Model mechanics

ART refills

Clinical consultations

Individual/group approach

Individual

Individual

Who attends?

Client or client-appointed representative

Client

Client recruitment

Where

At facility

By whom

Lay community health worker in facility waiting rooms
Posters/pamphlets in facility waiting room advertising model
Clinician offering enrolment to eligible clients

Eligibility assessment

By clinician during consultation

HIV disclosure

Does it happen?

No

Annual health care visit schedule for client

For 3-monthly ART refill & annual clinical consultation

  1. ART refill
  2. ART refill 
  3. ART refill
  4. ART refill + blood draw + clinical review + rescript

For monthly ART refill & bi-annual clinical consultation

  1. ART refill
  2. ART refill 
  3. ART refill
  4. ART refill
  5. ART refill
  6. ART refill + blood draw + clinical review + rescript
  7. ART refill
  8. ART refill 
  9. ART refill
  10. ART refill
  11. ART refill
  12. ART refill + blood draw + clinical review + rescript

Alignment of ART refill and blood draw visit

Does it happen?

Yes. ART refill, blood draw and clinical review all on same day

Aligment of ART refill and clinic visits

Does it happen?

Yes. ART refill, blood draw and clinical review all on same day

Strategy and timing for actioning high VL/other red-flag results

Strategy

Immediate recall of client and/or red flagged for referral by pharmacy assistant/lay health care worker at next ART refill visit

Minimum period for action/action failure risk

Immediately after result received at facility/high risk

Maximum period for action/action failure risk

1-3 months/low risk

Clinical outreach from facility potential

Does it happen?

No

ART refill preparation

Is ART pre-packed?

Possibly. See model variations

ART refill collection date

When

Appointment return date at facility

Clinical referral mechanism

Criteria

Client complaining of being unwell, client reporting symptoms during symptom screen

By

Lay health care worker

To

Clinician

When

Same day as ART refill return date at facility

Up referral (return to standard of care)

Criteria

Client missed ART refill date (variation with degree of flexibility)
Nurse assesses client to be clinically unstable requiring regular clinical follow up, including:

  • Develops TB
  • Serious OI
  • Other co-morbidity

Nurse identifies client with:

  • High VL (>400 copies/ml)
  • Evidence of clinical or immunological failure (in the absence of VL)
Communicated by

Pharmacy assistant/lay health care worker (missed refill date) or nurse (clinical)

Client records

Facility clinical folder

Not pulled or completed other than at clinical review

Client ART card

Presented at all ART refill visits for return date completion

Monitoring system

At pharmacy/dispensing room

Possible ART refill collection lists

At health care facility

ART refill visits are either not recorded or recorded on ART refill collection lists, which are used to complete a paper ART register or facility electronic monitoring system (EMR; where available)
Clinical visits are recorded in client folder and recorded in facility ART register or captured in EMR (where available) 

Staffing

In these models, every client is still managed as an individual, but has less frequent contact with clinicians. There may be an increase in the need for a lay health care worker or pharmacy worker cadre to dispense ART refills (especially if this was previously done by nurses)

Lay health care worker

Full-time equivalents (FTEs) differ depending on the number of ART refill and clinical visits per annum. These differences may increase the need for lay health care workers and reduce the burden on nursing staff

Provides education on model at facility
Distributes ART refill on ART refill visits (if not done by pharmacy)
Recalls clients with high VL/other red-flag blood results

 

Nurse

FTEs differ depending on the number of ART refill and clinical visits per annum. These differences may increase the need for lay health care workers and reduce the burden on nursing staff

Assesses eligibility for the model

Blood taking once/twice a year

Clinical review once/twice a year

Scripting once/twice a year

Review blood results and provide list to lay health care workers for recall immediately/at next ART refill visit

Facility manager

FTEs differ depending on the number of ART refill and clinical visits per annum. These differences may increase the need for lay health care workers and reduce the burden on nursing staff

Manages fast-track system within the facility including:

Ensuring model implementation

Pharmacy assistant/auxiliary worker

FTEs differ depending on the number of ART refill and clinical visits per annum. These differences may increase the need for lay health care workers and reduce the burden on nursing staff

Potentially pre-packs ART if it is distributed by the lay health care workers
Dispenses to clients
Completes ART refill visit for M&E

Data clerk

FTEs differ depending on the number of ART refill and clinical visits per annum. These differences may increase the need for lay health care workers and reduce the burden on nursing staff

Captures clinical review visits (and ART refills visits) from client cards/folder into electronic monitoring system (where available)

Training

Client training

Limited
Only required for individual client’s understanding of model participation

Training is limited to client education on the model offered and how participation works. This can be done briefly by the clinician offering participation and in more detail at by the lay health care worker at the first ART refill-only visit.

Facility staff training

Training for all staff who participate
Moderate for pharmacy/lay health care worker staff who distribute ART refill

Facility teams (with a focus on pharmacy) have to be trained to set up and run the model at their facility (see full model mechanics), including:
- Model enrolment
- Lay health care worker/pharmacy staff availability to distribute ART refill (if not done at pharmacy)
- Data clerks to record clients visits from ART collection lists

Considerations

Client considerations

Requires the client’s understanding of the pathway at each visit

This model requires each client to understand at which stations to report at which annual health care visit (for ART refill vs. clinical consultation visits)

Risks

Clients may queue unnecessarily at registry/counsellor/clinician or fail to queue for these and only report to the pharmacy (this is less likely if the entire clinic operates in the same way)

Opportunities

Time saved for client

Health system considerations

Monitoring client visits

This model does not require ART refill visits to be recorded in client folders

Risks

Client ART refill collections are not monitored and therefore missed visits are not followed up

Opportunities

Allows for simplified monitoring and reduced data entry. There is the potential to utilize pharmacy data as a proxy for a visit.

Additional tasks for lay health care workers

In this model, lay health care workers can distribute pre-packed ART at the refill-only visits 

Risks

The lay health care workers may not have time for additional tasks; they may not be a recognized cadre

Opportunities

Task shifting away from pharmacy to lay health care worker cadre

Resources

Published evidence