriate
referrals to the following
departments: Internal
Medicine, Neurology,
Thoracic Medicine, General
Surgery, Ophthalmology,
Paediatrics, Clinical
Pathology, Microbiology,
Biochemistry, STD.
A post graduate student
of Medicine dept was
also posted in the ART
centre for one week."
13. The doctors wanted
more training on behavior
change communication.
Will be covered with
technical update
for counsellors
Both the senior doctors
were trained and the effect
of the training was felt
during the mentorship.**
The training was
completed. Subsequent
to that, the academic
materials related to
behaviour change and
counselling were provided
to the Medical Ofcers
for further reading.
They can discuss with
the counselling mentor
for coordination and
clarications.
"Other recommendations:
1. Documentation - Death
and second line cases"
The doctors shall document
the death regularly
for all reported deaths
as per the previous
recommendations and
also ll the case sheets
for all old second line
initiated cases so that the
case record shall have all
information for tracking.
The case records were
complete as far as
the death records are
concerned. (Screened 40
case records during the
mentorship.) The doctors
were requested to analyse
the baseline characteristics
of mortality and they
were also requested to
discuss these cases in the
weekly review meetings.
The death auditing was
discussed in the monthly
ART centre review meeting.
They also conduct periodic
death reviews during their
internal staff meetings.
Unable to do it regularly
due to time constraints.
2. Initiation of
second line cases
As per the previous
recommendations, all
new second line cases
before initiation shall be
documented in the second
line/treatment failure case
sheet like before and send
to mentor, TANSACS and
TA for mentor's opinion,
program and budget related
process documentation.
It is being followed The documentation of
new cases started on
second line drugs were
complete but the old cases
with second line drugs
need to be completed.
3. During the weekly team
meetings important case
studies may be discussed
3. During the weekly team
meetings important case
studies may be discussed
including death auditing.
Important case studies
were being discussed
in their weekly staff
meetings including poor
adherence, treatment
preparedness and others.
New Recommendations
To maintain the growth
chart of children
upto 12 years
The growth charts
for children upto 18
years were provided
to the Medical Ofcers
for documentation
To develop a checklist
for the follow-up of
second line patients
Checklist given to the
doctors on second
line lab tests
To develop case studies
for e-meetings and
tele conferencing.
"A case of toxoplasmosis
was discussed with the
e-group and the same was
discussed at the ART MO
meeting.
The 3 Medical Ofcers
have provided appropriate
answers for the
questions (quiz) posted
at the e-group."
Note: This case sheet is being designed for documenting the patient details before initiating rst line alternate
regimen and second line regimen.
Name of the patient: Age: Sex: District:
Name of the TNFCC -ART centre:
Referred by: NGO follow-up:
Pre-ART No.: ART No:

1. Date of HIV diagnosis:

2. Reason for diagnosis:

3. Stage at diagnosis:
4. Date of ART initiation:
5. Criteria for ART initiation:
a. Clinical stage IV
b. CD4 < 200
c. CD4<350 and stage III
6. Date of registration at TNFCC-ART Centre:
7. When developed failure? -
Is it clinical, immunological or virological failure?
T staging
8. Resistance testing done yes or no?
Case Sheet Documentation
for treatment failure
Annexure - IV
9
.

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10. If done, resistance testing reports (provided resistance testing is done when the patient is on ART drugs)
11. Analysis of resistance testing and interpretation of resistance test report:
12. Appropriate second line drug regimen:

13. Appropriate lab tests done before second line ART initiation Yes/No
If yes, please mention the lab values.

Clinical Mentorship in Public Health Settings

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