Integrated Management of Adolescent and Adult Illness (IMAI) modules

1. Acute care
2. Chronic HIV care with antiretroviral therapy
3. General principles of good chronic care
4. Palliative care
Caregiver booklet

IMAI is the Integrated Management of Adolescent and Adult Illness (IMAI). The World Health Organization has coordinated the development of the IMAI guidelines and training materials, based on a working group involving 22 Departments and AFRO in addition to a large international working group.

The simplified WHO standardized guidelines are for ARV therapy within the context of primary health care, based at first-level health facilities or in district clinics. IMAI provides tools (standardized guidelines and standard training packages to teach these guidelines) for rapid country adaptation and use in their efforts to achieve the 3x5 goals. The modules cover chronic HIV care including ARV therapy, acute care (including the management of opportunistic infections and when to suspect HIV, linking to testing and counselling), palliative care (symptom management at home), and general principles of good chronic care (to support the health system transition from acute to chronic care).

The WHO IMAI guidelines (available below) and training packages (in development- see the WHO capacity building plan) support the rapid expansion of access to ART by supporting the shifts of key tasks to multi-purpose health workers at first-level facilities located in the community (health centres and clinics). By preparing nurses and clinical aids to provide acute care to adults, many opportunistic infections can be treated and the patient stabilized for ARV treatment without referral to district clinic. Management of patients near their home is important for equity and to achieve high levels of ARV adherence.

There are clear advantages to standardized and simplified evidence-based guidelines and training materials when attempting to go to scale while preserving quality. Standardized guidelines describe the competencies that form the basis for certification.

The target audience for the guidelines are first-level facility health workers who work in a district outpatient clinic or in peripheral health centres and clinics, in rural or urban areas, in low resource settings. These simplified guidelines will allow shifting key tasks from doctors to nurses, medical aids and other first level facilities in clinical management of ARV treatment and in the management of opportunistic infections in preparation for ART. The patient education, psychosocial support, and adherence preparation and support has been designed for implementation by lay providers. Most of the increase in human resources for ARV treatment will be from PLHA and other community members who both join clinical teams and support treatment and other care in the community.

At the district level, the nurses and lay providers following the IMAI guidelines would work in a clinical team with the doctor or clinical officer who would be also be guided by other WHO ART guidelines for senior clinicians. In peripheral health centres and clinics, the nurses and lay providers would need to stay in communication with these same more senior clinicians, by referral and back-referral and communication by cell phone or other means.

1. Acute care (including opportunistic infections, when to suspect and test for HIV, prevention)

Acute care presents a syndromic approach to the most common adult illnesses including most opportunistic infections. Clear instructions are provided so the health worker knows which patients can be managed at the first-level facility and which require referral to the district hospital or further assessment by a more senior clinician. Preparing first-level facility health workers to treat the common, less severe opportunistic infections will allow them to stabilize many clinical stage 3 and 4 patients prior to ARV therapy without referral to the district.

2. Chronic HIV care with antiretroviral treatment

This module includes patient education, psychosocial support, prevention for positives, clinical staging, prophylaxis (INH, cotrimoxazole, fluconazole), preparation for ARV treatment then clinical monitoring, response to side effects, adherence preparation and support, management of chronic problems, and data collection based on a simple treatment card. The Chronic HIV Care with ARV Therapy effectively integrates HIV care and prevention, increasing the potential for preventive interventions. The broader uptake of preventive interventions is essential for HIV control.

3. General principles of good chronic care

IMAI supports the introduction of an effective approach to chronic care (including a team approach, patient partnership, inclusion of “expert patients”/peer support staff on the clinical team, and effective adherence support). This approach could permit rapid expansion of human resources for HIV care while providing the skills and clinic capacity for effective management of other chronic illnesses. A short module describes the General Principles of Good Chronic Care. These principles are used in the Chronic HIV Care guidelines.

4. Palliative care: symptom management and end-of-life care

The module covers management of symptoms during acute or chronic illness, education of the patient, family and community caregiver to provide care at home, using the Caregiver Booklet; and end-of-life care. Symptom management is very important in patients on ARV treatment. In order to expand access to palliative care, this approach assumes that most of the care will be given by the patient’s family with back-up by multi-purpose health workers at first- level facilities. This module covers palliative care in both children and adults.

The Caregiver Booklet

The Caregiver Booklet is designed to be used by health workers to educate family members and other caregivers and then given to them to use as a reference at home.

These are interim guidelines released for country adaptation and use to help with the emergency scale-up of antiretroviral therapy (ART) in resource-limited settings. These interim guidelines will be revised soon based on early implementation experience. Please send comments and suggestions to :

For country adaptation, the modules and recording forms are also available in Microsoft Publisher 2000 (which is easy to use for anyone familiar with Word) and InDesign. The Caregiver Booklet is available in Pagemaker. A short protocol is available to support adaptation and pretesting of the Caregiver Booklet.