Antiretroviral (ARV) toolkit

Referral care and clinical mentoring

Clinical services based on the IMAI guidelines support primary care management and allow most care, treatment and prevention to be delivered near the patient's home. Busy health care workers should be able to manage most problems while referring more complicated cases to the district hospital.

Within a district, the levels of care need to be linked: the district hospital (outpatient and inpatient), health centres, and the community (including community-based organizations, community health workers, home-based care activities, TB and ART treatment support in the home). At the district level, the health workers 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 and trained with the second level ART and OI training course. Outside the district, there needs to be a few physicians and paediatricians with advanced ART and OI management skills—to see patients in referral or to consult by phone on complicated patients and special problems, and to serve as clinical mentors to medical officers.

Referrals might occur for the following reasons:

  • To manage complications, deal with treatment failure, or when diagnosis is in doubt. In this case one site will refer to another that is at a higher level (e.g. health centre to district hospital, or district medical officer to an experienced ART physician or paediatrician). Management of severe ART toxicity and complications of HIV infection requires consultation and referral.
  • For follow-up in the community. For regular follow-up and adherence support a hospital might refer a patient who is already on treatment to a health centre or to home based care that is closer to the community where the patient lives.

Patients may also decide to transfer their care:

  • When patients relocate.
  • Individual choice (for example, because of quality and confidentiality).      

The referral system must ensure that patients transfer smoothly between different facilities and levels of the health system. This is particularly important for patients on ART because they must not miss doses.

The majority of HIV care and ART will be provided "below" the level of a specialized physician or paediatrician. Good chronic HIV care with ART requires support for referral and back-referral and good communication. This care requires solid planning at the district level.

The second-level IMAI course

These training materials are aimed at doctors, medical officers or clinical officers that manage severe opportunistic infections, HIV-TB co-infection, ART toxicity and other complicated clinical problems as part of a district health system or a clinical team trained in IMAI.

Clinical mentoring

It is becoming increasingly apparent that clinical mentoring visits and telephone back-up after HIV care/ART training for case review, problem solving, quality assurance, and continuing education are key to building successful district networks for HIV care, and that clinical (and counselling) mentoring requires clinical expertise in ART/OI management that are often not found on the district management team. We have heard of several innovative approaches and want to gather these and share approaches and tools with others who are just beginning to train more peripherally than hospitals.

The public health approach to scaling up HIV care/ART requires operationalizing simplified treatment guidelines that facilitate decentralized ART/OI management. Decentralization of services to district hospitals and health centres increases access, promotes equity, and provides better support regarding adherence to care and treatment by providing HIV care/ART close to the patient's home. Effective training and routine follow-up after training are important to assure regular application of simplified guidelines that will benefit the largest number of patients.

Although the public health approach to HIV care/ART works to provide maximum access, a proportion of patients managed with first-line regimens and monitored by non-physicians will develop complications that require management by a doctor or medical officer and a proportion of those cases (with complications or severe illness) will benefit from the availability of hospital referral care, consultation by phone/email, or more skilled clinical input on-site by case consultation or case review. This is the clinical mentoring system that we would like to review and consider approaches and tools to support its broader availability in resource-constrained settings. 

The clinical mentoring discussion will focus on input by an experienced clinician with substantial ART and OI expertise (and their own back-up by specialists) who is able to respond to questions, to review clinical cases, and to provide ongoing training by providing feedback and assisting in case management during on-site visits.