Facilitator's Manual 2020 July 2020 Final

MINISTRY OF HEALTH
NATIONAL TRAINING CURRICULUM FOR ROLL OUT OF

THE CONSOLIDATED GUIDELINES FOR THE
PREVENTION AND TREATMENT OF HIV AND AIDS IN
UGANDA, 2020
FACILITATOR’S GUIDE
STD/AIDS Control Programme
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TABLE OF CONTENTS
TABLE OF CONTENTS ..................................................................................................................... 1
INTRODUCTION............................................................................................................................... 3
MODULE 1. Prevention of HIV ...................................................................................................... 24
1.1 Behavioral Change and Risk Reduction interventions .................................................... 25
1.2 Biomedical HIV Prevention interventions ........................................................................ 26

1.3 Structural interventions ...................................................................................................... 34
MODULE 2. HIV Testing Services ................................................................................................. 36

2.1 What are HIV Testing Services? ........................................................................................ 37
2.2 What are the Guiding Principles for HIV Testing Services (HTS)? ................................ 37
2.3 What are the HTS Protocol? ............................................................................................... 38
2.4 Targeted HIV testing .......................................................................................................... 39

2.5 HIV Screening tools ............................................................................................................ 40
2.6 HIV Testing Services Algorithm ........................................................................................ 43
2.7 What is Assisted Partner Notification (APN)? ................................................................. 44

2.8 What is HIV Self-Testing (HIVST)? ................................................................................... 49
MODULE 3: Psychosocial Care and Adherence Support for PLHIV ......................................... 51
3.1 What is psychosocial support? .......................................................................................... 52
3.2 Introduction to adherence .................................................................................................. 58

3.3 Preparing children, adolescents and adults for ART ....................................................... 59
3.4 Monitoring adherence to ART ........................................................................................... 63
3.5 Adherence Support............................................................................................................. 65
3.6 Intensive Adherence Counseling for Patients with detectable Viral Load ..................... 66
3.7 Delivering HIV Services for adolescents ........................................................................... 68
3.8 Module 3 Practice case studies to check participant understanding .............................. 68

MODULE 4. Elimination of Mother-to-child Transmission of HIV (eMTCT) and improving
Maternal, New-born, Child and Adolescent Health (MNCAH) ................................................. 70
4.1. eMTCT continuum of services ........................................................................................... 71
4.2 Services for non-pregnant adolescent girls and women .................................................. 72
4.3 Services offered during pregnancy.................................................................................... 73

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4.4 Services offered during labour and delivery .................................................................... 75
4.5 Services offered during the postpartum period ............................................................... 76
4.6 Care of the HIV-exposed infant/child ............................................................................... 76
4.7 Community eMTCT............................................................................................................ 77
MODULE 5: Maternal, Infant and Young Child Nutrition.......................................................... 79

5.1 Maternal Nutrition - Counselling Information................................................................. 79
5.2 Infant and Young Child Feeding ....................................................................................... 80
5.3 Nutrition assessment, counselling and support for PLHIV ............................................ 82
5.4 Management of Malnutrition............................................................................................. 84

MODULE 6. HIV Care and Treatment for Children, Adolescents and Adults ......................... 85
6.1 Minimum Service Package for PLHIV .............................................................................. 86
6.2 Diagnosis, Prevention and Management of Co-morbidities and Co-infections ............ 86
6.3 Antiretroviral therapy for people living with HIV .........................................................106

6.4 Pharmacovigilance.............................................................................................................127
MODULE 7. Service Delivery Models...........................................................................................130
7.1 Differentiated Service Delivery.........................................................................................130
7.2 Working with community structures to optimize delivery of HIV services .................140
MODULE 8. Integrating Continuous Quality Improvement into HIV Care Services.............143
MODULE 9 Logistics Management ...............................................................................................144
9.1 Principles of Logistics Management.................................................................................144
9.2 Inventory Management .....................................................................................................148

9.3 Good Dispensing Practices................................................................................................154
9.4 Completing ARV and eMTCT Medicines Report and Order Form ...............................158
9.5 Ordering for third line ARVs ............................................................................................164
9.6 TLD transition ....................................................................................................................165
9.7 Dispensing of medicines to patients under DSD.............................................................166

9.8 Filling the Viral Load, EID and SCD Commodities Order Form ...................................167
MODULE 10. Introducing Changes in HIV Care Tools ..............................................................171

10.1 Introducing Changes in HIV HMIS Tools .............................................................................171
10.2 Tracking guidelines roll out ....................................................................................................173
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INTRODUCTION
Training Goal: The goal of this training is to update clinical mentors/trainers with the Consolidated
Guidelines for HIV Prevention and Treatment, 2020 and build their capacity to conduct onsite training
of healthcare workers during the roll out process.
Training Objectives: By the end of the 5-day training course, participants will be able to:
1. Train health care workers on the Consolidated Guidelines for HIV Prevention and Treatment,
2020
2. Train health workers on the updated M&E tools and job aids
Participants: This five-day training is designed as an in-service training for HIV/AIDS clinical
trainers/mentors including medical doctors, clinical officers, nurses, midwives, dispensers,
pharmacists, M&E officers.
Detailed Facilitator’s Guide: This guide is for facilitators to use to conduct the training. The guide
includes suggested time allocations for covering topics, key talking points to include when
presenting new material, step-by-step instructions for carrying out the various participatory
exercises and activities, and answer keys for the case study exercises.
There is a set of other training tools that are required during the training include:
• Desk job aids summarizing the Consolidated Guidelines for HIV Prevention and Treatment,
2020
• PowerPoint presentations (only for logistics management training)
• Printouts of M&E tools and logistics tools
Always use this guide during training to ensure that consistent and accurate HIV care & treatment
messages are delivered to health professionals across the country during the roll out of the
Consolidated Guidelines for HIV Prevention and Treatment 2020
Training Content: This manual can be used for 2 training schedules and introduces participants
to the revised HIV/AIDS guidelines and revised desk job aids:
• Training of Trainers as a five-day schedule.
• Facility-based training as a three-day schedule.
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Training Schedules
A) TRAINER OF TRAINERS SCHEDULE

Time Day 1 Day 2 Day 3 Day 4 Day 5
8.00 - 8.30 am Registration & Recap day 1 (team lead) Recap day 2 Recap day 3 Recap day 4
introduction & guidance for the day
9.00-9.30am Training objectives GROUP WORK: HIV Care and Logistics and supply Post test
Updates in the CG Treatment for Children, chain management
Roll-out Plan Understanding the new Adolescents and GROUP WORK
(Cordelia/Eleanor) guidelines Adults: ART &VL Individual IP action
9.30-10.00am Pre-test Monitoring planning for Roll-out
10.00-10.30am Tea break Tea Break Tea Break Tea Break Tea Break
11.00am- 12.00 Exploring tools and TEACH-BACKS HIV Care and Support Monitoring and IP presentation of rollout
materials/ Plan for the for PLHIV: Advanced Evaluation plans e.g.
week: Prevention of HIV, HTS Disease/ CTX • Training report • Number of TOTs
• Walk through and Linkage to Care& format • Number of district
available materials Treatment • Monitoring & teams
• Demonstrate use supervision • Duration of
of relevant rollout Action
materials planning and
• Guidance for Way forward
group work
12.00- 1.00pm GROUP WORK EMTCT and improving CSM framework
Understanding new MNCH
guidelines (group
according to
speciality)
1.00-1.30pm Lunch break Lunch break Lunch break Lunch break Lunch break
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A) TRAINER OF TRAINERS SCHEDULE
Time Day 1 Day 2 Day 3 Day 4 Day 5
2.00-3.00pm GROUP WORK: Psychosocial care and Service delivery: Presentation of plans
Adherence support for Differentiated Service How to conduct
Understanding new PLHIV delivery facility-based training
3.00-5.00pm guidelines Service delivery: Service delivery: • Review the Next Steps
Working with Delivery of HIV timetable
Community Structures services to Adolescents • Discuss Trainer Closure
to Optimize Delivery of composition
HIV Services • Review training
plans Schedule
5.00pm Evening tea Evening Tea Evening tea Evening tea Evening tea
5.15pm Trainer debrief Trainer debrief meeting Trainer debrief meeting Trainer debrief Trainer debrief meeting
meeting meeting
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B) FACILITY-BASED TRAINING SCHEDULE
Time Day 1 Day 2 Day 3
8.00-8.30 am Registration, Welcome, Recap day 1 Recap day 2
introduction and objectives
9.00-9.30am Guidance from MOH (PPT/hand HIV Care and Treatment for Children, Adolescents Psychosocial care and Adherence
out) and Adults support for PLHIV
9.30-10.00am Pre-test Service delivery:
Differentiated Service Delivery
Working with Community Structures to

Optimize Delivery of HIV Services
10.30am Tea break Tea Break Tea Break

11.00am- Coaching and Mentorship Coaching Coaching and Mentorship
1.00pm • Timely VL
• Appropriate 1st line regimen
• IAC
1.00-1.30pm Lunch break Lunch break Lunch break
2.00-3.00pm Prevention of HIV EMTCT and improving MNCH Logistics and supply chain management
3.00-5.00pm HTS HIV Care and Support for PLHIV

Post test
5.00pm Trainers’ meeting Trainers’ meeting Trainers’ meeting
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Table 1: Summary of Changes in the 2020 Consolidated Guidelines
Module Reference Changes
Module 1: Training Manual PrEP eligibility has extended to include adolescents and young women including pregnant
HIV Module 1.2.4, Desk Job and lactating AGYW who are at substantial risk of acquiring HIV.
Prevention Aid page 8
Module 2: Training Manual In Uganda, Targeted HIV testing is being offered in various ways and is also referred to as
HIV testing Module 2.4, Desk Job ‘’Risk Based Testing’’. The forms of Targeted HTS include the following:
services Aid Page 15 • Index client Testing (including Social Networks Testing, APN)
• HIV Self Testing (HIVST) through ‘’focused’’ distribution of Self-Test Kits
It is important that all HTS providers offer targeted HTS since it maximizes identification of
PLHA, saves resources, reduces workload.
Training Manual Categories of HIV Negative persons to retest at specified time points
module 2.5, Desk Job
Aid page 22 - 23
Training Manual Children >18 months who are still breastfeeding should be re-tested 3 months after cessation
module 2.5, Desk Job of breastfeeding
Aid page 23
Module 3: No Changes
Psychosocial
care and
Adherence
support for
PLHIV
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Module 4: Training Manual Triple elimination of HIV, Syphilis and Hepatitis B: Guidelines for screening, testing and
eMTCT module 4.3, Desk Job management of Syphilis and Hepatitis B during pregnancy.
Aid pages 90-92
Training Manual • ART should be initiated on the same day, and adherence counseling should be
module 4.3 Desk Job initiated and sustained intensively for the first 3 months then maintained for life.
Aid page 88 • Initiate mother on once-daily FDC of TDF+3TC+DTG with pharmacovigilance.
• The mothers initiated on TDF + 3TC +EFV400 shall be transitioned to TDF + 3TC +
DTG at 6-9 months post-partum if VL within past 6 months is suppressed.
• If mother is already on ART >6 months with TDF/3TC/EFV, do VL test. If she is virally
suppressed, maintain her on TDF/3TC/EFV400 until 6-9 months after delivery and
then substitute EFV with DTG if VL within the past 6 months is suppressed.
• If she is already on a DTG-based 1st-line regimen and virally suppressed, maintain
on the same regimen.
• If she is already on ART and VL is not suppressed, manage as treatment failure and
switch to DTG-based 2nd line regimen (if no previous exposure to DTG).
• If she is on 2nd line ART with ATV/r or LPV/r and virally suppressed, maintain on
the same regimen until 6-9 months after delivery and then substitute PI with DTG if
VL within the past 6 months is suppressed and no previous exposure to DTG.
• ART should be initiated and maintained in mother-baby care point in MCH.
Training Manual ARV prophylaxis in HIV exposed infants who present after 6 weeks:
module 4.6 Desk Job • Do first PCR
Aid page 97 • Give ART (ABC/3TC/LPV/r bd; give weight appropriate dose) for 6weeks
• If PCR results are negative, give NVP for 6 weeks (after completing the 6 weeks
of ABC/3TC/LPV/r)
• If PCR results are positive, continue with ABC/3TC/LPV/r as first line ART.
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Irrespective of timing, the mother should be started on ART as soon as possible for
her own health and to decrease risk of transmission to breastfeeding baby.
Module 5: No changes
Maternal,
infant and
young child
nutrition
Module 6: HIV Training Manual Dosage of Anti TB medicines for children in the 25-32Kg weight band:
Care and module 6.2.6.3, Job aid • Intensive phase: RHZ (75/50/150)- 4 Tablets
Treatment for page 196 E (100)- 4 Tablets
children, Continuation phase: RH (75/50) -4 Tablets
Adolescents Training Manual ART regimens for TB/HIV co-infected patients initiating First-line ART
and Adults module 6.2.6.4, Desk Adults and adolescents ≥30Kg, including pregnant and breastfeeding women:
Job Aid page 129-130 • Preferred regimen: TDF +3TC+DTG (double the dose of DTG)
• Alternative regimens:
o Use ABC where TDF is contraindicated
o EFV400-based regimen
o ATV/r-based regimen (substitute Rifampicin with Rifabutin)
Children ≥ 20Kg -<30Kg:
• Preferred regimen: ABC+3TC+DTG (double the dose of DTG)
o Use AZT or TAF where ABC is contraindicated
o LPV/r-based regimen (substitute Rifampicin with Rifabutin or double dose
LPV/r)
o EFV-based regimen (children >3 years)
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Children <20Kg:
• Preferred regimen: ABC+3TC+DTG (double the dose of DTG)
o Use AZT where ABC is contraindicated
o LPV/r-based regimen (substitute Rifampicin with Rifabutin or double dose
LPV/r)
o EFV-based regimen (children >3 years or weighing >10Kg)
o RAL-based regimen (double dose of RAL)
o ABC+3TC+AZT (children <3 years or weighing <10Kg)
ART regimens for TB/HIV co-infected patients initiating Second-line ART

Adults and adolescents ≥30Kg, including pregnant and breastfeeding women:
• Preferred regimens: AZT or TDF +3TC+DTG (double dose of DTG)
AZT or TDF +3TC+ATV/r (substitute Rifampicin with
Rifabutin)
• Alternative regimen:
o LPV/r -based regimen (substitute Rifampicin with Rifabutin or double the
dose of LPV/r)
Children ≥ 20Kg- <30Kg

• Preferred regimens: TAF or AZT or ABC+3TC+DTG (double dose of DTG)
TAF or AZT or ABC+3TC+LPV/r (Substitute Rifampicin with
Rifabutin or
double dose of LPV/r)
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o LPV/r -based regimen (Substitute Rifampicin with Rifabutin or double the
dose of LPV/r)
o RAL-based regimen (double the dose of RAL)
o DRV/r-based regimen (Substitute Rifampicin with Rifabutin)
Children <20Kg
• Preferred regimens: AZT or ABC+3TC+DTG (double dose of DTG)
AZT or ABC +3TC+LPV/r (Substitute Rifampicin with
Rifabutin or double the dose of LPV/r)
o LPV/r- based regimen (substitute Rifampicin with Rifabutin or double the
dose of LPV/r)
o RAL -based regimen (double the dose of RAL)
o DRV/r- based regimen (substitute Rifampicin with Rifabutin)
After TB treatment the regimens should be optimized.
Training Manual ARV regimen substitutions for patients initiating TB treatment while already on ART
module 6.2.6.4, Desk Adults and adolescents ≥ 30Kg, including pregnant and breastfeeding women:
Job Aid page 131-132 • If on EFV based regimen: Continue with the same regimen and dose.
• If on DTG-based regimen: Continue the same regimen but double dose of DTG
• If on NVP-based regimen: Substitute NVP with EFV.
• If on ATV/r-based regimen: Continue the same regimen but substitute Rifampicin
with Rifabutin. If on 2nd line, substitute ATV/r with LPV/r and double the dose of
LPV/r. If on an ATV/r-based 1st line regimen and EFV is not contraindicated,
substitute ATV/r with EFV for the duration of TB treatment.
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• If on LPV/r -based regimen: Continue the same regimen but either substitute
Rifampicin with Rifabutin or double the dose of LPV/r.
Children ≥ 20Kg -<30Kg
• If on DTG-based regimen: Continue the same regimen but double the dose of DTG.
• If on EFV-based regimen: Continue the same regimen.
• If on NVP -based regimen: Substitute NVP with EFV (if >3 years) or if EFV is
contraindicated, give a triple NRTI regimen (ABC+3TC+AZT).
• If on LPV/r-based regimen: Continue the same regimen but either substitute
Rifampicin with Rifabutin or double the dose of LPV/r. If the child cannot tolerate
double dose of LPV/r, substitute LPV/r with Raltegravir and double the dose of
Raltegravir. Return to LPV/r after completion of TB treatment.
• If on DRV//r-based regimen: Substitute Rifampicin with Rifabutin.
Children <20Kg
• If on DTG-based regimen: Continue the same regimen but double the dose of DTG.
• If on LPV/r- based regimen: Continue the same regimen but either substitute
Rifampicin with Rifabutin or double the dose of LPV/r. If the child cannot tolerate
double dose of LPV/r, substitute LPV/r with Raltegravir. Double the dose of
Raltegravir. Return to LPV/r after completion of TB treatment.
• If on NVP-based regimen: If >3 years and >10Kg substitute NVP with EFV. If EFV is
contraindicated, give a triple NRTI regimen (ABC+3TC+AZT). If <3 years and <10Kg
give triple NRTI regimen (ABC+3TC+AZT).
• If on DRV/r-based regimen: Substitute Rifampicin with Rifabutin
After TB treatment optimize ART regimen if virally suppressed. If not virally suppressed
switch to 2nd or 3rd line ART.
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Training Manual Eligibility for TPT
module 6.2.6.5, Desk • HIV-positive children (≥one year of age), adolescents and adults with no signs and
Job Aid page 133 symptoms of TB
• HIV-positive infants and children <5 years with a history of TB contact who have no
signs and symptoms of active TB disease, irrespective of previous TPT
• HIV-positive pregnant mothers with evidence of exposure to active TB disease after
ruling out active TB
• HIV-positive pregnant mothers with a WHO Stage 3 or 4 event and/or CD4<200
without active TB
• For HIV-positive pregnant mothers without evidence of exposure to active TB
disease, TPT will be deferred until 3 months after delivery
For HIV positive+ adolescent girls and women on TPT who get pregnant, continue and
complete the TPT while closely monitoring for side effects
Training Manual Co-administration of DTG and TPT
module 6.2.6.5
Although studies have found that the co-administration of DTG and INH is well tolerated,
liver injury is a recognized adverse effect of each of these drugs. Since there is potential for
hepatotoxicity, the following are recommendations for co-administration.
• For newly identified patients, start on TLD with active symptomatic monitoring for
adverse events. Initiate TPT after 3 months. These 3 months allow time for potential
unmasking of TB and to monitor any toxicities that may arise from DTG, prior to
initiation of TPT.
• For stable patients already transitioned to DTG: If patient has been on TLD for 3
months or more, initiate TPT immediately
• Stable patients for DTG transition and have not received TPT before:
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o In case TLE stock is available: First complete TPT and then transition to
DTG
o In case TLE stock is not available: Transition to DTG and initiate TPT after
3 months
Note: All patients receiving INH prophylaxis and DTG+INH should be closely monitored
for signs and symptoms of liver toxicity as specified in the pharmacovigilance guidelines.
Training Manual TPT regimens:
module 6.2.6.5, Desk • 6H: Daily Isoniazid for 6 months.
Job Aid page 135 Note: Isoniazid may be available in combination with co-trimoxazole and pyridoxine
as a fixed dose combination referred to as Q-TIB: In this case, Q-TIB is also
administered daily for 6 months.
• Rifapentin-Isoniazid based regimens: Weekly Isoniazid and Rifapentine for 3
months (3HP): recommended for patients aged more than 2 years.
• 3RH: Daily Rifampicin and Isoniazid for 3 months (Recommended for children less
than 15 years).
Training Manual Management of Cryptococcal Meningitis

module 6.2.5.2, Desk Induction phase of treatment:
Job Aid page 123 Recommended:
• Amphotericin B liposomal (3mg/kg/day)/ deoxycholate (1mg/kg/day) + Flucytosine
(100mg/kg/day in four divided doses) for 1 week, followed by 1 week of fluconazole
(1200 mg/day for adults, 12 mg/kg/day for children and adolescents).
Or
• Fluconazole (1200 mg daily for adults, 12 mg/kg/day for children and adolescents) +
Flucytosine (100 mg/kg/day, divided into four doses per day.
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Or
• Amphotericin B deoxycholate (1mg/kg/day) + high-dose Fluconazole 1200mg/day.
Alternative:
Fluconazole 1200mg/day (or 6-12mg/kg/day in children)
Training Manual The Preferred First-line ARV regimen in adults, adolescents, pregnant or breastfeeding
module 6.3.2, Desk Job women and children initiating ART is DTG based.
Aid page 142
Adults and adolescents ≥ 30Kg, including pregnant and breastfeeding women
• Preferred 1st line regimen: TDF+3TC+DTG
o Use ABC where TDF is contraindicated
o EFV400-based regime
o ATV/r-based regimen
Children ≥ 20Kg- <30Kg

• Preferred 1st line regimen: ABC+3TC+DTG
o Use AZT or TAF where ABC is contraindicated (TAF in children> 6 years and
≥25Kg)
o LPV/r-based regimen
Children <20Kg
• Preferred 1st line regimen: ABC+3TC+DTG
o Use AZT where ABC is contraindicated
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o LPV/r-based regimen
o EFV-based regimen (Children >3 years and >10Kg)
o RAL-based regimen
Training Manual Eligibility for DTG:

module 6.3.2.2, Desk Adults being initiated on DTG should be screened for risk factors for NCDs:
Job Aid page 143 • Age over 40 years
• Overweight (BMI 25-30kg/m2) or Obese (BMI >30kg/m2)
• Duration on ART (>5 years)
1. Known diabetics should not be initiated or transitioned to DTG: Give EFV400 or a
PI.
2. Clients with 2 or more risk factors for NCDs and a high baseline RBS or FBS should
not be initiated or transitioned to DTG: Give EFV400 or PI.
3. Clients with 2 or more risk factors for NCDs with normal baseline RBS or FBS:
Initiate or transition to DTG and monitor RBS or FBS every 3 months for 6 months.
Training Manual When to substitute NNRTIs with DTG among adults and adolescents already on first line
module 6.3.2.3 ART
Patients on first line ART with a suppressed viral load result within the last 6 months, will
have their NNRTIs substituted with DTG to optimize treatment. Adolescents on ABC based
first line regimen who weigh ≥ 30kg, shall have their ABC substituted with TDF. The
regimens should be aligned to the recommended first-line regimens. Alternative regimens
will be used in case of contraindications to DTG.
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Training Manual When to substitute NNRTIs with DTG among pregnant and breastfeeding women
module 6.3.2.3 already on first line ART
Pregnant and breastfeeding women already on EFV-based first-line regimens will remain
on EFV400 based regimens throughout pregnancy until 6-9 months post-partum when EFV
should be substituted with DTG if VL within past 6 months is suppressed.
Training Manual Recommended programmatic drug substitutions in adults and adolescents

module 6.3.2.3, Desk
All adults and adolescents on NNRTI-based first line ART with suppressed VL will have
Job Aid page 144
their regimens transitioned to TDF+3TC+ DTG (TLD). Pregnant and breastfeeding women
on TDF+3TC+EFV (TLE) will maintain this regimen and transition to TLD 6-9 months post-
partum if the VL within the past 6 months is suppressed. Clients on PI-based regimens with
suppressed VL will be maintained on the same regimens.
Training Manual Recommended programmatic drug substitutions in children:

module 6.3.2.3, Desk
All children on NNRTI-based first line ART with suppressed VL will have their regimens
Job Aid page 145
transitioned to ABC+3TC+DTG. In the absence of appropriate DTG formulations, children
<20Kg should receive ABC+3TC+LPV/r. Children on PI-based regimens with suppressed VL
will be maintained on the same regimens.
Training Manual Children with a non-suppressed viral load

module 6.3.2.3
• If the child is on an NNRTI regimen and VL is not suppressed, switch to 2nd line
immediately and do IAC simultaneously. Do not postpone switch.
• If the child is on a DTG or LPV/r-based regimen as part of first line ART, conduct IAC
and repeat VL after 3 months. DTG and PI have high resistance barrier so poor
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adherence is a more likely cause for an unsuppressed VL than resistance. If VL is still
not suppressed after IAC interventions, switch to 2nd line ART. For children and
adolescents, this switch will be guided by an HIV drug resistance test.
Training Manual Frequency of viral load monitoring: The following criteria were added to the previous
module 6.3.5.2
• After every switch in treatment (after failure): The VL test should be done at 6 months
after a switch to second- and third-line ART.
• Third line ART patients: The VL test should be done every 6 months. If a VL >1000
Training Manual copies is detected (un-suppressed VL) then genotype testing is recommended.
module 6.3.5.2, Desk Genotype testing: The following categories of patients will receive Genotype testing to
Job Aid page 158 identify optimal ART regimens:
• All children failing in 1st line ART:

o Children exposed to AZT/3TC and ABC/3TC NRTI backbone and are failing
on their first-line ART treatment.
o Infants born to mothers failing treatment (first, second or third line)
o Children receiving Lopinavir/ritonavir or Dolutegravir on first-line ART and
who have a repeat viral load result >1000 copies/ml following intensified
adherence counselling.
• Patients failing on a PI-based regimen irrespective of line of care.
• Patients with a prior exposure to a PI and failing on a DTG based regimen and vice
versa.
• All patients failing on their second line ART.
• All patients failing on their third line ART.
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Training Manual Second- and Third-line ART regimens are selected based on previous ARV exposure with
module 6.3.6.2, Desk the aim to avoid the use of ARVs to which the client is likely to be resistant to in
Job Aid page 161 subsequent regimens.
Adults and adolescents ≥ 30Kg, including pregnant and breastfeeding women

• Preferred 2nd line regimens: DTG-based or ATV/r-based
• Alternative 2nd line regimens: ATV/r-based or LPV/r-based
Children ≥ 20Kg-<30Kg
• Preferred 2nd line regimens: DTG-based or LPV/r-based
• Alternative 2nd line regimens: LPV/r-based or DRV/r-based
Children <20Kg
• Preferred 2nd line regimens: DTG-based or LPV/r-based
• Alternative 2nd line regimens: LPV/r-based or DRV/r-based
All 3rd line regimens to be guided by resistance testing
Training Manual Programmatic drug substitution in 2nd line regimens

module 6.3.6.2, Desk Adults on ATV/r or LPV/r-based 2nd line regimens who are virally suppressed (basing on
Job Aid page 162 VL result within the past 6 months) and who did not receive DTG in their 1st line regimens
should have ATV/r or LPV/r substituted with DTG.
Pregnant and breastfeeding women on ATV/r or LPV/r-based 2nd line regimens who are
virally suppressed and who did not receive DTG in their 1st line regimens should be
maintained on the same regimens. At 6-9 months postpartum, if their VL is suppressed
(basing on VL result within past 6 months), ATV/r or LPV/r should be substituted with DTG.
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Although simplification of regimens including once-a-day dosing is a main goal of ART
optimization, children and adolescents who are virally suppressed and stable on 2nd line
regimens containing twice-daily LPV/r will be maintained on their regimens so as to
preserve their options for 3rd line regimens. Drug substitutions may be considered on a case
by case basis especially in children and adolescents in whom twice-daily dosing may hinder
adherence.
Training Manual This section has been introduced to emphasize the importance of timely screening,
module 6.4, Desk Job monitoring, investigating and management of adverse effects and toxicity of medications
aid pages 164-173 especially ARVs and anti-TB. This section provides guidance for the procedures for active
pharmacovigilance including standard operating procedures for the management of
hyperglycaemia following DTG initiation.
Module 7: Training Manual Multi-month prescriptions apply to stable clients in stable approaches. These guidelines
Service module 7.1.3 recommend the introduction of 6 months prescription for high risk clients in whom
Delivery
frequent drug pickups may compromise their adherence to ART. Only stable clients will
Models
be considered for 6-month refills of ART in addition to meeting all of the following criteria:
• ≥15 years
• Not pregnant or breastfeeding
• Repeat VL not due in less than 6 months
• Not TB/HIV co-infected
• No regimen switch or substitution in the last 6 months
• Completed INH prophylaxis
Six-month refills can be provided through FTDR or CDDP approaches.
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Training Manual DSD for children and adolescents:
module 7.1.3, Job aid • Stable children 2 - <10years can join FTDR or CDDP if their parents/care givers are
page 180 stable and choose to join these approaches
• Stable adolescents 10 – 14years can join CCLADs or CDDP if their parents/care givers
are stable and choose to join these approaches
• Stable adolescents (10 – 14years) can be CCLAD members if their parents/care givers
are stable and choose to join CCLADs but they cannot pick drugs on behalf of the
other members. The responsibility of picking drugs will be for the parent/care giver
in each CCLAD group.
• Stable adolescents 15 – 19years can join CCLADs or CDDPs if they choose to.
• Adolescents 15 – 19years can form an adolescent only group if they choose to.
Training Manual Early Differentiation: At 6 months after initiation of ART, a client can be classified as stable
module 7.1.3 and qualify to be differentiated into approaches for stable clients in the facility and the
community.
Training Manual Provision of TB Preventive Therapy (TPT) to clients in the various DSD models and
module 7.1.3, Job aid approaches
page 181 a. TPT initiation
• TPT should be initiated by a clinician regardless of which DSD approach the client
is on. Efforts should be undertaken to have baseline tests done (i.e. LFTs) prior to
initiation of TPT.
• TPT should be initiated at the health facility for all clients receiving ART services
through FBIM, FBG, FTDR and CCLAD.
• For clients enrolled onto CDDPs, TPT should be initiated from the CDDP during the
clinicians visit. Efforts should be undertaken to have baseline tests done (i.e. LFTs)
at the time of initiation of TPT.
21
• Patient education about side effects and when to return to the facility should be
provided at the time of TPT initiation regardless of DSD approach.
TPT and ART refills should be aligned
b. Monitoring clients on TPT

• Clinical monitoring for clients on TPT should be done at every clinical encounter
regardless of DSD approach the client is on:
o Monitoring can be done through history taking and physical examination for
signs suggestive of hepatic injury (i.e. Yellowing of eyes, body itching, body
rash)
o Monitoring can also be done through follow up phone calls to the clients.
During the phones calls health workers should explore for signs of liver
injury, adherence to treatment and provide client education.
o LFTs should be done at baseline and at 3 months
• Clients in more intensive approaches (i.e. FBIM and FBG) should be reviewed every
month for TPT and ART toxicities
• Clients in less intensive approaches (i.e. FTDR, CDDP and CCLAD) should be
reviewed at least once every three months. Review at 3- and 6-months post TPT
initiation should happen at the facility for clients enrolled onto FTDR and CCLAD.
Review at 3- and 6-months post TPT initiation for clients enrolled onto CDDP should
happen at the CDDP.
Module 8. No Changes
Integrating
Continuous
Quality
Improvement
22
into HIV Care
Services
Module 9 No Changes
Logistics
Management
Module 10. No Changes
Introducing
Changes in
HIV Care
Tools
23
MODULE 1. Prevention of HIV
Introduction: In Uganda, the HIV epidemic is driven by multiple behavioral, biomedical and
structural factors. As such, there is no single HIV prevention intervention that is sufficient to
prevent all HIV transmissions. The country, therefore, adopted a combination HIV prevention
approach which uses a mix of biomedical, behavioral and structural interventions to meet the
HIV prevention needs of the population to have the greatest possible impact on reducing new
infections.
This module will provide guidance on how to implement interventions that reduce new HIV
infections among children, adolescents, young people, adults and key and priority populations.
Proposed Time: 2 hours and 30 minutes
Key Questions:
1. What are the behavioral change and risk reduction interventions?
2. What are the biomedical prevention interventions?
3. What are the structural interventions?
Note to facilitator
The main focus of this session is to introduce the Consolidated Guidelines for HIV Prevention and
Treatment 2020 on preventing HIV transmission.
The presentation is designed to be interactive and to get participants to practice how to use the new
desk job aid on preventing HIV transmission.
Note: As you introduce the KEY QUESTIONS for this presentation, pass out the Desk Job Aid and tell
participants that all Consolidated Guidelines for HIV Prevention and Treatment 2020 have been
incorporated into this job aid and that it will be used all through the training process.
Materials Needed:
• Desk job aid/flip chart
Methods: Brainstorming, presentation using the facilitator’s flip chart, exercise in pairs (Q/A
session).
24
1.1 Behavioral Change and Risk Reduction interventions
Instructions for Facilitator:

➢ Step 1: Ask the participants to turn to page 3 of the Desk Job Aid (Overview of HIV
prevention interventions) and to tell you what behavioural change and risk reduction
services they offer for prevention of HIV transmission.
o Refer to Page 41 of the Consolidated Guidelines and Table 2 below and clarify
where necessary.
Note to facilitator
Purpose of behavioural change and risk-reduction interventions: To delay sexual debut; reduce
unsafe sex, especially concurrent sexual partnerships; and discourage cross-generational and
transactional sex.
Table 2: Services for Behavioral Change and Risk Reduction

Area Guidance
Service • Each health facility/program needs a focal person for HIV prevention
delivery • All staff offering HIV prevention services need to be trained including
training in Gender & Sexuality Diversity (GSD)
• Peer-led model for key and priority populations including young
people
• Outreaches and Drop-in Centres for key and priority populations
• Job aids to support standardization for quality assurance
• Linkage and follow-up between facility and community is important
• Promote youth and key populations friendly services
Risk • Assess sexual behavior of the client (Ask if condoms are used,
assessment for frequency, number of partners, transactional sex/sework and if the
client client is involved in transactional sex/sex work encourage correct and
consistent condom use)
• Discuss knowledge of partner HIV status about sexual behavior
• Assess for STIs and link to treatment
• Discuss sexual and reproductive health services and link to services as
appropriate
• Offer HTS to sexually active clients who have not tested in the last 12
months or have had unprotected sex in last three months
• Conduct psychosocial assessment
25
Area Guidance
Provide socio- • Build a lifestyle of prevention among young people

behavioural • Discuss delay of onset of sexual debut in children and adolescents
change (abstinence)
communicatio • Discuss correct and consistent condom use and offer condoms as
n (SBCC) and appropriate
link to services • Discourage multiple, concurrent sexual partnerships to promote
as appropriate faithfulness to a partner of known HIV status
• Discourage cross-generational and transactional sex
• Discourage risky cultural practices such as widow inheritance, wife
replacement and childhood marriages
• Identify, refer and link clients to other available services at facility and
community programs
• Assess for violence (physical, emotional, or sexual); if client discloses
sexual violence, assess if the client was sexually asaulted and act
immediately (see section 3.5.1 for GBV case management and section
3.3.3 for PEP)
Condom • Discuss correct and consistent condom use as an option for risk-
promotion and reduction
provision • Discuss benefits of condom use
• Clarify any questions and dispel myths around condoms
• Demonstrate negotiation skills for safer sex
• Allow the client to role play negotiation skills for safer sex and how to
introduce condoms in relationship
• Provide condoms to client
1.2 Biomedical HIV Prevention interventions
Instructions for facilitator:

prevention interventions) and to tell you what biomedical prevention services they offer
for prevention of HIV transmission and what are the processes in offering them? Write on
the flip chart.
o Refer to Page 42 of the Consolidated Guidelines where necessary
26
Note to facilitator
Biomedical Prevention Interventions: These include eMTCT, safe male circumcision (SMC),
ART for prevention, PEP, PrEP, Condom, blood transfusion safety and STI screening and
treatment.
1.2.1 Condom programming
Instructions to the facilitator:
➢ Step 3: Ask participants what entails condom programming (male and female condoms)
1. Discuss the issues surrounding condom use and non-use, distribution and supply
in their health facilities/community (male and female condom) with participants.
2. Discuss the target groups for condom use with participants
3. Allow participants demonstrate steps for correct condom use (male and female
condom)
Note: After the discussion, summarise as follows;
Condom programming for HIV prevention is a means of ensuring that sexually active persons at
risk of HIV and unintended pregnancies are motivated to use condoms, have access to quality
condoms, and can use them correctly and consistently.
Target groups for condom use: The following have been identified as target populations and
include the populations at high risk of HIV transmission or acquisition, such as:
o Adults and youth engaged in multiple sexual partnerships.

o Men and women who engage in transactional sex and their clients.
o Adults working away from home such as transport and migrant workers, uniformed
Forces, fisher folk, boda-boda riders.
o People who inject drugs and men who have sex with men
o Adults and youth who access family planning clinics/service delivery points
o Discordant couples
o Individuals taking PEP and PrEP
➢ Step 4: Summarise steps for correct condom use
27
1.2.2 Safe Male Circumcision (SMC)
SMC reduces the risk of HIV acquisition among circumcised men by approximately 60%. The
table below describes the process involved in providing SMC.
➢ Step 5: Ask participants to describe the process of providing safe male circumcision. List
on the flip chart and go through the table below to clarify. Refer to Page 6 of the Desk Job
Aid (Safe male circumcision) or Page 43 of the Consolidated Guidelines.
Table 3: Process of providing Safe Male Circumcision

Process Description
Priority groups • All males including infants although focus is on pivotal age of 15-29years
for SMC
Recommended • Conventional surgery using the dorsal slit method and Shangring for
methods for adults; Mogen clamp for infants
SMC • WHO pre-qualified devices
Eligibility • Screen for STIs: If STIs are present defer the circumcision and treat the STIs
screening for • Tetanus immunization status:
SMC o Administer three dose TT vaccination schedule for both
conventional and device methods: First TT shot on day 0, 2nd
TT shot on day 28 and 3rd TT shot after 6 months
• Penile abnormalities: If there are any penile abnormalities, refer for specialist
care
• Bleeding disorders: If there is a history of bleeding disorders, defer SMC and
refer
• Existence of chronic disease conditions such as diabetes or hypertension:
defer SMC and refer
Consent/assent • All clients should receive information regarding SMC and understand the
benefits and risks of SMC
• The client should provide consent/assent prior to the procedure
HIV Testing • All SMC clients should be offered HTS, though clients may opt out
o A positive HIV test is not a contraindication to circumcision
o Initiate ART in men and adolescents who test positive
Follow up after • Following conventional surgery: at 48 hours, seven days and at six weeks
SMC • Following device circumcision: follow the manufacturer guidance for the
device used
Refer to SMC guidelines for details
28
1.2.3 Post-Exposure Prophylaxis for HIV
Post-Exposure Prophylaxis (PEP) for HIV is the short-term use of ARVs to reduce the likelihood
of acquiring HIV after potential exposure.
1. Ask participants to define PEP
2. Discuss the categories of exposures
3. Brainstorm the steps for PEP service provision
➢ Step 6: Ask participants to turn to page 7 of the Desk Job Aid (Post Exposure Prophylaxis)
or Page 44 of the Consolidated Guidelines and describe the steps of providing Post-
Exposure Prophylaxis (PEP). List on the flip chart and go through the table below to
clarify.
Steps in assessing a potential PEP recipient

The healthcare workers should use the steps described in the table below to assess clients for PEP
eligibility and provide PEP.
Table 4: Steps for providing Post-exposure prophylaxis (PEP)

Step Description
Step 1: Conduct a rapid assessment of the client to assess exposure and risk and
Clinical provide immediate care.
assessment Occupational exposure:
and After a needle stick or sharp injury
providing • Do not squeeze or rub the injury site
first aid • Wash the site immediately with soap and water
• Don’t use strong irritating antiseptics (like bleach or iodine)
After a splash of blood or body fluids in contact with intact skin
• Wash the area immediately
• Don’t use strong irritating antiseptics (like bleach or iodine)
For exposure-specific injuries, refer to the PEP Guidelines
Step 2: Provide PEP when:
Eligibility • Exposure occurred within the past 72 hours; and
assessment: • The exposed individual is not infected with HIV; and
• The ‘source’ is HIV-infected, has unknown HIV status or is high risk
Do not provide PEP when:
• The exposed individual is already HIV-positive
• The source is established to be HIV-negative
29
Step Description
• Individual was exposed to bodily fluids that do not pose a significant
risk (e.g. tears, non-blood-stained saliva, urine, sweat)
• Exposed individual declines an HIV test
Step 3: Counsel on:
Counselling • The risk of HIV from the exposure
and support • Risks and benefits of PEP
• Side effects of ARVs (page 144 - 148 in the job aid)
• Enhanced adherence if PEP is prescribed
• Importance of linkage for further support for sexual assault cases
Step 4: • PEP should be started as early as possible ideally within the first two
Prescription: hours but not beyond 72 hours of exposure
• Recommended regimens include:
o Adults and adolescents with weight of ≥30Kg:
Preferred: TDF+3TC+DTG
First Alternative: TDF+3TC+ATV/r
o Second Alternative: TDF+3TC+EFV
Children < 30Kg:
Preferred: ABC+3TC+DTG
Alternative:ABC+3TC+LPV/r
• A complete course of PEP should run for 28 days
• Do not delay the first doses because of lack of baseline HIV test or any
reason
• Document the event and patient management in the PEP register (ensure
confidentiality of patient data)
Step 5: • Review client after one week for adherence support
Provide • Discontinue PEP after 28 days
follow-up • Perform follow-up HIV testing at one month, three and six months after
exposure
• Counsel and link to HIV clinic for care and treatment if HIV-positive
• Provide prevention/education and risk reduction counselling if HIV-
negative
1.2.4 Oral Pre-Exposure Prophylaxis (PrEP)

o PrEP is the use of ARV drugs by HIV uninfected persons to prevent the acquisition of
HIV before exposure.
30
o PrEP will initially be offered in a few accredited ART sites that have the capacity and
funding to provide a complete package and whose outcomes will inform further roll-
out. PrEP is not yet being rolled out in all public health facilities. The Ministry of
Health, AIDS Control Program will provide guidance on further scale-up to all public
health facilities.
Instructions for facilitators:
1. Ask participants to define PrEP
2. Discuss with participants who should be eligible for PrEP
3. Discuss criteria for PrEP accreditation and list some facilities offering PrEP
➢ Step 7: Ask participants to turn to pages 8 - 9 of the Desk Job Aid (Oral Pre-exposure
prophylaxis) or Page 45 of the Consolidated Guidelines and describe the steps of
providing pre-exposure prophylaxis (PrEP). List on the flip chart and go through the table
below to clarify. The table below describes processes involved in offering PrEP.
Table 5: The process of providing Pre-Exposure Prophylaxis (PrEP)

Process Description
Screening for PrEP provides an effective additional biomedical prevention option for HIV-
risk of HIV negative people at substantial risk of acquiring HIV infection. These include
people who:
• Live in discordant sexual relationships
• Have had unprotected vaginal sexual intercourse with more than one partner
of unknown HIV status in the past six months
• Have had anal sexual intercourse in the past six months
• Have had sex in exchange for money, goods or a service in the last six months
• Use or abuse of drugs especially injectable drugs in the last six months
• Have had more than one episode of a STI within the last twelve months
• Are part of a discordant couple, especially if the HIV-positive partner is not
on ART or has been on ART for less than six months or not virally suppressed.
• Recurrent post-exposure prophylaxis (PEP) users. (Recurrent implies PEP use
more than 3 times a years).
• Are members of key or priority populations who are unable or unwilling to
achieve consistent use of condoms.
NB: Eligibility is likely to be more prevalent in populations such as discordant
couple, sex workers, fisher folk, long-distance truck drivers, men who have sex
with men (MSM), uniformed forces, and adolescents and young women including
pregnant and lactating AGYW at substantial risk.
31
Screening for After meeting the substantial risk for HIV criteria:
PrEP eligibility • Confirm HIV-negative status using the national HTS algorithm
• Rule out signs and symptoms of acute HIV infection
• Assess for hepatitis B infection: if negative, patient is eligible for PrEP; if
positive, refer patient for Hepatitis B management.
Note:
• HEP B positive test is not a contraindication for initiating PrEP, however
precaution needs to be taken when making a decision to stop PrEP to avoid
HEP B viral load flare.
• Creatinine test and creatinine clearance calculation using GFR formula is
done. Do not offer PrEP if Creatinine clearance is less than 1.2mg/dl. Note:
Absence of this should not delay PrEP initiation in persons with no signs and
symptoms of renal impairment. If available, creatinine test can be done at
initiation and repeated every 6 months.
• Assess for contraindications to TDF/FTC or TDF/3TC.
Steps to Provide risk-reduction and PrEP medication adherence counseling:
initiation of • Provide condoms and education on their use
PrEP • Initiate a medication adherence plan
• Prescribe a once-daily pill of TDF (300mg) and FTC (200mg) or TDF (300mg)/
3TC (300mg)
• Initially, provide a 1-month TDF/FTC or TDF/3TC prescription (1 tablet orally,
daily) together with a 1-month follow-up date
• Counsel client on side effects of TDF/FTC or TDF/3TC
Follow-up/ • After the initial visit, the patient should be given a two-month follow-up
monitoring appointment and thereafter quarterly appointments
clients on PrEP • Perform an HIV antibody test using the national HTS algorithm and every
three months. Note: HIVST is not recommended in patients on PrEP.
• For women, perform a pregnancy test if there is history of amenorrhea.
• Review the patient’s understanding of PrEP, any barriers to adherence,
tolerance to the medication as well as any side effects.
• Review the patient’s risk exposure profile and perform risk-reduction
counseling.
• Evaluate and support PrEP adherence at each clinic visit.
• Evaluate the patient for any symptoms of STIs at every visit and treat
according to current STI treatment Guidelines.
32
Guidance on • Acquisition of HIV infection
discontinuing • Suspected signs and symptoms of acute HIV infection following a recent
PrEP exposure within 4 weeks
• Changed life situations resulting in lowered risk of HIV acquisition (no longer
at substantial risk of HIV acquisition)
• Intolerable toxicities and side effects of ARVs
• Chronic non-adherence to the prescribed regimen despite efforts to improve
daily pill-taking.
• Personal choice
• HIV-negative in a sero-discordant relationship when the positive partner on
ART for >6months has achieved sustained viral load suppression (condoms
should still be used consistently). The HIV negative partner can be allowed to
continue PrEP even if the positive partner is virally suppressed if they choose
to.
For detailed guidance on the provision of PrEP, please refer to the Technical Guidance on Pre-Exposure
Prophylaxis for Persons at High Risk of HIV in Uganda, 2020.
1.2.5 Key/Priority Population Programming

➢ Step 8: Ask participants to:
1. Brainstorm on who are the key and priority populations
2. What is the difference between key and priority populations?
3. What puts them at risk of acquiring HIV?
4. What are the risk reduction interventions for key populations?
Note: Summarise the discussion and wrap up with the information below:
• Worldwide, Key/priority populations are disproportionately burdened by HIV and

contribute significantly to new HIV infections.
• Globally, while the key populations are defined as sex workers, men who have sex men,
trans-genders, injecting drug users and prisoners. This definition is informed by the fact
that they are more burdened by HIV, and are surrounded by stigma, discrimination, legal
and socio-cultural dimensions that make it harder to access interventions.
• Priority populations are country context specific and in Uganda these include fisher folk,
truckers, uniformed forces, immigrant workers among others. Priority populations may
be at high risk of HIV but do not have legal, socio-cultural issues that affect them
because of who they are, and are not stigmatized or discriminated although they may
have access issues that could arise from other environmental factors that surround them.
33
• Targeted services for KP/PP increase access/uptake to services and reduce stigma.
Innovative approaches/models have improved reach of these populations within their
communities and increased access and uptake of health services.
For detailed guidance on the provision of PrEP, please refer to the Technical Guidance on Pre-
Exposure Prophylaxis for Persons at High Risk of HIV in Uganda, 2016.
1.3 Structural interventions
Instructions for Facilitators:
1. Brainstorm on structural drivers of HIV infection

2. Briefly discuss structural interventions
3. Discuss Gender Based Violence
prevention interventions) or Page 48 of the Consolidated Guidelines and tell you what
structural prevention services they offer for prevention of HIV transmission and what are
the processes in offering them? Write on the flip chart
Note to facilitator
Structural prevention services aim to address: Gender based violence, negative social cultural
practices such as widow inheritance, female genital mutilation that increases vulnerability to HIV
transmission, the need for social support and protection by linking people to alternative livelihood
programs such income generating activities and senior citizen scheme.
Structural interventions are approaches that reduce HIV risk at the individual or group level.
These are elements outside individual knowledge or awareness that have the potential to
influence peoples’ vulnerability to HIV infection. The interventions focus on addressing
social (stigma, gender inequality), cultural (religious beliefs), economic (lack of livelihood
opportunities) and legal- political (laws and regulation) factors. This section will focus on
interventions to address gender-based violence within health care settings.
1.3.1 Prevention and management of Gender-based violence
➢ Step 10: Explain to participants that:
Gender-based violence (GBV) has the potential to increase the risk of acquiring HIV. GBV
can negatively affect retention and ART adherence of clients leading to poor treatment
outcomes. Screening for, preventing and responding to GBV promptly will reduce the risk
of HIV infection and may improve treatment outcomes of those at risk for GBV.
34
➢ Step 11: Introduce the screening tool on page 10 of the Desk Job Aid (Prevention and
management of GBV) or Page 48 of the Consolidated Guidelines and highlight the
following:
• Service delivery points recommended for GBV screening include: OPD, ART clinic,
ANC/MCH and IPD.
• Every site providing GBV services and post-violence care should have the following:
o A written algorithm with steps for active case identification and follow-up.
o At least one staff member trained to provide post-violence care.
o A focal point for GBV services at each facility.
o Provision of PEP.
The table below describes the minimum package of post-rape care services and child protection
after GBV.
Table 6: Minimum package for post-rape care services

Health facilities should provide the following clinical services as part of post-rape care:
Initial assessment of the client
• Rapid HIV testing and referral to care and treatment if HIV-positive
• Post-exposure prophylaxis (PEP) for HIV if tested negative
• STI screening/testing and treatment
• Forensic interviews and examinations
• Emergency contraception, if person reached within the first 72 hours
• Counselling
The health facility should also identify, refer and link clients to non-clinical services:
Some of the services include the following:
• Long term psycho-social support.
• Legal counselling.
• Police (investigations, restraining orders).
• Child protection services (e.g. emergency out of family care, reintegration into family
care when possible, permanent options when reintegration into family impossible).
• Economic empowerment.
• Emergency shelters.
• Long-term case management.
Reporting:
• Health facilities should use HMIS 105 to report GBV
35
MODULE 2. HIV Testing Services
Introduction: HIV testing is the entry point to HIV prevention, care, treatment and support
services. The aim of HIV Testing Services (HTS) is to diagnose HIV early and correctly to ensure
early access to prevention, treatment and support services.
By 2016, only 78% of the estimated 1.3 million HIV-positive persons in Uganda knew their HIV
serostatus, and 93% of these were receiving antiretroviral treatment (UPHIA, 2016). To improve
access and efficiency, HIV testing services (HTS) should be made available to all persons at risk
of HIV infection using cost-effective and high-impact approaches.
Proposed Time: 2 hours and 30 minutes
Key Questions:
1. What are HIV Testing Services?
2. What are the guiding principles for HTS?
3. What is the HTS Protocol?
4. When should retesting for HIV be done?
5. What are the changes in the HIV Testing Services Algorithm?
6. What is Assisted Partner Notification?
7. What steps are involved Assisted Partner Notification?
8. What is HIV Self-Testing?
9. What processes are involved in HIV Linkage?
Note to facilitator
The focus of this session is to outline the steps of delivery of HTS. The presentation is
designed to be interactive and to get participants to practice how to use the desk job aid on
preventing HIV transmission.
Materials Needed:
• Desk Job Aid
• HIV Test kits
Methods: Brainstorming, presentation using the facilitator’s flip chart, exercise, Q/A session.
36
2.1 What are HIV Testing Services?

➢ Step 1: Present the HIV Testing Services. Clarify as needed.
HTS delivery includes a range of activities and services that are described in the pathway on page
11 of the Desk Job Aid (HIV testing services) or Page 20 of the Consolidated Guidelines.
2.2 What are the Guiding Principles for HIV Testing Services (HTS)?

➢ Step 2: Ask participants to turn to page 12 of the Desk Job Aid (Guiding principles of
HTS) or Page 20 of the Consolidated Guidelines and describe the guiding principles of
HTS. Write on the flip chart. Ensure all the 5Cs listed below are mentioned. Clarify as
needed.
Guiding Principles for HIV Testing Services (HTS)
HTS delivery shall be non-discriminatory and offered using a Public Health approach that
observes the 5Cs (Confidentiality, Consent, Counselling, Correct test result and Connection to
appropriate services) irrespective of HTS approach. These principles are described below with
emphasis on newer HTS approaches.
• Consent: All persons 12 years and above should consent to HTS on their own. In situations
where consent cannot be obtained, the parent or guardian (of a child), next of kin, or legally
authorized person should consent. Verbal consent is sufficient for all HTS approaches
including HIVST.
• Confidentiality: All providers should ensure privacy during HTS provision. All information
discussed with clients should not be disclosed to another person without the client’s consent.
Confidentiality in the HIV Self- testing (HIVST) context should be maintained around the
distribution of HIV self-test kits, testing and shared HIV self-test result.
• Counseling: All persons accessing HTS should be provided with quality counseling before
and after testing as per the approved HTS protocol. Adequate information before and after
the HIVST should be made available to individuals through health worker demonstrations,
instructional/demonstration videos and print material among others.
• Correct test result: HTS providers should adhere to the national testing algorithm and must
follow the Standard Operating Procedure (SOP) for HIV testing to ensure that clients receive
correct HIV test results. Adequate and clear instructions with graphic illustrations on how to
conduct HIVST should be provided with the test kits to ensure a person can ably follow the
correct procedure to obtain accurate results.
37
• Connection to care: Providers should link HTS clients to appropriate HIV prevention,
treatment, care and support services. All clients seeking HIVST should be linked to HIV post-
test services based on outcome of the test. For those with HIV negative HIVST, link HIV
prevention services. Individuals whose HIV self-test results are reactive/Positive should be advised
on further HIV testing for diagnosis at the nearest health facility and if found to be HIV positive
should be linked to HIV treatment services. Information on linkage including a helpline for
any additional support should be provided.
2.3 What are the HTS Protocol?

➢ Step 3: Ask the participants to turn to page 14 of the Desk Job Aid (HIV Testing services
protocol) or Page 26 of the Consolidated Guidelines and describe the steps they follow
when providing HTS services.
Write the responses on the flip chart and clarify by going through the table below
HIV Testing Services Protocol
HTS service provision should follow the steps described below.
Table 7: HIV testing provision steps/protocol

Activity Description
1. Pre-test information Help the client/patient to know the ways HIV is transmitted and
and counseling basic HIV preventive measures, benefits of HIV testing, possible
test results and services available, consent and confidentiality,
individual risk assessment, and fill the HTS card. Allow
clients/patients to ask questions.
2. Risk assessment Carry out risk screening to assess for risk factors for HIV
including: being in a sexual relationship with multiple concurrent
sexual partners, belonging to a key or priority population, being a
sexual contact to an index client and being a biological child of an
HIV positive client.
3. HIV testing Will be done using blood. For those below 18 months, a DNA PCR
test will be done and those above 18 months an antibody test will
be done. Refer to the HIV testing algorithms for the different age
groups.
38
Activity Description
4. Post-test counseling Assess readiness to receive results. Give results simply. Address
(individual/couple) concerns, disclosure, and partner testing and risk reduction.
Provide information about basic HIV care and ART care; complete
the HTS card and HTS register.
5. Linkage to HIV Provide information about available prevention, treatment, Care

Prevention, and support services. For HIV positive individuals fill the
Treatment, Care and triplicate referral form and complete Linkage and Pre-ART
support Services Register. For Negative individuals refer for appropriate HIV
prevention services.
2.4 Targeted HIV testing

Instructions for facilitators
➢ Step 4: Give the participants the following definition of Targeted HIV testing:
Targeted HIV testing is the process in which HTS is focused on an individual or group of
individuals who are at high risk of HIV acquisition. Targeted HIV testing requires HTS providers
to follow a set criterion to determine eligibility of an individual or groups of individuals before
HTS is provided.
Make a comparison with routine HTS:

Routine HTS entails systematically offering an HIV test to patients seeking health care regardless
of known risk factors.
Highlight the reasons for this approach to testing:

88% PLHIV have been identified in Uganda, which makes it difficult to identify the undiagnosed
PLHIV with general population approaches.
Highlight the benefits of Targeted HIV testing

• Early identification for population groups with high incidence
• Maximizes use of testing resources
• Allows health facilities to focus their activities on higher risk populations
• Yields a higher positivity rate than routine or standard testing
• Reduced workload from the already constrained health workforce
39
Ask the participants to turn to page 15 of the Desk Job Aid (Targeted HIV testing) or Page 21 of
the Consolidated Guidelines and discuss the risk factors that drive the HIV epidemic:
• Being in a sexual relationship with multiple concurrent partners
• Belonging to a key or priority population
• Being a sexual contact to an index client
• Being a biological child to an HIV positive client
• Not knowing your Partner’s status
• Being in discordant relationship
HTS therefore needs to focus on such people who are at high risk of being HIV positive.
Ask the participants for examples of targeted HIV testing approaches they have used, list the
answers on a flip chart and supplement with the examples below:
• Index client Testing (APN, Social Networks Testing
• HIV Self Testing (HIVST) through ‘’focussed’’ distribution
2.5 HIV Screening tools

➢ Step 5: Ask participants to turn to Page 16 of the Desk Job Aid (HIV Testing Eligibility
Screening Tool for children and adolescents with unknown HIV status -18 months to
14 years) or Pages 26-29 of the Consolidated Guidelines and review the purpose,
applicability, procedures and instructions below for using the tool.
• Purpose: The tool guide describes how to use the HIV testing eligibility screening tool and
job aid.
• Applicability: This tool guide is applicable to all personnel involved in screening children
and adolescents aged 18 months14 years for eligibility to test for HIV.
• Procedure and instruction: The eligibility screening tool will be administered directly to
children and adolescents aged 12 years and above and to caregivers if children are aged
below 12 years. Please see the following instructions:
o Create a rapport with the child/adolescent and caregiver.
o Assure confidentiality of all information being shared during the process of
eligibility screening.
o Be alert in observing both verbal and non-verbal communication from the
child/adolescent and/or caregiver during the screening. Interject when necessary to
confirm they are okay.
o Clarify questions when asked or if something is unclear to the child/adolescent
and/or the parent/caregiver.
o Be empathetic.
40
➢ Step 6: Explain how to determine the child’s HIV status using the diagram below and
how to determine which child should be screened with the Eligibility tool.
➢ Step 7: Demonstrate how to screen with the eligibility tool using the following screening
questions for all children of unknown HIV status.
Table 8: HTS Screening questions for children and adolescents

No Screening Question Guidance
1 Is the child’s mother Ask the mother whether she knows her current HIV status. If the
HIV positive? mother is not present, ask if the child or caregiver knows the HIV
status of the child's mother. The response may be ‘Yes’ or ‘No.’ If
the mother’s HIV status is known, ask if positive or negative. If
the mother’s HIV status is positive, test the child for HIV. If the
mother’s HIV status is negative or not known, continue to ask
questions 2-6 as shown below.
2 Has the child/have The answer to this question is ‘Yes’ if there has been any change
you been sick in the in the health condition, even if it is relatively minor. Ask if the
last three months? child received medication or made a clinic visit in the last 3
months, or if they were bedridden or not playing.
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No Screening Question Guidance
3 Has the child/have You may need to ask this question in two parts: 1) If there was
you had recurring any skin problem (e.g., rash, itching and sores) and 2) If these
skin problems? were recurrent. Observe the child for any skin rash or scars
suggestive of a previously treated skin rash. If child/caregiver
reports 1 or 2 isolated incidents of a skin problem that
disappeared on its own or with treatment, select ‘No’ to this
question.
4 Has the child/have Weight loss may not be easy to determine. Use different
you lost weight in the examples to describe weight loss, such as a decrease in body size,
last few months? muscles, and/or loose or sagging clothes. Choose either ‘Yes’ or
‘No’ depending on whether the child has lost weight in the last 3
months. If the respondent is ‘Not sure’, the answer is likely ‘No’.
5 Has the child/have Establish if the child has ever had or been treated for TB. Select
you ever had TB? ‘Yes’ if child has ever been diagnosed or treated for TB. Select
‘No’ if TB was suspected but not confirmed, or a persistent cough
is reported, or if child reports that ‘I think I was treated for TB,
but not sure’, or if the caregiver reports this on behalf of the child.
6 Is the child/are you A child or caregiver may not easily be able to tell what growing
growing well? well means. To assess if a child is growing well, ask if the child’s
height, weight or milestones compare with those of other
children in the same class or of the same age or not.
Select children that should be tested: For each screening question on the right, a “YES” response
for the first four questions and “NO” for the last question are shaded in gray because of their
significance in determining if a child should be tested.
• If the answer to the question, “Is the child’s mother HIV-positive?” is ‘Yes’, test the child
for HIV.
• If the answer to the question, “Is the child’s mother HIV-positive?” is ‘No’ or ‘I don’t
know’, ask the set of 5 questions to the right.
If 2 or more responses to the 5 questions on the right shaded in gray are selected, test the child
for HIV.
➢ Step 8: Ask the participants to turn to Page 17 of the Desk Job Aid (HIV testing Screening
Tool for adults) and briefly go through the screening tool for adults.
42
2.6 HIV Testing Services Algorithm
➢ Step 9: Ask participants to turn to page 18 (Testing algorithm for HIV Exposed Infants
<18 months of age) and page 19 (The HIV Testing Algorithm for Persons Aged 18
Months and Above) of the Desk Job Aid or Pages 30 and 33 of the Consolidated
Guidelines and describe the steps undertaken when carrying out an HIV test for persons
aged <18 months and aged 18 months and above. Clarify by going through the algorithms.
Show participants how the kits look like.
Note: if the child is still breastfeeding at 18 months or above and the HIV test is negative, a final
test should be done 3 months after the child stops breastfeeding
Resolving inconclusive HIV Test Results following a first Inconclusive result
For clients whose results are inconclusive after the recommended 14 days following a first
inconclusive test result, a sample should be collected, labelled “2nd INC” and sent to the national
reference laboratory (CPHL) for testing. A result will be sent back as either POSITIVE or
NEGATIVE. Sample and result transportation will utilize the existing hub system.
2.6.1 MCH HIV and Syphilis Testing Algorithm

➢ Step 10: Introduce the session by stating that: Within MCH settings, the HIV /syphilis
duo test will be used as screening with Stat-Pak as confirmatory.
Women who are already known HIV positive will still need to test for Syphilis using the single
rapid syphilis tests.
▪ Need to take advantage of Duo kit for syphilis testing and treatment scale-up.
▪ For those where HIV status cannot be ascertained on the MCH algorithm, re-testing
should be done by laboratory using the National adult HTS algorithm (i.e. Determine,
Stat-Pak, SD Bio-line). Very few mothers will require the tie breaker.
▪ APN should be provided for those testing positive for HIV or Syphilis and encourage
partner testing for negative.
This same algorithm will be used for re-test for verification
➢ Step 11: Ask participants to turn to page 21 of the Desk Job Aid (HIV Testing Algorithm
using the HIV-Syphilis Duo Kit in MCH Settings) or Page 32 of the Consolidated
Guidelines and describe the steps undertaken when carrying out HIV testing in MCH
settings. Show participants how the kits look like.
43
Emphasize the following:
o Within MCH settings, the HIV /syphilis duo test will be used as screening test with
Stat-pak as confirmatory for women who previously tested negative for HIV and
syphilis negative or those whose status is unknown.
o Women whose HIV positive status is already known should be tested for Syphilis
using the single rapid syphilis tests.
o Women who have tested positive for syphilis and with evidence of having been
treated for syphilis within a year should be tested using the algorithm above.
2.6.2 When should re-testing for HIV be done?

➢ Step 12: Ask participants to turn to pages 22 and 23 of the Desk Job Aid (When to re-test
individuals with previous negative results) or Page 34 of the Consolidated Guidelines
and describe what categories of people need to be retested for HIV and when the HIV re-
testing should be done. Clarify by going through the table.
2.7 What is Assisted Partner Notification (APN)?

➢ Step 13: Ask participants, what their understanding of APN is and the populations
eligible for APN.
Write the responses on the flip chart. Clarify by going through page 24 of the Desk Job Aid
(Assisted partner notification) or Page 25 of the Consolidated Guidelines.
Assisted Partner Notification (APN) is a process through which index clients (i.e., infected
persons who are eligible for APN services) are interviewed to elicit information about their sexual
partners, who can then be confidentially notified of their possible exposure or potential risk, and
offered HIV testing services.
Eligible Populations for APN Services include:
1. New HIV-positive
2. On ART, not virally suppressed
3. On ART with new risk (STI, new sexual partner)
4. Pre-ART
44
2.6.2 What are the steps in Assisted Partner Notification (APN)?
➢ Step 14: Ask participants to use the APN FLOW chart on page 25 of the Desk Job Aid
(APN flow chart) to discuss the steps in APN.
➢ Step 15: For the following section, distribute printouts of the Index client interview, the
Sample Consent Form for APN, the Sample Phone Call script for APN and a Sample Field
Visit script for APN. Turn to page 26 of the Desk Job Aid (Index client interview format)
for the interview steps. Guide the participants through a practical session of role plays of
the APN Procedures including the Index client interview, completion of the Sample
Consent Form for APN, Sample Phone Call script for APN and a sample Field Visit script
for APN. Refer to the guide below:
APN Procedure
1) How to introduce APN to index clients:

Inform the index client that:
• The clinic is offering services for identified HIV-positive persons to assist the client
to contact their sexual partners so that these partners can learn their HIV status.
• The service is offered because we know disclosure of HIV status to partners can
be difficult.
2) Index client interview format (Role play for between and APN Counselor and a client)
Introduction:
• Give your name and describe your role
• Confirm the client’s identity: “I need to make sure I’m talking to the correct person. Please tell
me your name and birth date.”
• State the purpose of the interview: “I’m here to discuss with you more about your HIV status
and respond to any questions you may have.”
• Explain Confidentiality: “Everything we discuss today is private and will not be shared with
anyone who is not involved in your medical treatment.”
• Obtain client’s consent for APN: Inform index client of purpose of APN and benefits of
ensuring that all partners get tested for HIV:
o HIV-Negative partners can access HIV prevention services including condoms, PrEP and
male circumcision.
o HIV-Positive partners can start on HIV treatment to keep them healthy and reduce
chances of passing HIV to other sexual partners and/or children.
• Ask for consent to notify partners: “I would like to seek your consent to access a service for
identified HIV-positive persons. We will ask you for information about you and your sexual
partner (s). Knowing yours and your partners’ HIV status is beneficial for you and your partners’
45
health. You are free to say no and you will not be reprimanded. Are you ready to enroll in the
service?”
• Document consent and file consent form in index client’s HIV care card or file separately
with APN documents if client enrolled at another health facility.
Client assessment:
• Understanding of HIV
- Ask “What does HIV mean to you?” Asking about the client’s understanding
of HIV creates a foundation for the interview. Practice active listening and
ask open-ending questions to clarify any point.
• Client Concerns
- Ask “What concerns do you have?”
- Share with the client: “What we’re going to talk about is especially important
and will prevent spreading HIV. I am going ask personal and sexual questions, the
same questions I ask of everyone. If at any time you feel uncomfortable, please let
me know”
• HIV Knowledge
- Ask “What have you heard about HIV?”
- Share with the client: How HIV is spread; Importance of treatment; How
others can HIV and not know it.
• Social History
- Ask about the client’s: age, date of birth, marital Status.
- Determine the number of partners the client has had in the past 12 months
- Ask about partners in different ways to confirm the number of partners;
Sex without condoms; sex for favors, gifts, money; sex with HIV+ person
• Medical History
- Ask about chronic medical diseases and history of hospitalization
APN intervention
• Partner Elicitation: Partner elicitation is the process of asking clients to provide names
and contact information of their partners.
o Obtain name and contact information. Ask the client to list the names of all persons
they have had sex with, including people they may have only had sex with one
time in past twelve months.
o If there are also persons the client has shared needles with, ask for their names
(applies only to social contacts of people who inject drugs (PWIDs)).
o Ask for the names any child(ren) who may need an HIV test but these will not be
recorded in the APN register.
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• Risk Reduction
o Discuss the client’s specific HIV concerns
o Emphasize using condoms with HIV-negative partners to prevent spread
o Ask the client to plan ways he/she will reduce risk
o Convey confidence that the client can complete the plan and protect others from
HIV
o Provide needed referrals for other support and health services
• Partner Notification Plan
o Help the client make a notification plan for each partner, including which
notification strategy is best.
o The client’s relationship, comfort with and knowledge about each partner may
differ.
o You must take the time to educate the client about the options and assist the client
to make a plan in detail.
• The client may choose different notification options for different partners.
3) Sample consent form for APN (Role play between APN Counselor and client)
Dear Sir/Madam my name is ____________ a health worker at _____________ Health
facility. I would like to invite you to access a service for identified HIV-positive persons.
We will ask you for information about you and your sexual partner (s). Knowing yours
and your partners’ HIV status is beneficial for you and your partners’ health. If you agree
we will contact your sexual partners for HIV testing. All the information shared with us
will be kept confidential and we will not reveal your identity to any of your named sexual
partners. If you have any questions concerning this service, feel free to ask and I will do
my best to answer you.
You may sign below to indicate your willingness to access this service.
Client Name ____________ Health Worker Name _________________
Signature or thumb print ________Signature or thumb print ___________
Date___________ Date__________________________
4) Sample phone call script for APN (Role play between APN Counselor and Client’s
partner)
Good day. My name is ___________________________ and I am a health worker at
[Facility Name]______________________.
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Am I speaking with __partner’s name______________?
[IF NO]: Is __partner’s name______________ available?
[If partner is not available]: Thanks. I’ll try back later.
[If YES]: To confirm I am talking with the right person, can you please tell me your age?
[Confirm age provided is same or within range of age reported by index client]
[If age is not same]: I’d like to plan a time to meet you in person. When is a convenient
time you can come to the ____________facility?
[If identify confirmed]: I have some important information for you. Are you in a private
location/place? Is now a good time to talk?
[If NO]: When would it be a better time for me to call you?
[If YES]: I am a health worker and everything we talk about is private. I am calling
because someone who cares about you gave me your telephone contact so that I give you
this health-related information. You might have been exposed to HIV. It is therefore
important that you get tested for HIV right away so that you can learn your HIV status.
HIV treatment is free of charge and can prevent serious illness.
We would prefer that you come to the ____________facility and discuss. HIV Testing
Services are available Monday – Friday from 8:30 in the morning until 5:00 in the evening.
Alternatively, we can send a health worker to your home for an HIV test. Which option
would you prefer?
When you come to _______________ health facility, ask for ________________(say your
names), I will be available.
Please feel free to reach me on ____________(say your telephone contact) or my colleague
_________ (say names and telephone contact) at ___________ health facility in case I am
not around.
[FACILITY TEST]: What day would you like to come in for an HIV test?
[HOME TEST]: What date and time would you prefer for the health worker to come to
your home for an HIV test?
Thank the client for his or her time with you.
5) APN home visit guide

Before leaving for a home or work visit:
• Review the record and memorize partner’s information and precise objectives of the visit
• Store confidential information in a secure place
• Become familiar with the environment and anticipate obstacles
Locate the partner, confirm identity, seek private setting, then notify
Use Sample Field Visit Script below:
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SAMPLE FIELD VISIT SCRIPT FOR APN (Role play between APN Counselor and Client’s
partner)
Field Visit at home or work
Good day. My name is ___________________________ from [Facility Name]______________.
I am looking for [partner’s name]. Is he/she around?
[IF NOT]: Ok, thanks. Do you know when he/she will be back?
[Once the partner is in front of you]: Is there a private place that we can talk?
[Once you are in private area where others cannot overhear]: To confirm I am talking with the
right person, can you tell me your age? [Confirm age provided is same or within range of age
reported by index client]
[Once identity is confirmed]: My job to talk with people who have been exposed to HIV and
other infections. Everything we talk about is private. I am here because someone who is
concerned with your life informed me that you may have been exposed to HIV. It is important
that you get tested for HIV right away so you can learn your status. HIV Treatment is free of
charge and can prevent serious illness.
• [For community HIV testing, preferred, if available]: I can test you for HIV right
now. Shall we get started?
• [For escorted HIV testing, preferred]: We can go together right now to [Name of
health facility] for HIV testing. Shall we go?
• [For referral for HIV testing, last alternative]: I can refer you to [Name of health
facility] for an HIV test as soon as you can go. When can you make time to come to
the clinic? Its important you get tested as soon as possible. HIV testing services are
available Monday – Friday from 8:30 in the morning until 5:00 in the evening.
Additional message of confidentiality assurance
• Reassure the partner that you will not disclose their results to anyone and that you
will not tell them who provided their contacts.
• In case the partner also tests positive, we shall request he/she provide sexual
contacts and help the partner start HIV treatment right away.
2.8 What is HIV Self-Testing (HIVST)?

➢ Step 16: Ask participants, what their understanding of HIVST is
Write the responses on the flip chart. Clarify by going through page 35 and review other HIVST
content on pages 27-35 of the Desk Job Aid or Page 25 of the Consolidated Guidelines.
49
2.8.1 What processes are involved in HIV linkage?

➢ Step 17: Ask participants, what their understanding of “Linkage to HIV care and
treatment” is.
Write the responses on the flip chart. Clarify by reviewing the flow chart on page 36 of the Desk
Job Aid (Linkage to HIV care and treatment services) or Page 35 of the Consolidated Guidelines.
2.8.2 Steps to facilitate intra-facility linkage

➢ Step 18: Ask participants to turn to page 37 of the Desk Job Aid (Internal facility linkage
for HIV-positive individuals) or Page 36 of the Consolidated Guidelines and describe in
detail the steps involved in tracking a newly-diagnosed HIV-positive patient to ensure
linkage to care at the facility they tested from. Clarify the process as may be appropriate.
2.8.3 Steps to inter-facility & community -facility linkage

➢ Step 19: Ask participants to turn to pages 38 and 39 of the Desk Job Aid or Pages 37-38
of the Consolidated Guidelines to describe in detail the steps involved in tracking a newly-
diagnosed HIV-positive patient to ensure linkage to care in the following scenario:
o Describe the process of linking a client to HIV care at a different facility from the
one they tested from.
o Describe the process of linking a client that tested in the community to HIV care
at a health facility
Clarify the process as may be appropriate.
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MODULE 3: Psychosocial Care and Adherence Support for PLHIV
Key Questions:
1. What is Psychosocial Support in the context of care for PLHIV?
2. What are some of service packages for managing psychosocial issues in the context of HIV
and AIDS?
3. What are some of the assessment tools in PSS services delivery?
4. What is IAC and its benefits in HIV care?
5. How do we provide PSS and IAC using the 5As Approach?
Materials Needed:
• Desk Job Aid per pair of participants
• Consolidated Policy Guidelines (5 hard copies per class)
• Tools for Screening PSS Issues among PLHIV (5 copies per tool class)
- Screening for depression amongst PLHIV using PHQ-2
- Screening for GBV among PLHIV
- HEADSS tool for screening among Adolescents
- Checklist for OVC Screening for Vulnerability at the Facility
Methods: Presentation, brainstorming, Q/A with desk job aid

Introduction to the Module:
With implementation of test and treat, the need for psychosocial care and support is more critical
to enhance adherence, retention and viral suppression. People living with and affected by HIV
and AIDS have numerous psychosocial problems and needs that require identification and
redress holistically, to help them maintain psychosocial wellbeing. Psychological and social needs
vary, depending on sero-status, stage of disease, prognosis and other factors. Providing
psychosocial support can bring about behavioural changes in support of prevention, care, and
treatment among people living with HIV, their partners and families. This module will focus on
the key interventions to guide provision of psychosocial care and adherence support to the
different sub-populations amongst people living with HIV and AIDS (PLHIV).
51
SESSION 1: Psychosocial Support for PLHIV
3.1 What is psychosocial support?

➢ Step 1: Ask participants to brainstorm on the meaning of psychosocial support in the

context of care to PLHIV. Solicit and record a few responses on flipchart paper.
➢ Step 2: Display and discuss the meaning of PSS. Ask one member to read loud the
definition.
• Emphasize to participants that PSS services should be provided by a multidisciplinary

team. Refer participants to page 42 of the Desk Job Aid (Who should provide PSS) or
Page 122 of the Consolidated Guidelines.
• Tell participants that the guidelines recommend designation of a PSS Focal Person at
facility level for each ART site. Explain the PSS focal person’s roles as outlined below:
The PSS facility focal person will ensure that:

➢ PSS services are well coordinated within the facility and community
➢ A strong and effective referral and linkage system is established and maintained
➢ Documentation of PSS services is accurately done
➢ Routine reporting for PSS services is done.
3.1.1 Discuss PSS minimum Service standards
➢ Step 1: Present the minimum service standards for PSS
PSS minimum Service standards
• S1: All health facilities should provide a conducive environment both physical and social for
providing psychosocial support
• S2: All PSS service providers should have the competences to deliver quality PSS services
• S3: All health care providers should routinely assess clients for PSS needs and provide appropriate
care and support to PLHIV as an integral component of comprehensive HIV prevention, care,
treatment and support
• S4: All health facilities should establish and maintain an effective referral and linkage system for
provision of a minimum package of PSS services for PLHIV
• S5: All Health Facilities shall use data collected to improve the quality of PSS services of HIV care
services.
52
➢ Step 2: Discuss how the above standards can be achieved using the table below
Table 9: Standards for providing Pyschosocial Support Services

Standard What should be done
S1: All health • Create space within the health facility to provide room for screening and
facilities should provision of individual and group psychosocial support
provide a • Ensure privacy
conducive • Arrange the PSS service space to suit different population categories
environment both (adolescents, men, children, women)
physical and social • Organize the HIV/ART care points client flow to include psychosocial
for providing support
psychosocial • Ensure a safe and confidential filing, record keeping and storage system
support • Provide relevant supplies and logistics for providing PSS (play materials,
job aids, edutainment etc)
S2: All PSS service • The health facility management should ensure that:
providers should o All PSS service providers are trained in PSS according to national
have the standards
competences to o Health workers are mentored and supervised regularly to keep
deliver quality PSS their skills updated
services o Health workers have the required job-aids and tools to enable
them provide PSS to all categories of populations including
children, adolescents, pregnant women, and key populations
• PSS should be provided following MOH approved standard approaches
for different sub-populations
o Determine the relevant approaches for providing PSS (Individual,
couple or group approach).
o Create or make referrals to peer support groups/clubs for
provision of PSS
o Integrate PSS services in all health-related plans and routine
health care services
o Offer PSS services in community settings following a targeted
approach especially for priority populations.
• Identify and support a focal person to oversee PSS service provision
S3: All health care The health workers should assess clients PSS needs using standard screening
providers should and assessment tools. These include:
routinely assess
• PHQ-2 Depression screening tool
clients for PSS
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needs and provide • GBV screening tool

appropriate care • HEADSS tool
and support to • OVC Screening tool
PLHIV as an
integral
component of
comprehensive
HIV prevention,
care, treatment
and support
S4: All health • Establish intra and inter facility referral and linkage systems for
facilities should psychosocial issues which the provider may not have capacity to
establish and address.
maintain an • Establish referral network from the facility to other community
effective referral services.
and linkage system • Ensure availability of a service directory for different PSS services
for provision of a within the health facility catchment area. The directory should specify
minimum package name of provider, services offered, contact person, address of
of PSS services for provider, costs (if involved) and service time.
PLHIV • The PSS focal person remains the designated focal person for referrals
and linkages.
• Avail and mentor PSS providers on the use of approved
documentation tools (Community-facility referral and Linkage
register and the Comprehensive HIV Referral Form)
• Routinely document all facility-community and community-facility
referrals and feedback in approved tools.
• Establish and strengthen feedback mechanisms (phone calls, physical
follow up, etc)
S5: All health • Document and report PSS services using MOH approved tools. Key tools
facilities shall use include HIV Care/ART Card, ART Register, Linkage and Referral
data collected to Register, Referral and Linkage form, Peer Psychosocial Support Tracking
improve the Log and HMIS 106a.
quality of PSS • Develop SOPs to guide documentation and reporting of PSS services.
• Conduct periodic internal data review to ensure data quality.
54
services of HIV • Utilize PSS data for continuous quality improvement.

care services
➢ Step 3: Allow time for questions and observations to ensure comprehension by

participants.
3.1.2 Describing the Comprehensive Service Package for Psychosocial Care and Support for
PLHIV.
➢ Step 1: Ask participants to list the components of PSS that they know of
➢ Step 2: Acknowledge responses
➢ Step 3: Ask participants to turn to page 41 of the Desk Job Aid (Comprehensive service
package for providing psychosocial care and support for PLHIV) or Page 123 of the
Consolidated Guidelines and lead a discussion on the Comprehensive service package for
providing psychosocial care and support for PLHIV.
➢ Step 4: Discuss the PSS Service Package for the different sub-populations amongst PLHIV.
Refer participants to pages (43-48) of the Desk Job Aid
3.1.3 Screening for psychosocial needs among PLHIV

➢ Step 1: Introduce session by explaining the meaning of the concept of “Psychosocial
Screening” and the importance of PSS screening.
Psychosocial Screening: An in-depth evaluation of the psychosocial dynamics (mental status,

social status and functional capacity within the community) of a person that affect the person
and his/her environment. It takes account of the individual’s perception of self and his/her
ability to function in the community.
➢ Step 2: Ask participants to mention why PSS screening is important. Discuss responses
to bring out the importance of PSS screening using the notes below:
The Importance of PSS Screening

• To identify areas that promotes and/or inhibits maximum independence.
55
• To develop an effective treatment plan that promotes maximum independence and
functioning.
• To assess and manage common PSS problems amongst PLHIV particularly
depression, which results into poor treatment outcomes due to poor ART adherence.
➢ Step 3: Discuss tools for screening various psychosocial issues.

Emphasize that the existing tools for adherence assessment remain in use and other social issues
should be identified through the provider-client interaction. Tools for screening unique issues
will be discussed in this session.
➢ Step 4: Ask participants to turn to pages 49-51 of the Desk Job Aid or Annex 10 of the
Consolidated Guidelines and lead the discussion on how to use the HEADSS Tool.
➢ Step 5: Answer participants’ questions at every segment of the HEADSS Tool.
➢ Step 6: Ask participants to turn to page 52 of the Desk Job Aid (Screening for depression
amongst PLHIV using PHQ-2) or Page 119 and Annex 12 of the Consolidated Guidelines
and lead the discussion on how to screen for depression. Answer any questions that arise.
➢ Step 7: Ask participants to turn to page 53 of the Desk Job Aid (Checklist for OVC
screening for vulnerability at the facility) or Page 134 of the Consolidated Guidelines
and lead the discussion on how to screen for vulnerability. Answer any questions that
arise.
Note to facilitators
Emphasize that all children in care MUST be screened for vulnerability and linked to OVC
programs within the catchment of the health facility.
➢ Step 8: Ask participants to turn to page 54 of the Job Aid (Screening for GBV among
PLHIV) or Page 49 of the Consolidated Guidelines and discuss how to screen for GBV
among PLHIV with the participants. Answer any questions that arise.
➢ Step 9: Allow a few minutes for participants to share their experiences, concerns and
questions on using the tools to screen for PSS problems
3.1.4 Psychosocial and Counselling Framework among PLHIV
➢ Step 1: Ask participants to briefly describe the process of providing counselling and
psychosocial support
➢ Step 2: Acknowledge the responses and emphasize that MOH adopted the 5As
counselling and psychosocial Framework to guide provision of standardised PSS care for
PLHIV.
56
Emphasize that this framework should be used to address any PSS issues that clients present.
➢ Step 3: Display the 5A Counselling and Psychosocial Framework

➢ Step 4: Ask participants to turn to page 55 of the Desk Job Aid (5As Psychosocial and
Counseling Framework) or Page 126 of the Consolidated Guidelines so that they follow
the discussion
➢ Step 5: Discuss every segment of the framework and answer any questions that arise.
➢ Step 6: Summarize key messages.
SESSION 2: Adherence Preparation, Monitoring and Support
Key Questions:
1. How do we conduct Pre-ART adherence counseling?
2. How do we determine readiness for ART?
3. What is the importance of disclosure in enhancing adherence?
4. What are the key aspects of ongoing adherence counseling?
5. What are the effective methods and tools used to monitor and enhance adherence?
6. How do we document adherence counseling and assessment on the HIV care card?
Materials needed:
• Desk job aid per pair of participants
• Worksheet with questions for health workers
• HIV care card for each participant
Instructions for facilitator: The focus of this session is to understand how to prepare patients for
ART, assess adherence to ART over time and provide ongoing adherence support. The session is
designed to be interactive and get participants to systematically prepare clients for adherence.
Note to facilitator
Remind participants it is recommended that ART is initiated at the earliest opportunity in

all people with confirmed HIV infection, regardless of clinical stage or CD4 cell count.
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Tell participants that different types of patients have unique needs and therefore the ART
preparation process is critical as well as ongoing counseling to ensure they adhere to the
medication.
3.2 Introduction to adherence
3.2.1 What is adherence?

➢ Step 1: Lead a discussion on the meaning of ‘adherence’ stressing the five “rights”. Make
sure participants understand and can name and describe each of the five “rights”
described below:
Five “Rights” of ARV adherence
ARV adherence means:
1. Taking the right medicine
2. In the right dose
3. At the right time
4. In the right way, and
5. At the right frequency
Adherence can also be described as the clients’ ability to follow a treatment plan by taking the
right medicine, in the right dose at the right time and in the right way. A client who adheres
demonstrates good self-care. Good adherence is required for all medicines, including
cotrimoxazole, anti-TB medicines and ARVs. It is an informed choice. Children and adolescents
should also participate in making their adherence plan.
3.2.2 Why is adherence important?

➢ Step 2: Lead a discussion on the benefits of good adherence and consequences of poor
adherence. Record participants’ responses and be sure to emphasize the following points.
Benefits of adherence include:

• Suppressing viral replication
• Improving immunological outcomes
• Improving clinical outcomes
• Decreasing the risk of developing ARV drug resistance
• Reducing the risk of transmitting HIV
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Consequences of non-adherence include:
• Incomplete viral suppression
• Continued destruction of the immune system and decrease of CD4 cell count
• Progression of disease (developing opportunistic infections)
• Emergence of resistant viral strains and HIV transmission
• Limited future drug options and higher costs for individual treatment
3.3 Preparing children, adolescents and adults for ART

➢ Step 3: Ask participants to describe the adherence preparation process for adults and
children in their facilities. The discussion should point out key aspects in adherence
preparation process including but not limited to:
o Assessment of clients’ basic knowledge about HIV and ARVs
o Use of the 5As to guide counselling
o Determining readiness to start ART
o Assessment for potential barriers
o Creating an adherence plan.
3.3.1 Counseling messages for patients to help them adhere to ART

➢ Step 4: Ask participants to turn to page 56-58 of the Desk Job Aid (Key messages during
pre-ART adherence counselling) and review the key messages to be delivered during
pre-ART and ongoing adherence counseling for children, adolescents, and adults.
Caregivers, children and adolescents should be educated on the following key areas:
3.3.2 Using the 5As to Guide the Delivery of Pre-ART Adherence Counseling

➢ Step 5: Ask participants to turn to page 59- 60 of the Desk Job Aid (5As for adherence
preparation support) or Page 126 of the Consolidated Guidelines and discuss the
components of each of the 5As and discuss how the 5As can help guide the delivery of
pre-ART adherence counseling and psychosocial support. Review the components of the
5As in the table below as needed.
Note to facilitator
The healthcare team should use the 5As principle for chronic care as a guide to offer pre-
ART adherence counseling and psychosocial support. The 5As are:
Assess, Advise, Agree, Assist and Arrange.
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3.3.3 Barriers to ART adherence

➢ Step 6: Discuss potential barriers to ART adherence for different populations. Ensure that
the discussion includes the points summarized in the table below. Emphasize that ART
initiation should not be unnecessarily delayed; however potential barriers should be
assessed and addressed before ART initiation. Continue with adherence counselling as
patient takes ARVs. Initiate ART for all children and eligible adults as soon as readiness
is determined.
Table 10: Barriers to adherence

Population Barriers
Infants and • Lack of a committed, involved and responsible caregiver
children • HIV infected caregiver/parent with ill-health/adherence/emotional
challenges
• Caregiver’s job obligations
• Child may refuse to take the medicine
• Multiple caregivers for the child
• Poor palatability of some medicines
• Difficulty in swallowing medicines
• High pill burden,
• Frequent dosing changes
• Limited choice of paediatric formulations
• Child abuse and neglect
• Stigma and discrimination
• Non-disclosure to the child and family members
Adolescents • Psychosocial issues such as peer pressure, the perceived need to
conform
• Inconsistent daily routine
• Abuse and neglect
• Left out of decisions and have limited opportunities to discuss their
concerns
• Limited availability of adolescent-specific treatment literacy and
adherence counselling tools
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Population Barriers
• For adolescents who are transitioning from paediatric to adolescent
care, additional challenges may include
o Assuming increased responsibility for their care
o Issues relating to disclosure to peers or partners
o Difficulties in navigating the healthcare system
• Lack of links between adult and paediatric services and inadequately
skilled health workers.
• The adolescent stages of growth and development
• Alcohol and substance abuse
•
Pregnant and • Pregnancy-related conditions such as nausea and vomiting may
breastfeeding negatively affect treatment adherence
women • Suboptimal understanding of HIV, ART, and eMTCT
• Lack of partner disclosure and support
• Fear of stigma and discrimination,
• Non-disclosure
• GBV
• Drug sharing
• Service delivery barriers including poor-quality clinical practices, gaps
in provider knowledge and training, poor access to services
Adults • Social barriers (e.g. long work schedules/job time/nature of Job)
• Forgetfulness
• Lack of trust in providers or medicines
• Lack of social support
• Non-disclosure
• Drug side effects
• Pill burden
• Inadequate information about ARVs
Key populations • Stigma and discrimination

• Provider attitude
• Nature of job/engagement
• High mobility
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Population Barriers
• GBV
• Lack of peer support
• Lack of knowledge by health workers of KPs
People with • Uncontrolled depressive symptoms
mental health • Forgetfulness
conditions and • Poor organization
substance abuse • Poor comprehension of treatment plans
3.3.4 Determining readiness for ART
Instructions to facilitators:
➢ Step 7: This session is about checking patient readiness to start ART. Ask participants to
discuss how to assess whether a patient is ready to start ART. Look for mention of the
following components of readiness in the discussion:
o Acceptance of HIV-positive status
o Patient/caregiver demonstrates good understanding/knowledge of HIV, ART and
adherence
o Commitment/consent to taking lifelong therapy
o Client has disclosed or has disclosure plan
o Client demonstrates willingness to keep clinic appointments
o Adherence support
o Adequate nutrition support
o For children, has a committed primary caregiver who is counselled
o Client/caregiver has an adherence plan
➢ Step 8: Next, review the ART Readiness Assessment Form on pages 61-62 of the Desk Job
Aid (ART Readiness Assessment Form) or Page 128 of the Consolidated Guidelines with
participants and ask participants to discuss how to use the ART Readiness Assessment
Form to determine if patients are ready to begin ART. Remind participants that proper
client counselling and education before the initiation of and during ART is vital for good
adherence.
3.3.5 Developing an ART Adherence Plan

➢ Step 10: Walk participants through the Checklist for developing an adherence plan on
page 63 of the Desk Job Aid or Page 127 of the Consolidated Guidelines which is a guide
to for developing an individual adherence plan for each patient.
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3.4 Monitoring adherence to ART
Introduction: Adherence to ART requires life-long assessment and monitoring and should be
part of each clinic visit, as factors that influence adherence are dynamic and require different
approaches to address them as they change over time. Adherence assessment should be
conducted on every clinic visit and ongoing adherence counselling offered. The purpose is to
identify patients who are having most difficulty with adhering to treatment so that more
adherence support can be provided.

➢ Step 11: Ask participants to discuss how to monitor adherence to ART. Have them turn
to page 64 of the Desk Job Aid (Monitoring adherence to ART) or Page 128 of the
Consolidated Guidelines. Make sure that all methods to assess adherence that are
recommended below are discussed.
o Viral Load Monitoring: Viral load monitoring is considered the gold standard for
monitoring adherence and confirming treatment response. All HIV-infected
patients should receive a viral load test 6 months after initiating treatment and
annually thereafter (every 6 months for children). Following an initial high viral
load (>1000 copies/mL), enhanced/intensive adherence counselling should be
carried out before conducting a second viral load test. Viral load monitoring will
be discussed in more detail in Module 4.
o Self-Reporting: Self-reporting is a rapid, inexpensive, easily carried out in clinical
settings and is frequently used in routine care. It involves asking questions
regarding missed doses to establish adherence. It is essential that these questions
be posed in as non-threatening and sensitive a way as possible. All patients,
especially adolescents should be encouraged to speak openly, and they should be
reassured that many people find it difficult to take all their medications.
➢ Step 12: Ask participants to review the four-question guide below for determining
adherence and reasons for not adhering to ART.
Table 11: Four question guide for reviewing an adherence plan

Question Client Response
1. How many times do you take drugs in a day?
2. What time do you take it?
3. How many doses have you missed in the past month?
4. What are the reasons for missing your drugs?
Note: At each clinic visit, assess and record the corresponding adherence codes on the HIV care card
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3.4.1 Pill counting
Introduction: This approach compares the actual to the expected consumption of ART since last
dispensed by the pharmacy. The effectiveness of pill counting is limited by the fact that patients
may discard tablets not taken before their routine clinic visit leading to overestimated adherence.
Pill count performs better when combined with self-reported adherence.

➢ Step 13: Ask participants to review the method for using pill-counts to determine
adherence levels.
Using pill counts to determine adherence levels

Ask clients/care givers to return with their pill packs/boxes at each visit with any pill balances.
Count the number of pills the patient has in the medicines bottle.
Determine the number of pills the patient should have taken since the last clinic visit.
Compute the percent adherence using the formula below:
𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑖𝑙𝑙𝑠 𝑡𝑎𝑘𝑒𝑛

% adherence= (𝑇𝑜𝑡𝑎𝑙 𝑛𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑝𝑖𝑙𝑙𝑠 𝑒𝑥𝑝𝑒𝑐𝑡𝑒𝑑 𝑡𝑜 ℎ𝑎𝑣𝑒 𝑏𝑒𝑒𝑛 𝑡𝑎𝑘𝑒𝑛 ) ∗ 100%
After computing % adherence to determine the adherence level, support the client
accordingly.
Note: At each clinic visit, assess and record the corresponding adherence codes on the HIV care card.
3.4.2 Determining adherence levels from self-report and pill-counting, and recommended
actions

➢ Step 14: Have participants review the table below.
64
Table 12: Determining adherence levels from self-report and pill count and recommended
action
Missed doses per months
Percent Adherence
Once daily Twice daily Recommended Action
adherence ranking
dosing dosing
• Review adherence plan
<2 doses ≤2 doses ≥95% Good
• Support to continue adhering well.
2-4 doses 4-8 doses 85–94% Average • Address the causes of average/poor
≥5 doses ≥9 doses <85% Poor adherence
• Review adherence plan
Note: Adherence >105% could imply potential drug sharing or other inconsistencies in dosing and should
be investigated.
3.4.3 Pharmacy Refill/Clinic Records
➢ Step 15: Briefly discuss adherence assessment using pharmacy refill and clinic records.
Adherence can also be assessed by viewing the patient’s clinic and pharmacy records. Such
records document if and when a patient or caregiver collected their ARVs; irregular collection
may indicate adherence challenges. Additionally, computerized pharmacy records assist health
managers to assess the overall adherence. Pharmacy records are more reliable than self-reporting
if documentation is accurate.
3.5 Adherence Support
➢ Step 1: Have the participants discuss the different adherence support interventions they
have implemented with their clients. Supplement the discussion with the interventions
below:
Adherence support interventions should be provided to people on ART. The following

interventions have demonstrated benefit in improving adherence and viral suppression:
• Adherence counseling: This is a one on one interaction between the client and health care
provider aimed at helping the client identify barriers related to their adherence and develop
strategies to overcome the identified barriers.
• Peer support system: This enables clients to learn from each other’s experiences and to cope
better with the disease. A peer is a person who shares similar characteristics with a particular
group of people. In HIV care, peers include mentor mothers in the eMTCT
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program, adolescent peer supporters (YAPS), expert clients and other peers as patients and
caregivers usually relate better to peers. Peer support can be provided either in form of peer
counseling or peer support groups.
• Mobile phone calls and text messages: These should be used with the patient’s or caregiver’s
consent. The patient or caregiver should provide the appropriate phone numbers to avoid
accidental disclosure when messages are sent to a wrong person.
• Reminder devices like calendars, pill boxes, cell phone alarmsand diaries can be used by
clients.
• Behavioral skills training and medication adherence training: These include module-based
interventions and those designed to improve life skills, attitudes, behavior and knowledge.
• Fixed-dose combinations and once-daily regimens: When available, health-care workers
should prescribe fixed dose combinations because they reduce the pill burden. If once daily
regimens are available and recommended, they should be used.
• Use of treatment buddies(supporters): This is an individual identified by the client to take on
the role of a treatment supporter. This person reminds/gives the client their medication
whenever it is time and reminds them of their refill dates.
• Peer-led dialogues: These include group discussions among clients. They could discuss the
challenges they face and come up with possible solutions.
3.6 Intensive Adherence Counseling for Patients with detectable Viral Load
➢ Step 1: Introduce session by describing the meaning of “Intensive adherence counselling”

and its benefits in HIV care using the notes below:
Intensive adherence counselling (IAC) is the counselling offered to patients with a non-
suppressed viral load. IAC helps a client develop a comprehensive plan for adhering to ARVs by
identifying their barriers to adherence, gaining insight of the barriers, and exploring possible
ways to overcome barriers and making a plan to adhere to medicine. IAC requires a
multidisciplinary team including clinicians, nurses, counsellors, family members and peers, etc.
It may also require consultations from experts or referrals to address the issues related to stigma,
disclosure, and nutrition.
Intensive adherence counseling (IAC) refers to a targeted structured counseling and support
intervention that aims to support patients to achieve viral suppression.
o Targets patients with a non-suppressed viral load (>1000 copies/ml)
66
o Helps patients identify problems that influence their adherence and find appropriate
solutions
o Helps rule out the possibility of poor adherence before switching ART
➢ Step 2: Explain to participants that IAC should be provided by a multidisciplinary team

(Refer them to page 65 of their Desk Job Aid Providing Intensive Adherence Counseling
and support (IAC) to clients with non-suppressing viral load) or Page 131 of the
Consolidated Guidelines.
➢ Step 3: Ask participants to explain how they currently provide IAC. Take note of the
deviations in the explanation.
➢ Step 4: Discuss the IAC Flow Chart. Refer participants to their Desk Job Aid, page 66
(IAC Flow Chart for VL non-suppressed clients) or Page 133 of the Consolidated
Guidelines. Answer any questions that arise.
➢ Step 5: Emphasize key considerations when providing IAC and support to non-
suppressed children and adolescents:
• All children and adolescents on NNRTI-based regimens with a non-suppressed viral load:
o Switch immediately to second line ART without waiting for a repeat viral load
result.
o IAC should be initiated immediately and provided monthly.
o IAC should be continued until child stabilizes on their new regimen for a
maximum of 6 months.
o Resume routine adherence support aligned to clinic appointments.
• Children and adolescents on DTG or PI-based regimens: DTG and PIs have a high barrier
to resistance, so poor adherence is a more likely cause for an unsuppressed VL than
resistance. Therefore, for children on DTG or LPV/r-based first line regimens with non-
suppressed VL:
o Conduct IAC and repeat VL after 3 months.
o If VL is still not suppressed after IAC interventions, switch to 2nd line ART.
➢ Step 6: Discuss steps to be followed in conducting the IAC Sessions. Refer participants to
Pages 67-71 of the Desk Job Aid or Page 131 of the Consolidated Guidelines.
➢ Step 7: Allow participants to internalize and ask any questions
➢ Step 8: Summarise the session with key messages.
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3.6.1 5As for adherence support for people with non-suppressed viral loads
The multidisciplinary team should use the 5 As to offer intensive adherence counselling and
psychosocial support. These are; Assess, Advise, Agree, Assist and Arrange.

➢ Step 9: Review the 5 As for intensive adherence counselling with the participants.
3.7 Delivering HIV Services for adolescents
Key Questions
1. What services are required for adolescents?
2. How should these services be delivered?
➢ Step 1: Ask the participants to refer to pages 72-77 of the Desk Job Aid (Delivering HIV
services for adolescents) or Page 135 of the Consolidated Guidelines to discuss delivering
of HIV services to adolescents. Inform participants that to improve access to HIV
prevention and treatment services and improve the health outcomes of adolescents; health
care providers need to provide adolescent-friendly health services (AFHS). AFHS services
are visible, flexible, affordable, confidential, culturally appropriate and universally
available.
3.8 Module 3 Practice case studies to check participant understanding
Instruction for activity: Ask participants to work in pairs and use their desk top job aide to
answer the following questions as you read them out one at a time. Participants should all answer
each question before moving onto the next.
Questions:
1. What are the 5 rights of Adherence?
o Answer: Right medicine, Right dose, Right way, Right frequency, Right way
o Facilitator should make sure that there is good understanding of the 5 Rights.
2. Mr Mbasa a 40 year old, has tested HIV positive at your facility today.
o He tells you he is not ready to disclose to his partner until they test together but he
wants to start treatment. Will you start him on ARVs today?
▪ Answer: Yes
o What steps would you take to prepare him for ART adherence?
▪ Facilitator should make sure there is good understanding of the process of preparing a
patient for ART and assessing adherence readiness.
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3. Mbindule, an HIV-positive lactating mother on ART at your clinic, brought her 10 year old
son, Kakine, for an HIV test. Kakine tests HIV-positive and Mbindule tells you she cannot
make any decision without consulting the husband who works in Gulu. What will you do?
o Facilitator should ensure the following elements are discussed:
▪ Conduct pre-ART counselling
▪ Discuss disclosure to husband (disclosure plan: what, when, how)
▪ Discuss disclosure to son
▪ Emphasize benefits of ART
▪ Schedule next adherence counselling session within one week pending
husband’s consent
4. Ogundipe, a 27 year old man, was supplied 60 pills of TDF/3TC/DTG on 20/1/2014. He
returned to the clinic on his appointment on 16/02/2014 with 10 pills, exactly 26 days. On
assessment he tells you he missed a few doses on occasions when he forgot to take the pills.
o What is his adherence level? (Facilitator should assess for all the methods of assessing for
adherence and calculating adherence levels)
▪ Answer:
• Number of pills taken =(30-10)=20
• Number expected to have been taken=26
• Adherence= (20/26)x100 =76.9%
o What will you document on his ART Card?
• Answer: Poor (P)
o On receiving his viral load results, his viral load count was 10,000 copies/ml. What
would you do? (Facilitator should make sure that all components of the 5As for non-
suppressed patients are discussed).
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MODULE 4. Elimination of Mother-to-child Transmission of HIV
(eMTCT) and improving Maternal, New-born, Child and Adolescent
Health (MNCAH)
Proposed Time: 2hr
Key Questions:
1. What is the eMTCT continuum of services?
2. What are the services for non-pregnant women?
3. What are the services offered during pregnancy?
4. What are the services offered during labour and delivery?
5. What are the services offered during postpartum period?
6. What care services are offered to the HIV-exposed infant/child?
7. What is community eMTCT?
Materials Needed:
Instructions for the facilitator:
• Inform participants that eMTCT interventions should be integrated into the MNCAH
services which include but not limited to ANC, labour and delivery, postnatal care, sick
child clinic and YCC at health facilities, and community sites.
• Remind participants that the eMTCT response is still based on the 4 pronged approached.
• Emphasize the eMTCT updates to the guidelines as listed below:
o Preferred 1st line ART regimens for pregnant and breastfeeding women initiating
ART.
o Provision of HTS, syphilis and Hepatitis B testing in ANC.
o Guidance on what to do if a mother refuses ART or if you know adherence is poor.
o Guidance on what to do if baby presents after 6 weeks.
o Guidance on the HEIs testing algorithm with a 3rd DNA-PCR test added.
o EPI/PMTCT/EID integration to improve DNA-PCR uptake and coverage.
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4.1. eMTCT continuum of services
Introduction: The section defines which services in each eMTCT prong are offered in each of the
parts of the MNCAH services continuum; before pregnancy, antenatal, labour and delivery,
postnatal and community.

➢ Step 1. Ask participants to describe the continuum of services.
➢ Step 2 List the responses on a flip chart
• Clarify by going through the figure below.
The eMTCT continuum of services
Non-pregnant women
During pregnancy
Primary
prevention of HIV HIV/Syphilis testing and Labour and delivery
infection counseling - (PITC)
PITC (offer PITC if Postpartum
HIV testing Retest after 3 months if never tested or tested
services negative negative more than 3 PITC (offer PITC if never
months ago) tested or tested negative
Prevention of ART for mother, and more than 3 months ago
Safer delivery practices
unintended basic HIV care (CPT,
to decrease risk of infant Routine immunisation,
pregnancies ITNs) exposure to HIV growth monitoring,
infant and young child
Infant feeding counseling ART and septrin refill
and adherence feeding support
and support
counseling Early infant diagnosis
VL testing for HIV ARVs to the (EID) and ART for
infected women newborn/NVP infected infants
prophylaxis ART and septrin refill
BCG/polio vaccination and adherence
counselling
Family planning
methods
Community eMTCT
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4.2 Services for non-pregnant adolescent girls and women
4.2.1 Primary prevention of HIV infection
Introduction: Preventing HIV in adolescent girls and women of reproductive age reduces the risk
of HIV infection to infants because over 90% of pediatric HIV infections are through MTCT.
➢ Step 1: Review some of the services to prevent HIV infection in adolescent girls and
women of reproductive age with participants presented on page 81 of the Desk Job Aid
(Services for preventing HIV infection in adolescent girls and women of reproductive
age) or Page 56 of the Consolidated Guidelines.
4.2.2 Prevention of unintended pregnancies among adolescent girls and women living with
HIV
Introduction:
Family planning (FP)/contraception for adolescent girls and women living with HIV reduces the
number of unintended pregnancies, thereby reducing the number of infants exposed to HIV and
the overall risk of MTCT. FP/contraception also provides intrinsic benefits by saving lives and
enhancing the health status of adolescent girls and women and their families. However,
FP/contraception services should be provided based on respect and fulfillment of reproductive
rights and choices. Adolescent girls and women should not be coerced into FP; their sexual and
reproductive choices should be respected and safeguarded.
➢ Step 2: Instruct participants to refer to page 82-84 of the Desk Job Aid or Pages 56-58 of
the Consolidated Guidelines for the principles and process of offering FP to women living
with HIV
➢ Step 3: Review the FP recommendations in the guidelines
➢ Step 4: Take them through the drug interactions between different types of contraception
and ARVs.
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4.3 Services offered during pregnancy
➢ Step 1: Review the package for ANC and eMTCT for pregnant women on pages 85-89 of
the Desk Job Aid (ANC and eMTCT services for pregnant women) or Page 58 of the
Consolidated Guidelines with the participants.
1. Remind participants of the need to provide ANC services for all pregnant women.
2. Inform them that the service package comprises at least 8 ANC visits.
3. Take participants through the risk assessment procedure for the un-born baby (foetus).
4. Emphasize the key services, which should be provided to all pregnant women to
participants.
5. Highlight the concept of triple elimination of HIV, Syphilis and Hepatitis B (Refer to pages
90-92 of the Desk Job Aid or Pages 63-65 of the Consolidated Guidelines
6. Emphasize the recommended ART regimen (TLD), and the VL testing algorithm for
eMTCT mothers.
• Provide HTS, syphilis and Hepatitis B testing and management in ANC.
• Offer the recommended ANC package for all pregnant women (regardless of HIV
status, refer to SRH guidelines)
• Laboratory investigations specific to HIV-positive pregnant women especially note
the following:
o For HIV-positive women: perform a baseline CD4 count. The test result is not
required for ART initiation
o Do Hb test for women beginning AZT-based ART at baseline and four weeks after
initiating ART.
o Do sickling test for all women not tested before
o Urinalysis
o For HIV-positive pregnant women already on ART, do VL test at first ANC visit,
then follow the National VL testing algorithm (VL testing chart)
o For newly diagnosed HIV-positive pregnant women, do VL test 6 months after
initiating ART and then follow the National VL testing algorithm (VL testing
chart).
o Comprehensive care for pregnant women with HIV including Septrin prophylaxis
➢ Step 2: Ask the participants to turn to page 95 of the Desk Job Aid (Risk Assessment
during ANC, labour, delivery and postpartum) or Page 68 of the Consolidated
Guidelines. Assess risk of unborn baby among pregnant women with HIV at ANC 1
especially paying specific attention the following:
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o Conduct a risk assessment of the unborn baby at 1st ANC among all HIV positive pregnant
women and flag those at high risk including:
o Newly initiated on ART in the 3rd trimester or breastfeeding period.
o Most recent VL in non-suppressed.
o Closely monitor all high-risk pregnancies
Antenatal care package for all pregnant women (regardless of HIV status)
o Risk reduction counseling and support especially paying attention to the following:
o Encourage consistent and correct condom use
o Encourage women to deliver at the health facilities
o For negative pregnant women, offer other prevention services like SMC to partner
and mitigate or manage GBV
Provide ART for all identified HIV positive women
Highlight the following updates to the guidelines

• ART should be initiated on the same day, and adherence counseling should be initiated and
sustained intensively for the first 3 months then maintained for life.
• Initiate mother on once-daily FDC of TDF+3TC+DTG with pharmacovigilance.
• The mothers initiated on TDF + 3TC +EFV400 shall be transitioned to TDF + 3TC + DTG at
6-9 months post-partum if VL within past 6 months is suppressed.
• If mother is already on ART >6 months with TDF/3TC/EFV, do VL test. If she is virally
suppressed, maintain her on TDF/3TC/EFV400 until 6-9 months after delivery and then
substitute EFV with DTG if VL within the past 6 months is suppressed.
• If she is already on a DTG-based 1st-line regimen and virally suppressed, maintain on the
same regimen.
• If she is already on ART and VL is not suppressed, manage as treatment failure and switch
to DTG-based 2nd line regimen (if no previous exposure to DTG).
• If she is on 2nd line ART with ATV/r or LPV/r and virally suppressed, maintain on the same
regimen until 6-9 months after delivery and then substitute PI with DTG if VL within the
past 6 months is suppressed and no previous exposure to DTG.
• ART should be initiated and maintained in mother-baby care point in MCH.
➢ Step 3: Review the visit schedules for HIV-infected pregnant women:

HIV-positive pregnant women already on ART and stable:
▪ For the stable pregnant and breastfeeding mother, please consider the following
o Viral suppression
o Adherence above 95%
o On ART for more than one year Stage T1 and no active OIs
o Not due for vital lab tests in the next two monthse.g., viral load
o Has disclosed to significant other/ household member/ family member
74
o 8 ANC visits
o Synchronize ART refills and adherence support with the ANC visits.
▪ HIV-positive pregnant women initiating ART in ANC (new clients) or unstable:
o Recently initiated on ART (less than one year on ART)
o Poor viral suppression: most recent VL of above 1000 copies/ml
o Adherence less than 95%
o Stage T3,4 and active OIs
o Comorbidities/ co-infection
o CD4 less than 500
▪ Due for vital lab tests in the next two months,e.g. viral load
▪ Has not disclosed to significant other/ household member/ family member
o Two weeks after initiating ART
o After that, monthly until delivery
o Follow routine MCH schedule after delivery together with the exposed infant visit
schedule
4.4 Services offered during labour and delivery
Instructions for facilitators: Labour and delivery are the periods of highest risk of transmission
and should be handled with extra care to avoid transmission from mother to the child.
➢ Step 1: Emphasize to participants the services to be offered on page 93 of the Desk Job
Aid (eMTCT services during labour and delivery) or Page 66 of the Consolidated
Guidelines include:
• Ascertain HIV status, offer PITC for the partner
• Provide safe obstetric practices (refer to the SRH guidelines)
• ART for the mother
• ARV prophylaxis for the HIV-exposed infant:
o Initiate NVP prophylaxis for the infant at birth
▪ Low risk: Counsel mother and provide NVP syrup for six weeks
▪ High risk: Counsel mother and provide NVP syrup for up to 12 weeks (high-
risk infants are described in the Care of the HIV Exposed Infant section.
• Establishing breastfeeding
• At discharge Counsel the mother and provide an appointment to return for postnatal
services and exposed infant testing and care at six weeks. If the mother is not going to
receive services at this facility, link the mother to HIV care services at the facility of their
choice using linkage guidelines in HTS section on linkage to care.
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4.5 Services offered during the postpartum period
Instructions for facilitators: Following delivery, address the treatment, care and support needs
of HIV-infected women, their children and families (prong 4), provide family
planning/contraceptive services (prong 2) and continue to prevent HIV in women who were
negative during pregnancy, labour, and delivery. The HIV-infected mother should continue to
receive her care in the mother-baby care point until the baby is 18 months of age.
➢ Step 2: Discuss the key services to be provided during the postpartum period with the
participants. Ask the particpants to turn to page 94 of Desk Job Aid (eMTCT services in
the postpartum period) or Page 69 of the Consolidated Guidelines:
• Provide postnatal services for all mothers regardless of HIV status (General examination,
treatment and monitoring of maternal conditions according to national guidelines)
o Provision of Iron and folic acid to mothers for 3 months after delivery
o Provision of preventive care e.g. TT for those who missed
o Screening for cervical and breast cancer.
o Information and services for family planning/contraception
o Partner involvement in care of mother and baby
• HIV and syphilis testing services (offer HTS if never tested or tested negative during
pregnancy, labour of delivery) `
• Provide HIV care and management for the HIV-infected mother and family
o ART and septrin refill and adherence counselling
o Early infant diagnosis (EID) and ART for infected infants
o Infant and young child feeding support
o Routine immunisation, growth monitoring,
• Offer psychosocial support services (link mothers and new-borns to relevant support
groups)
4.6 Care of the HIV-exposed infant/child
➢ Step 1: Review the care of the HIV exposed Infant (HEI) with participants reviewing pages
96-99 of the Desk Job Aid (HIV - exposed infant care services) or Page 69 of the
1. Remind participants that:

• HEI should receive care at the mother-baby care point, together with their mothers,
until they are 18 months of age.
• The goals of HEI care services are to:
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1. Prevent the infant from being infected with HIV through MTCT
2. Diagnose HIV infection early and treat
3. Offer child survival interventions to prevent early death from preventable
childhood illnesses
• The HEI and the mother should consistently visit the health facility at least nine times
during that period. They visit monthly until 6 months of age and thereafter every 3
months till the infant is 18 months of age.
• The mother-baby pair should be supported to adhere to the visit schedule.
• The visits are synchronized with the child’s immunization schedule.
2. Take participants through the services below and emphasize the changes in HEI testing
algorithm with DNA-PCR testing at 9 months of age.
Remind participants of the revised HEI testing procedure by re-visting the testing algorithm
as per the HTS section of both Page 16 of the Desk Job Aid and the Consolidated Guideines.
4.7 Community eMTCT
Introduction:
Community eMTCT services should be provided through existing community structures and
support networks for PLHIV. These structures and networks should be supported to provide
unique services that meet the needs of pregnant and breastfeeding mothers and their infants. All
eMTCT implementing sites should establish a network of community-based structures and
systems within their catchment area to support the health facility to deliver a minimum package
of community-based eMTCT services.
4.7.1 Minimum Package of Community eMTCT services

➢ Step 1: Take participants through the community eMTCT services minimum package as
indicated below:
• Community sensitization and mobilization for HIV prevention, reproductive health and
eMTCT services.
• Identification, counseling, and referral of pregnant/lactating mothers for comprehensive
ANC services including screening for TB symptoms, skilled delivery, eMTCT services for
mother and baby including EID, post-natal care, IYCF and FP/ contraception.
• Identification of partners and children of pregnant and breastfeeding women in
communities and ensuring that they know their HIV status, either through
outreaches/home-based HTS or through referral.
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• Address social and behavioural factors that affect uptake of eMTCT services including
stigma, disclosure, discrimination, GBV, etc.
• Adherence support.
• Follow-up, linkage, and tracking of mother-infant pairs through at least 18 months
postpartum and ensure infant’s final survival and HIV status is known.
• Community ART and cotrimoxazole refills.
• Provision of psychosocial support through Family Support Groups or other community-
based PLHIV support groups, OVC programs, and household economic
strengthening/income generating activities.
• Assess all eMTCT families for eligibility for OVC programs.
• Promote family care, treatment, and support, including treatment support for those who
are not part of the family
• Health education and advocacy for eMTCT services
This package should be delivered using continuous quality improvement approaches and
monitored using a well-defined monitoring and evaluation (M&E) structure.
4.7.2 Establishing/strengthening Community eMTCT services
➢ Step 2: Take participants through the various community structures for eMTCT services
➢ Step 3: Remind them of the importance of establishing/strengthening community eMTCT

services (Refer to the Consolidated Guidelines)
➢ Step 4: Ask participants to share experiences on community structures in their

communities, and how these are being utilized for eMTCT services delivery
➢ Step 5: Take participants through the following strategies to establish/strengthen

community eMTCT services:
i. Establish partnerships and networks with community-based organizations
(CBOs), NGOs and networks of PLHIV for community service delivery.
ii. Identify, train and facilitate community health workers,
iii. Establish coordination mechanism.
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MODULE 5: Maternal, Infant and Young Child Nutrition
Proposed Time: 60 minutes
Key Questions:
1. Why is good nutrition important for pregnant and breastfeeding HIV positive women?
2. What are the optimal Infant and Young Child Feeding recommendations in the context of
HIV/AIDS?
Materials Needed:
Methods: Presentation, brainstorming, Q/A with desk job aid.

Instructions for facilitator: This section discusses dietary recommendation for pregnant and
lactating women, as well as infant and young child feeding (IYCF) practices in the context of
HIV/AIDS. It is guided by the Uganda Maternal Nutrition Guidelines (2010) and Infant and Young
Child Feeding Policy Guidelines (2012 edition).
By the end of the session, participants should be able to: Duration

Explain dietary recommendations for HIV pregnant women and lactating 10 min.
mothers optimal breastfeeding practices for HIV positive mothers
Describe 30 min.
Describe principles for optimal complementary feeding, including 20 min.
optimal hygiene practices
5.1 Maternal Nutrition - Counselling Information

➢ Step 1: Ask the participants to turn to page 102 of the Desk Job Aid (Nutrition
counseling for pregnant women) or Page 77 of the Consolidated Guidelines and discuss
nutrition counselling messages for pregnant women. Highlight the points below:
• A woman’s nutritional status before and during pregnancy and lactation influences
the baby’s and her own health.
• Pregnancy and lactation increase the body’s demand for energy, protein, and
other nutrients.
• Maternal malnutrition, including both underweight and overweight, increases risk of

poor birth outcomes and illness and death of mother and child.
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5.2 Infant and Young Child Feeding
➢ Step 2: Ask the participants to turn to page 103 of the Desk Job Aid (Feeding a child 0
- 6 months) or Page 78 of the Consolidated Guidelines and discuss feeding guidelines
for infants 0-6 months of age. Highlight the points below:
• Breast milk is the ideal food for infants, containing all the energy, nutrients, and
water needed for the first 6 months of life and for protecting the infant from disease.
In addition, it is easily digested, and helps a baby’s development.
• National guidelines in Uganda recommend exclusive breastfeeding for HIV Exposed

Infants starting within 1 hour of birth up to 6 months of life followed by continued
breastfeeding up to 1 year of age.
For HIV-positive infants, breastfeeding should continue for 2 years or more.
HIV-positive mothers should receive lifelong ARV treatment starting in

pregnancy
Most women can produce sufficient breast milk for their infant. The more an
infant suckles, the more milk a mother will produce. It is critical to support a
woman’s confidence in her ability to breastfeed her infant.
• Breast milk changes to meet the needs of the growing and developing infant.
Colostrum is the first milk produced and is rich in antibodies, growth factors, protein,
and vitamin A to provide the infant’s ‘first immunization’. It is essential that babies
receive colostrum. By the second week of life, colostrum has transitioned to mature
milk.
• Optimal breastfeeding requires appropriate positioning and attachment to allow the

baby to suckle effectively and avoid breast problems for the mother.
➢ Step 3: Give participants an overview of maintenance of exclusive breastfeeding

under special circumstances:
HIV positive mothers may consider expressing and heat-treating breast milk as an interim
feeding strategy to maintain exclusive breastfeeding under special circumstances considered to
be high risk for HIV transmission:
• When maternal VL is not suppressed.
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• The infant has low birth weight or is otherwise ill in the neonatal period and unable to
breastfeed.
• The mother is unwell and temporarily unable to breastfeed or has a temporary breast
health problem such as mastitis
• If ARV drugs are temporarily not available.
For the procedures of heat treatment, refer to the IYCF Guidelines.
5.2.1 Complementary Feeding
➢ Step 4: Discuss the recommendations for feeding children at different ages: 6-12 months,
12-24 months, and 2-6 years. Ask the participants to turn to pages 104-106 of the Desk
Job Aid or Pages 79-80 of the Consolidated Guidelines and highlight the points below:
• Starting at 6 months of age, children need more nutrients that breast milk alone can
provide. Therefore, feed them complementary foods in addition to breastfeeding them.
• Continue breastfeeding until child is 12 months old.
➢ Step 5: Discuss the different counselling messages with the participants:
• Start with 1 to 2 spoonfuls of mashed food twice a day and gradually increase
frequency, amount, and texture of food as child gets older.
• Provide a variety of foods (not just the staple food), including animal and plant
foods in a range of colours to ensure the child is getting a variety of nutrients.
Actively engage the child while feeding to encourage him or her to eat.
• Practice good hygiene, including good food hygiene.

• Wash hands with soap and flowing/poured water before preparing food and feeding.
• Treat drinking water and water for washing or mixing into foods that will not be cooked
further.
• Store treated water in a covered container with a small mouth. Serve water by pouring or
using with a clean ladle.
• Cover food with a cloth, net, or lid and avoid contamination of cooked food with raw food.
• Cook and reheat food thoroughly (heat to steaming).
• Promote WASH practices: water, sanitation, hygiene.
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5.3 Nutrition assessment, counselling and support for PLHIV
5.3.1 Nutrition assessment and classification
Key Questions:
1. What is anthropometry?
2. What do you need to take anthropometric measurements?
3. How do you measure weight, height/length, MUAC accurately?
4. How do you use anthropometric measurements to determine nutrition status of an
individual?
Materials Needed:
• Anthropometric Equipment: Length/height boards; mid-upper arm circumference
(MUAC) tapes of appropriate sizes for children and adults; weighing scales for infants,
children, and adults; and rope for hanging Salter scales
• Dolls for practicing weighing and measuring
• WHO growth curves and field tables (available at www.who.int/childgrowth/standards/en/)
• BMI and BMI for age look-up tables (available at www.fantaproject.org/tools/bmi-look-up-tables)
• BMI wheel for adults and children (5 years to <19 years)

Demonstrate ability to use common anthropometric equipment to 30 min.
take accurate measurements
Use a combination of anthropometric measurements to 30min.
determine nutrition status of individual
Use able to manage and care for malnourished PLHIV 30min
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5.3.2 Nutrition assessment
➢ Step 1: Ask the participants to turn to page 107 of the Desk Job Aid (Nutrition care and
support for PLHIV) or Page 107 of the Consolidated Guidelines and elaborate the
activities involved in nutrition and health education, nutrition assessment, nutrition
classification, nutrition counselling, treatment and education follow-up.
➢ Step 2: Explain and demonstrate the accurate measurement of the assessment

parameters (MUAC, length/height and weight) on pages 108-112 of the Desk Job Aid.
Practice: Divide participants into groups and have them practice measuring weight, height, and
MUAC. Each pair should record the measurements for use in the next session.
5.3.3 Classification of nutritional Status
➢ Step 1: Discuss BMI and how to calculate BMI using the BMI wheel on page 113 of the
Desk Job Aid (Determining BMI)
➢ Step 2: Discuss classification of nutrition status using z-scores and use of WHO field tables
and charts; making reference to available charts and tables. Discuss classification of
nutrition status using cut-offs on page 114 of the Desk Job Aid (Nutrition Assessment,
Classification, and Care Plan) or Page 112 of the Consolidated Guidelines.
• Practice: Have participants practice calculating BMI.
• Practice: Have participants practice use of MUAC cut-offs, BMI wheel to determine
nutrition status
• Practice: Have participants practice using WHO charts and field tables to determine
z-scores and nutrition status.
NB: When using the BMI wheel, ‘severe underweight’ means SAM, ‘moderate underweight’
means MAM, and ‘mild underweight’ means at-risk for malnutrition
All facilitators should support the participants as they practice.
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5.4 Management of Malnutrition

Describe common types of therapeutic and supplementary foods used in 20 min.
nutrition care
Describe types of care in management of acute malnutrition 20 min.
Training Materials
Samples of therapeutic and supplementary foods: F-75, F-100, ready-to-use therapeutic food
(RUTF), and fortified blended food, such as corn-soya blend (CSB).
➢ Step 1: Discuss the management of malnutrition on page 114 of the Desk Job Aid
(Nutrition Assessment, Classification, and Care Plan) or Page 112 of the Consolidated
Guidelines.
Facilitators Notes -Key Points
• In addition to the necessary supplies and equipment, appropriately trained health

workers are necessary for successful management of acute malnutrition.
• To prevent relapse, a client’s social and medical problems need to be addressed.
• The current classification of acute malnutrition recommends three different levels of care:
Inpatient therapeutic care (ITC) for clients with severe acute malnutrition (SAM) and medical
complications, clients with moderate acute malnutrition (MAM) and medical complications.
Outpatient therapeutic care (OTC) for clients with SAM who pass an appetite test and have no
medical complications.
Supplementary feeding for clients with MAM and no medical complications.
• SAM is managed with therapeutic foods, including ready-to-use therapeutic food

(RUTF) and milk-based F-75 and F-100, which are used in inpatient care only.MAM is
managed with fortified blended food, such as Corn Soy blend.
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MODULE 6. HIV Care and Treatment for Children, Adolescents
and Adults
Introduction: The aim of this session is to familiarize participants with the new consolidated
guidelines for care and treatment of children, adolescents and adults living with HIV. This section
will introduce the minimum healthcare services package for PLHIV, the latest guidance on how
to prevent, screen and manage co-infections and co-morbidities, and updated information on
ART for PLHIV.
Proposed Time: 4 hours
Key Questions:
1. What are the components of the minimum care package for PLHIV?
2. Why should PLHIV be given minimum care package?
3. What is Advanced HIV Disease (AHD)?
4. What are the components of the package of care for PLHIV with AHD?
5. Why is early diagnosis key to decreasing mortality due to cryptococcal disease?
6. What are the strategies for screening, identification and management of early cryptococcal
disease?
7. What is the current recommended management of cryptococcal meningitis (CM)?
8. How do we screen for TB in HIV infected patients using the Intensified TB Case Finding
Guide (ICF)?
9. How do we diagnose TB in children?
10. How do we treat TB in HIV-infected patients?
11. What ARVs do we use in patients with TB/HIV co-infection?
12. When should HIV positive children, adolescents and adults be started on ART?
13. Why are we starting all people living with HIV on ART?
14. What are the new regimens for initiating children, adolescents and adults on ART?
15. How do we prescribe appropriate ARV doses for children, adolescents and adults?
16. Why do we monitor response to ART?
17. How do we monitor response to ART?
18. What does it mean to switch an ARV regimen?
19. How do we make a decision to switch from 1st line to 2nd line?
20. What 2nd line ARV regimens are used in Uganda?
21. What 3rd line ARV regimens are used in Uganda?
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22. How do we screen, monitor, investigate, manage and report adverse effects and drug
toxicities to ARVs?
Materials Needed:
• Desk job aid
• Loose copies of ICF guide, ARV dosing chart
Methods: Brainstorming, presentation using the flip chart, Q/A with job aid
6.1 Minimum Service Package for PLHIV
Introduction: The Ministry of Health developed a minimum healthcare services package for
PLHIV to standardize the programming, implementation and delivery of integrated HIV services
in Uganda. The details of this minimum healthcare services package can be found in Integrated
Health Care Services Package for HIV Prevention, Treatment and Care Services for Uganda.
Key Questions:
1. What are the components of the minimum care package for PLHIV?
2. Why should PLHIV be given minimum care package?
➢ Step 1: Ask participants to turn to page 116- 117 of the Desk Job Aid (Minimum Service
Package for PLHIV) or Pages 81-82 of the Consolidated Guidelines and describe the
minimum services a person living with HIV should receive. Record responses and make
sure all categories are discussed. Clarify as necessary.
6.2 Diagnosis, Prevention and Management of Co-morbidities and Co-infections
6.2.1 Screening for Co-morbidities
Introduction: The consolidated guidelines provide information on screening and management of

co-morbidities. More information on care and treatment for PLHIV with comorbidities can be
found in Chapter 6 of the Consolidated Guidelines.
➢ Step 1: Direct participants to review the guidance presented on pages 136-138 of the Desk
Job Aid or Pages 115-120 of the Consolidated Guidelines. These pages of the desk job aid
cover the screening procedures for diabetes mellitus, hypertension and depression.
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Inform participants that more information on co-morbidities screening and management
can be found in the full Consolidated Guidelines.
6.2.2 Cotrimoxazole Preventive Therapy (CPT)
Key questions:
1. What is the importance of Cotrimoxazole Preventive Therapy (CPT)?
2. What categories with PLHIV are eligible for CTX?
3. When do you stop CTX?
Note to facilitator
The focus of this session is to discuss the use of CTX in PLHIV

➢ Step 1: Ask participants to tell you why Cotrimoxazole Preventive Therapy (CPT) is
important. Next, introduce the topic with the following points:
• Cotrimoxazole preventive therapy (CPT) can reduce the risk of malaria, diarrhea and
pneumonia caused by bacterial infections; hospitalization; and mortality.
• However, the benefits of CPT reduce markedly in clients who are stable on ART. For this
reason, only certain categories of PLHIV should be maintained on CPT
➢ Step 2: Direct participants to page 119 in the Desk Job Aid (Cotrimoxazole preventive
therapy) or Page 86 of the Consolidated Guidelines to review guidance on the use of
cotrimoxazole therapy. When facilitating this section, follow through step by step with
the participants on the different categories of PLHIV who are eligible for CTX, who should
be given CTX, when to stop CTX and when to restart CTX.
• The following groups have been prioritized for CPT:
a. Exposed infants (from 6 weeks until discharge from MBCP at 18 months)
b. PLHIV newly initiating on ART
c. Pregnant and breast-feeding women
Note that additional intermittent preventive treatment for malaria using sulfadoxine-
pyrimethamine (SP) is not required for pregnant women on CPT.
d. Children aged 15 and below
e. Patients suspected to have treatment failure or with symptoms of Advanced HIV
Disease
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The five (5) conditions below should be fulfilled prior to CPT discontinuation:
a. Patient should be older than 15 years of age

b. Patient should not be Pregnant
c. Patient should have been on ART for at least one year
d. Patient’s last VL should be suppressed
e. Patient should not have a treatment WHO stage 3 or 4 event at the time of stopping
CPT or other symptoms of Advance Disease
CPT can be restarted in the following scenarios:
a. New pregnancy: In case CPT was stopped earlier (in stable women), re-start CPT and
maintain it throughout pregnancy and in the immediate postpartum period (up to 6
weeks after delivery).
b. Suspected treatment failure If VL becomes unsuppressed in a patient whose CPT was

previously discontinued, re-start CPT and continue until the VL is suppressed once again.
c. New Treatment WHO stage 3 or 4 condition. In case CPT was discontinued earlier, it can
be restarted when a patient develops an active WHO stage 3 or 4 infection and continued
until the condition has been treated and resolved.
Points to emphasize
• PLHIV newly initiating on ART should be put on CTX and stop after the first suppressed VL.
• CPT should not be given to people with known allergy to sulpha-containing drugs or
trimethoprim, severe anaemia,and/or severe neutropenia (<5000 cells/mm3).
• In patients with Cotrimoxazole hypersensitivity, Dapsone should be used. Dapsone provides
protection against PJP. It does not have the other preventive benefits CPT provides. Therefore,
pregnant women receiving Dapsone should also receive IPT with SP.
• In the rare event that patient who has hypersensitivity to Cotrimoxazole also reacts to
Dapsone, Atovaquone can be given as an alternative.
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6.2.3 Screening and management of Advanced HIV Disease (AHD)
Key questions:
1. What is Advanced HIV Disease?

2. What are the components of the package of care for PLHIV with AHD?
Note to facilitator
The focus of this session is to introduce the concept of screening and management of Advanced HIV
Disease

➢ Step 1: Ask participants to tell you what they understand by AHD and why they think
discussing AHD is important. Next, introduce the topic with the following points:
• For adults and adolescents, and children five years or older, ADH is defined as CD4 cell
count <200cells/mm3 or with a current WHO stage 3 or 4 event.
• All children younger than five years of age with HIV are considered as having advanced
HIV disease due to high viremia and rapid disease progression with high mortality.
• PLHIV with AHD are particularly at high risk of death, even after initiating ART, with
this risk increasing with decreasing CD4 cell count. The most common causes of death
among adults with AHD include tuberculosis (TB), Cryptococcal Meningitis and severe
bacterial infections.
6.2.4 Screening, identification and management of Advanced HIV disease

➢ Step 1: Ask the participants to open page 120 of the Desk Job Aid (Screening for the
management of Advanced HIV Disease in adults) or Page 86 of the Consolidated
Guidelines. When facilitating this section, follow through the algorithm step by step with
the participants
Emphasize to participants that the algorithm suggested for AHD screening relies on the ability of
the health facility to have CD4 testing done. Symptoms screening is also helpful in case CD4 is
not readily available.
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Note: It is important to do CD4+ testing for newly diagnosed patients and for patients
suspected to be failing on treatment.
6.2.5 Management of Advanced HIV disease
➢ Step 2: Ask the participants to open page 121 of the Desk Job Aid (Components of the
package of care for PLHIV with Advanced Disease) or Page 83 of the Consolidated
Guidelines. When facilitating this section, follow through the table for the recommended
package of interventions for managing PLHIV with AHD. It includes screening,
prophylaxis and treatment for opportunistic conditions, rapid ART initiation and
enhanced adherence support.
Note 1: Rapid ART Initiation
All patients should undergo the Symptom Screen and the Advanced Disease Pathway (see Figure
10 above) Patients presenting for the first time or those returning to care and not on ART should
undergo the Symptom Screen and the Advanced Disease Pathway before rapid ART initiation
is offered. Rapid ART initiation should be deferred when Symptom Screen is positive or when
CD4 is <100cells/mm3. However, CD4 testing is not a pre-condition for ART initiation.
Note 2: Adherence support
People with advanced HIV disease require closer follow-up during the first 3 months to ensure
adherence to treatment and return visits since they are likely to be ill, have a higher pill burden
(treatment of comorbidities) and drop out of care. Follow up can be through clinic or home visits,
telephone consultation, text messaging.
Note 3: People interrupting treatment
Those who interrupted treatment and have a negative Symptom Screen and CD4 >100 should be
restarted on their old regimen, receive three intensive adherence counselling sessions with
documented good adherence (one month apart) and a viral load after 3 months of restarting
therapy.
6.2.6 Exercises to check participant understanding
Instructions for facilitators: Ask participants to work in pairs to answer the following question
using the desk job aid. Using the job aid to answer the questions helps them familiarize
90
themselves with the tool and increases their changes of using it thereafter. After answering the
questions, ask different pairs to share their answers with the whole group.
1. What danger signs should the health worker look out for when screening a patient for
advanced disease?
Answer: T>39C, RR > HR > 120, new seizure, unable to work without assistance
2. How do would you manage a newly diagnosed patient with CD4 400 and with no signs or
symptoms after screening for advanced disease?
Answer: Start ART, INH and CTX
Final points to emphasize:
• Identifying people with advanced HIV disease who are eligible for elements of a package
of care requires CD4 cell count testing since some severely immunosuppressed
individuals remain asymptomatic.
• Additionally, all patients should undergo the symptom screen and Advanced Disease
Pathway and be assessed for all symptoms.
• Early ART initiation is the most important and cost-effective preventive strategy to reduce
the incidence and high mortality associated with AHD.
• Patients should ideally initiate ART at as soon as diagnosed and ready to start and
definitely before a decline in the CD4 cell count to less than 200 cells/mm3, or development
of WHO stage 3 or 4 disease.
• The management of Cryptococcal Disease and TB are discussed further in the subsequent
sections.
6.2.7 Diagnosis, prevention and management of Cryptococcal disease in children,
adolescents and adults
Key Questions:
1. Why is early diagnosis key to decreasing mortality due to cryptococcal disease?
2. What are the strategies for screening, identification and management of early cryptococcal
disease?
3. What is the current recommended management of cryptococcal meningitis (CM)?
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Note to facilitator
The focus of this session is to introduce the cryptococcal diagnostic algorithm and treatment to the
healthcare workers.

➢ Step 1: Ask participants to tell you why they think discussing cryptococcal meningitis
(CM) is important. Next, introduce the topic with the following points:
o Cryptococcus neoformans is the most common cause of HIV-associated adult
meningitis. The disease can initially manifest as a transient pneumonia, and as the
fungus spreads to the blood and eventually the brain, patients may present with
symptoms of severe headache, vomiting, seizures, altered consciousness
photophobia, neck stiffness and Kernig’s sign.
o The diagnosis of cryptococcal meningitis requires a lumbar puncture and thus
patients with suspected meningitis should be assessed and referred to a facility
where the procedure can be performed.
o Patients with a positive cryptococcal antigen test on blood (cryptococcal
antigenemia) without any symptoms will generally develop meningitis within 3
weeks. Giving fluconazole to patients with asymptomatic cryptococcal disease
improves their survival and prevents CM.
o The majority of patients with cryptococcal antigenemia have a CD4 count <100
cells/μL. All patients with CD4 count <100 cells/μL should be screened for
cryptococcal antigen.
6.2.7.1 Screening, identification and management of early Cryptococcal disease

➢ Step 2: Ask the participants to open page 122 of the Desk Job Aid (Algorithm for
screening and managing cryptococcal disease) or Page 102 of the Consolidated
Guidelines.
• . When facilitating this section, follow through the algorithm step by step with the
participants
o Emphasize to participants that the algorithm suggested for cryptococcal antigen
screening and evaluation of patients with symptoms relies on the ability of the
health facility to do CD4 testing. It is important to do CD4+ testing for newly
diagnosed patients and for patients suspected to be failing on treatment.
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6.2.7.2 Management of Cryptococcal Meningitis

➢ Step 3: Ask the participants to open page 123 of the Desk Job Aid (Treatment of
Cryptococcal Meningitis) or Page 104 of the Consolidated Guidelines. When facilitating
this section, follow through the table for treatment of cryptococcal meningitis.
o Emphasize that cryptococcal meningitis can only be made after demonstrating
presence of cryptococcal antigen in cerebral-spinal fluid or a positive culture
showing cryptococcal organisms. There are 3 phases in the treatment of
Cryptococcal Meningitis: the induction phase, consolidation phase and
maintenance phase.
6.2.8 Exercises to check participant understanding
➢ Step 4: Ask participants to work in pairs to answer the following question using the desk
job aid. Using the job aid to answer the questions helps them familiarize themselves with
the tool and increases their changes of using it thereafter. After answering the questions,
ask different pairs to share their answers with the whole group.
Questions:
1. Cryptococcal meningitis is the most common type of meningitis among HIV-infected

patients in Sub-Saharan Africa.
a. Answer: Yes
2. An HIV-infected patient with a CD4 of 75cells/μL has no signs of meningitis but has a
positive blood cryptococcal antigen test. He is not yet on ART. How would you treat this
patient? Check all that apply
a. Send him home to return in 4 weeks
b. Start him on Fluconazole
c. Start ART counselling and start ART in 2 weeks
3. If you performed a lumbar puncture in the patient above because he had a headache and
found that he had a positive CrAg test, what are the drugs you would start him on?
a. Answer:
o Amphotericin B (Liposomal), Flucytosine and Fluconazole.
OR
o Amphotericin B (Deoxycholate) and fluconazole.
OR
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o Fluconazole and Flucytosine
o If Amphotericin or Flucytosine are unavailable, start high dose fluconazole.
Final Points to Emphasize:
• Prompt referral for HIV testing and care should be undertaken as soon as appropriate
following diagnosis of cryptococcal disease.
• Optimal use of antifungal treatment regimens and approaches can improve survival,
clinical and neurological outcomes, and rapid fungal clearance, while minimizing drug
related toxicities.
• Patients who have a diagnosis of cryptococcal meningitis should be started on ART at
least 4-6 weeks after the diagnosis and treatment of the cryptococcal meningitis.
6.2.9 Tuberculosis (TB) Screening, Treatment and Prevention among PLHIV
Key Questions
1. How do we screen for TB in HIV infected patients using the Intensified TB Case Finding
Guide (ICF)?
How do we diagnose TB in children?
2. How do we treat TB in HIV infected patients?
3. What ARVs do we use in patients with TB/HIV co-infection?
4. How do we prevent TB disease in persons living with HIV?
Proposed Time: 30 mins
Note to facilitator
The focus of this session is to understand how to screen, diagnose and manage TB among HIV
patients.
6.2.9.1 Screening for TB in PLHIV using the Intensified TB Case Finding Guide (ICF)

➢ Step 1: Ask participants how they screen for TB in their health facilities: what tools do
they use, what questions are asked, and in which areas TB screening is done. Make sure
that the responses include:
o Tools: ICF form or guide,
o Questions used for screening: cough, fevers, hemoptysis, contact, weight loss, poor
weight
o Areas where screening is done: OPD, HIV clinic, IPD etc
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➢ Step 2: Introduce the Intensified TB Case Finding (ICF) Guide and ask participants to turn
to the ICF on page 124 of the Desk Job Aid (Tuberculosis (TB) screening) or Page 89 and
Annex 5 of the Consolidated Guidelines. Read the top part of the ICF guide to emphasize
where the ICF guide should be placed and used (OPD, IPD, HIV clinic and congregate
settings) and who should administer it.
o Remember to inform participants about change of the term “TB suspects” to
“presumptive TB.”
Note to facilitator
Emphasize to participants that: ICF guide can be administered by a health worker or a lay provider at
the health facility and give examples of lay providers (VHTs, Expert clients, RCT volunteers) etc.
➢ Step 3: Go through the ICF guide step-by-step by asking one participant to read step 1,
another step 2 and another step 3.
➢ Step 4: Ask participants to listen to the case scenario on the next page and answer one
question at a time using the ICF guide.
o Case scenario 1: Rita is a 3 year old girl who started ABC/3TC+ LPV/r 4 weeks ago.
As part of TB screening what questions would you ask the caretaker?
▪ Answer: Step 1 of ICF guide except Question 4
o If Rita’s caretaker answers, “yes” to Question1, how would you proceed?
▪ Answer: Refer to the clinician for further investigations given that Rita is 3
years old and is unable to produce sputum on her own. Record information
in comprehensive ART card and ART register.
▪
6.2.9.2 Using the Algorithm for diagnosis of TB in PLHIV

➢ Step 1: Ask participants how TB is diagnosed in their health facilities.
o Answers could vary from clinical diagnosis (symptoms, signs and radiological-X-
ray), to laboratory diagnosis (Urine TB LAM, microscopy or GeneXpert or culture).
➢ Step 2: Ask participants why is the algorithm needed?
o You answer: Because making a diagnosis of TB in PLHIV is challenging. Remind
the participants that:
▪ Making a diagnosis of TB PLHIV is challenging because:
• TB symptoms in PLHIV may be non- specific.
• Sputum culture which is the gold standard test is not easily
accessible.
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• For very sick patients a urine TB LAM can be done
➢ Step 3: Introduce the algorithms for diagnosis of TB in PLHIV. Ask the participants to go
to pages 125 and 126 of the Desk Job Aid (Algorithms for diagnosis of TB in children
and in adults/adolescents) or Annexes 6 and 7 of the Consolidated Guidelines and ask the
participants to go through step by step in pairs.
➢ Step 4: Ask participant to listen to the case scenarios below and answer questions one at
a time.
o Scenario 1: A 9 year old boy with unknown HIV status presents with poor weight
gain for 1 year and cough for 2 week. How would manage him-use algorithm?
▪ Answer: Obtain a sputum sample for GeneXpert or microscopy and do
HIV test, then follow steps in algorithm.
o Scenario 2: A 4 year old HIV positive girl presents with a cough for one week after
initiation of ART. How would you manage her-using the algorithm?
▪ Answer: Obtain sample for GeneXpert or microscopy and follow the
algorithm. Remember to follow the HIV positive arm in case of a negative
GeneXpert or microscopy test.
o Scenario 3: 40 year old HIV positive woman presents very sick with h/o loss of
weight in the last one months with fever for more than 3weeks with cough for more
than 2 weeks.
▪ Answer: Obtain urine for TB LAM test if possible do a GeneXpert. If Urine
TB LAM test is positive follow the algorithm to manage the patient.
➢ Step 5: Draw the attention of participants to the recommendations on GeneXpert in the

algorithms for TB diagnosis. Emphasize the following talking points to participants:
o The GeneXpert test is a newer diagnostic tool that detects DNA from TB bacteria
and avails results within two hours.
o The test also provides information on the presence of rifampicin resistance.
o Indications for GeneXpert test include:
▪ PLHIV
▪ MDR TB high risk groups (smear +ve TB retreatment cases, MDR TB
contact, health workers)
o Emphasize that for facilities where there is no access to the GeneXpert test,
microscopy test should be done.
o Remind the participants that the Xpert MTB/RIF (GeneXpert) test is the
recommended initial TB diagnostic test for all PLHIV with presumptive TB.
However, for PLHIV with CD4<200 cells/ µL and seriously ill PLHIV (have
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danger signs), a lateral flow urine lipoarabinomannan assay (Urine TB LAM) test
should be done because it has a shorter turnaround time followed by Gene Xpert
which is more sensitive and can detect rifampicin resistance. If either test is
positive, classify patient as PBC (Pulmonary Bacteriologically Confirmed) and
start anti-TB treatment.
o There is a plan in place to have more GeneXpert machines in the country.
o Inform participants that GeneXpert samples can be sent to the GeneXpert testing
labs using the EID transport system (motorcycle riders) and leave a list of
laboratories that have GeneXpert machines with them.
o Samples for GeneXpert may include sputum, gastric aspirates.
➢ Step 6: Emphasize to the participants the importance of:
o Knowing the symptoms of TB in children
o Obtaining a sample before deciding on the next step
o Knowing the child’s HIV status in TB diagnosis
➢ Step 7: Remind/inform the participants that:
o There are different sites which can be affected by TB, including lungs, lymph
nodes, bones, the brain, abdomen, etc.
Table 13: Terms and definitions used in TB management

Term Definition
Presumptive TB A patient who presents with symptoms or signs
(Previously known as a TB suggestive of TB
suspect).
Bacteriologically confirmed TB One in whom a biological sample is positive by smear
case microscopy, culture, or GeneXpert
Clinically diagnosed TB case One who does not fulfil the criteria for bacteriologically
confirmation but has been diagnosed with active TB e.g.
using CXR, histology
Multidrug resistance (MDR) Resistance to at least both isoniazid and rifampicin
Relapse A patient who was previously treated for TB, was
declared cured or treatment completed at the end of the
most recent course of treatment, and is now diagnosed
with a recurrent episode of TB
Treatment failed A TB patient whose sputum smear or culture is positive
at month 5 or later during treatment
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Loss to follow-up (previously A TB patient who did not start treatment or whose
known as Default) treatment was interrupted for 2 consecutive months or
more
6.2.9.3 TB Treatment

➢ Step 1: Introduce the participants to the TB treatment regimens for children and adults on
page 127 of the Desk Job Aid (Anti-TB treatment regimens for infants, children,
adolescents, and adults) or Pages 90-91 of the Consolidated Guidelines.
➢ Step 2: Ask 4 participants each to read aloud one TB patient categories, matched with the
treatment regimens and the duration of treatment.
o Ethambutol is SAFE to use in children in the recommended doses.
o Streptomycin is no longer the preferred first-line in retreatment of TB.
o The health worker should attempt to obtain a sample for GeneXpert test and
drug susceptibility testing.
o If the GeneXpert test reveals rifampicin-sensitive TB, treat as a new patient
under DOT.
o If the GeneXpert test reveals rifampicin-resistant TB, refer the child to MDR
treatment site.
o If the GeneXpert test is negative or not done, refer the child to a regional
referral hospital.
Note to facilitator
Emphasize to participants that they do not have to cram the categories but should always
refer to the job aid to decide on which anti TB drugs to use and for what period
Emphasize to participants that paediatric Ethambutol is provided in a separate pill and
therefore should not break adult HERZ for children
➢ Step 3: Refer the participants to pages 201 and 202 of the Desk Job Aid or Pages 90-91 of
the Consolidated Guidelines for the TB Dosing charts.
TB treatment regimen guidelines
➢ Step 4: Conduct a Q&A session to demonstrate how to use the patient category to choose
the correct TB regimen and deciding the duration of anti-TB treatment. Have participants
refer to page 127 of the Desk Job Aid to answer the questions below.
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1. A 3 year old HIV positive girl, has a negative microscopy test, and has a positive
history of TB contact
a. Answer: 2RHZE/4RH
2. A 5 year old boy new sputum smear-positive PTB
3. A 2 year old boy with TB meningitis.
4. 10 year old boy is newly diagnosed with sputum smear-negative TB but has
extensive parenchyma involvement.
5. 30 year old with confirmed MDR-TB.
a. Answer: Refer to MDR TB treatment centre
6. 25 year old man previously treated sputum smear-positive PTB comes back after
2 months off treatment.
a. Answer: Refer to table below.
Table 14: TB Retreatment

Retreatment Cases What to do Result
Patients previously Do GeneXpert • If GeneXpert reveals Rifampicin sensitivity treat as
treated for TB to screen for susceptible
(Re-treatment cases Rifampicin • If GeneXpert reveals Rifampicin resistance, refer to
e.g. relapse, lost to resistance MDR treatment site
follow up, • If unable to obtain a sample or GeneXpert is
treatment failure) negative refer to District or Regional Hospital for
further evaluation
6.2.9.4 ARV regimens for patients with TB/HIV co-infection

➢ Step 1: Emphasize the following talking points to the participants:
o Remind participants that if not treated, TB is a major cause of mortality among
HIV patients.
o All HIV patients with TB co-infection are eligible for ART.
o For HIV patients with TB infection who are not yet on ART, they need to initiate
ART within 2–8 weeks of starting TB treatment.
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➢ Step 2: Remind participants that:
o Persons living with HIV MUST be screened for TB at every clinic visit.
o HIV patients starting ART may develop TB disease as part of the immune
reconstitution inflammatory syndrome.
o When a patient on ART develops TB disease we may need to modify their ARV
regimen to avoid drug interactions.
o Patients on ART who develop TB disease should start TB treatment immediately
and consider modifying their ARV regimen.
➢ Step 3: Introduce the participants to the recommended regimens for TB/HIV co-infected
patients initiating ART on page 129 of the Desk Job Aid (ART regimen for TB/HIV co-
infected patients initiating 1st line ART) and on page 130 of the Desk Job Aid (ART
regimen for TB/HIV co-infected patients initiating 2nd line ART) or Pages 92-93 of the
Consolidated Guidelines. Explain to the participants how the job aid should be used.
Highlight the following:
o If the patient is not on ART, initiate anti-TB treatment immediately and start ART
two weeks after initiation of TB treatment.
o For adults with CD4 count less than 50 cells/mm, ART should be initiated BEFORE
completing two weeks of anti-TB treatment
o Patients should be initiated on ART following the ART guidelines for initiating 1st
and 2nd line ART, however considerations must be taken to avoid drug-drug
interactions that interfere with effectiveness of ART (see pages 129 and 130 of the
Desk Job Aid (ART Regimen for TB/HIV co-infected patients initiating 1st and
2nd line ART) or Pages 92-93 of the Consolidated Guidelines).
o The use of Rifampicin with PIs is contraindicated. These guidelines recommend
substitution of Rifampicin with Rifabutin when using PIs. However, in the absence
of Rifabutin:
▪ LPV/r can be given at double the usual dose (give double the dose in the
morning and double the dose in the evening).
▪ Doubling the dose of ATV/r or DRV/r is NOT recommended. ATV/r and
DRV/r should only be used with a TB regimen containing Rifabutin
(Programme Rifabutin should be reserved for such patients). In the
scenario where Rifabutin is unavailable, an alternative ARV should be
selected.
▪ For patients initiating 2nd line ART, it is important to take into
consideration the previous failing regimen to ensure selection of an
effective regimen for use in 2nd line ART-TB co-treatment.
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▪ Raltegravir (given as a double dose) is recommended in TB-HIV co-
treatment for children who cannot tolerate double dosing of LPV/r or for
whom Rifabutin is unavailable for treatment with DRV/r.
o Children <20Kg on TB treatment should only be initiated on a triple NRTI regimen
(ABC+3TC+AZT) if all the other options provided in the table above are not
feasible, as this is an inferior regimen.
o After completion of TB treatment, all ART regimens that are not optimal, should
be optimized in line with the ART guideline (pages 142 and 161 of the Desk Job
Aid) or Pages 148 and 167 of the Consolidated Guidelines.
➢ Step 4: Ask participants to review the ARV regimen substitutions table on page 131 of the
Desk Job Aid (ARV regimen substitutions for adults and adolescents initiating TB
treatment while already on ART) and on page 132 of the Desk Job Aid (ARV regimen
substitutions for children initiating TB treatment while already on ART) or Pages 95-
96 of the Consolidated Guidelines.
• Highlight the following issues:
o It is NOT recommended to initiate DTG and TB treatment concomitantly due to
the risk of adverse events and complexity of ensuing management therefore avoid
optimizing regimens to DTG-based regimens while starting TB treatment.
o In case ARVs are to be substituted in patients initiating TB treatment while on
ART, careful consideration of previous ART regimens should be taken in order not
to give an ARV to which the client may already have resistance.
o Raltegravir (given as a double dose) is recommended in TB-HIV co-treatment for
children who cannot tolerate double dosing of LPV/r or for whom Rifabutin is
unavailable for treatment with DRV/r.
o Children on NVP-based regimens should be switched to a triple NRTI regimen
(ABC+3TC+AZT) only if EFV is contraindicated, as this is an inferior regimen.
o After completion of TB treatment, ensure that the ART regimen is optimized:
▪ If virally suppressed, optimize the regimen.
▪ For adults, when optimizing 2nd line PI-based regimens, ensure that the
client was not previously exposed to DTG in the 1st line ART regimen. If
the client was on a DTG-based 1st line ART Regimen and is currently on a
PI-based 2nd line regimen and virally suppressed, maintain the PI-based
regimen after TB treatment.
▪ If viral load is not suppressed switch the client to 2nd or 3rd line following
the recommendations on Page 161 of the Desk Job Aid (2nd and 3rd-line
ART Regimens) or Page 167 of the Consolidated Guidelines.
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➢ Step 5: Then answer the following questions using the desk job aid on recommended
regimens for TB/HIV co-infected patients ALREADY on ART. The trainers should
support the participants on how to use the desk job aid to get the answers.
Questions to check participant understanding:

1. What ARV regimen should 2 year old HIV boy who is on ABC/3TC+NVP be put on when
he develops TB disease?
o Answer: ABC + AZT/3TC. When TB treatment is completed, optimize regimen to
ABC+3TC+DTG or LPV/r if DTG is unavailable.
2. What ARV regimen should a 1 year old girl who was started on ABC/3TC + LPV/r be put
on when she develops TB disease?
o Answer: Substitute Rifampicin with Rifabutin or double the dose of LPV/r or
substitute LPV/r with Raltegravir (double dose).
3. John is 4 years old and has been on AZT/3TC+EFV for 3 months, he develops TB disease,
should we modify his ARV regimen?
o Answer: No. After TB treatment, optimize regimen to ABC+3TC+DTG or LPV/r.
4. Sarah a 17 year old girl who is on TDF/3TC + NVP and has developed TB, does she need
any ARV modification?
o Answer: Yes Regimen: Substitute NVP with EFV give TLE. After TB treatment
optimize to TLD.
5. What regimen substitution should a 35 year old man on TDF/3TC+DTG be put on if he
developed TB disease?
o Answer: None. Double the DTG dose, give DTG twice daily
➢ Step 7: Remind participants that:
• For patients on ART who get TB disease, start them on TB treatment immediately
and remember to modify their ARV regimen to avoid drug interactions as
applicable.
• Always remember TB/HIV co-infected patients may have other co-morbidities
which may also need drug substitutions.
• Patients on both TB and ARV medicines need to be monitored closely for side
effects from either TB drugs or ARVs or both.
• All modifications made on the drug regimens and TB treatment MUST be
documented in the appropriate HMIS tools including the comprehensive care
card, ART register and TB register.
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6.2.9.5 TB Preventive Therapy (TPT)
Introduction: HIV is the strongest risk factor for developing TB disease. TB accounts for more
than a quarter of deaths among HIV-positive patients in Uganda. It is therefore important to
prevent TB in HIV-positive patients. TB preventive therapy reduces the risk of developing TB by
approximately 60% in HIV-positive patients.

➢ Step1: Ask participants to refer to recommendations on TB Preventive Therapy on page
133 and the screening and management algorithm on page 134 the Desk Job Aid or Pages
97-99 of the Consolidated Guidelines.
Participants should note that it is important to exclude active TB before initiating. Discuss
the eligibility criteria for TPT:
• TPT.
• All HIV positive adults, adolescents and children >12 months without signs and
symptoms of active TB should be given TPT irrespective of prior history of TB
treatment and TB exposure.
• HIV-positive infants and children <5 years with a history of TB contact who have
no signs and symptoms of active TB disease, irrespective of previous TPT.
• All HIV-positive adults, adolescents and children who complete TB treatment
should receive TPT after treatment.
• HIV-positive pregnant mothers with a history of contact with a TB patient a after

ruling out active TB.
• HIV-positive pregnant mothers with a WHO Stage 3 or 4 event and/or CD4<200

without active TB.
Note:
• For HIV-positive pregnant mothers without a history of TB exposure , TPT will
be deferred until 3 months after delivery.
• For HIV positive women and adolescent girls on TPT who get pregnant, continue
and complete the TPT while closely monitoring for side effects.
➢ Step 2: Refer participants to the TPT Regimens table on page 135 of the Desk Job Aid
(TPT regimens) or Pages 98-99 of the Consolidated Guidelines and review the
recommended TPT regimens.
103
➢ Step 3: Refer participants to the TPT dosing table on page 203 of the Desk Job Aid (TPT
dosing chart) or Page 100 of the Consolidated Guidelines and review appropriate dosing
and duration of the different regimens.
o 6H: Daily Isoniazid for 6 months. Isoniazid may be available in combination with co-
trimoxazole and pyridoxine as a fixed dose combination referred to as Q-TIB: In this case,
Q-TIB is also administered daily for 6 months.
o 3HP: Weekly Isoniazid and Rifapentine for 3 months (recommended for patients aged
more than 2 years).
o 3RH: Daily Rifampicin and Isoniazid for 3 months (recommended for children less than
15 years).
➢ Step 4: Highlight the considerations for the co-administration of DTG and TPT: Although
studies have found that the co-administration of DTG and INH is well tolerated, liver
injury is a recognized adverse effect of each of these drugs. Do NOT initiate DTG and
INH concomitantly. Since there is potential for hepatotoxicity, the following are
recommendations for co-administration.
o New Patient: For newly identified patients, start on TLD with active symptomatic
monitoring for adverse events. Initiate TPT after 3 months.
o For stable patients already transitioned to DTG: If patient has been on TLD for 3
months or more, initiate TPT immediately.
o Stable patients for DTG transition and have not received TPT before:
▪ In case TLE stock is available: First complete TPT and then transition to DTG
▪ In case TLE stock is not available: Transition to DTG and initiate TPT after 3
months
6.2.9.6 TB Prevention

➢ Step 1: Emphasize to participants that TB prevention should adhere to the following
principles.
o Vaccination with BCG to prevent severe forms of TB in children.
o BCG is protective against severe forms of TB such as miliary TB and TB meningitis
and is administered at birth in Uganda. However, if an infant did not receive BCG
at birth and is confirmed to be HIV-positive, s/he should not be given BCG if they
have symptomatic HIV infection. Defer BCG till they are stable on ART.
o Early identification and prompt treatment of TB patients.
o Providing TPT.
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o Implementation of infection control practices within the health facility and
household settings.
6.2.10 Hepatitis B/HIV Co-Infection

➢ Step 1: Direct participants to review guidance presented on page 136 of the Desk Job Aid
(Management of HIV/Hepatitis B co-infection) or Page 105 of the Consolidated
Guidelines and address any questions. Inform participants that more information on
screening, diagnosis and management of hepatitis B can be found in the full Consolidated
Guidelines.
6.2.11 Pneumocystis Jiroveci Pneumonia (PJP)

➢ Step 2: Direct participants to review guidance presented on page 137 of the Desk Job Aid
(Management of Pneumocystis Jiroveci pneumonia) or Page 105 of the Consolidated
Guidelines and address any questions. Inform participants that more information on
screening, diagnosis and management of PJP can be found in the full Consolidated
Guidelines.
6.2.12 Other Opportunistic Infections

➢ Step 3: Inform participants that more information on screening, diagnosis and
management of other OIs can be found in the full Consolidated Guidelines.
6.2.13 Non-Communicable diseases (NCDs)

➢ Step 4: Direct participants to review guidance on screening, diagnosis and management
of NCDs (Diabetes, Hypertension and Depression) presented on page 138 -140 of the Desk
Job Aid or Pages 115-120 of the Consolidated Guidelines and address any questions.
Inform participants that more information on screening, diagnosis and management of
NCDs can be found in the full Consolidated Guidelines.
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6.3 Antiretroviral therapy for people living with HIV
Introduction: The aim of antiretroviral therapy is to suppress viral load levels amongst all PLHIV
to undetectable levels and reduce the risk of morbidity and mortality associated with HIV, as well
as reduce transmission of HIV. The Consolidated Guidelines recommend a ‘test and treat’ policy;
that is, ART should be initiated at the earliest opportunity in all people with confirmed HIV
infection, regardless of clinical stage or CD4 cell count.
6.3.1 When to initiate ART in children, adolescents and adults
Key Questions:
1. When should HIV positive children, adolescents and adults be started on ART using the
Consolidated Guidelines for HIV Prevention and Treatment 2020?
2. How do you evaluate a newly diagnosed HIV person for ART initiation?
Instructions for Facilitator:

➢ Step 1: remind participants about the test and treat criteria
o Ask participants to turn to page 141 of the Desk Job Aid (How to evaluate newly
diagnosed PLHIV for ART initiation) or Page 143 of the Consolidated Guidelines
and review the criteria.
o Remind participants about the Symptom Screening algorithm and Advanced
Disease Pathway (Refer to page 120 of the Desk Job Aid or Page 86 of the
Consolidated Guidelines)
Emphasize that: Symptom screening algorithm and Advanced Disease Pathway should be used
to screen all new adult and adolescent patients.
ART should be initiated at the earliest opportunity in all people with confirmed HIV infection,
regardless of clinical stage or CD4 cell count.
➢ Step 2: Ask participants to discuss how to evaluate patients for ART initiation using the
algorithm on page 141 of the Desk Job Aid (Algorithm: How to evaluate newly
diagnosed HIV-positive children, adolescents, and adults for ART initiation) or Page
143 of the Consolidated Guidelines.
➢ Step 3: Remind health workers that starting ART regardless of WHO clinical stage or CD4
does not eliminate the need for WHO clinical staging and baseline CD4 count for patient
monitoring. WHO staging and CD4 tests should therefore be done, however you don’t
have to wait for CD4 results to initiate the patients.
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6.3.2 1st line ARV Regimens for children, adolescents and adults.
Key Questions:
1. What are the new recommended regimens for initiating children, adolescents and adults
on ART?
Proposed Time: 1hour and 15 minutes

➢ Step 1: Introduce the new 1st line ARV regimens for initiating ART in children, adolescents
and adults to participants. Participants should follow along on page 142 of the Desk Job
Aid (First line ART regimens) or Page 148 of the Consolidated Guidelines
The guidelines specify the order of preference of the regimens and offer criteria for
selection of alternative regimens. In children, regimens are based on weight.
Emphasize the use of DTG-based regimens as the preferred first line regimen for ALL
PLHIV.
Note to facilitator
Emphasize the following when presenting the preferred 1st line regimens:
• All newly diagnosed PLHIV should be initiated on DTG-based regimens.
• In circumstances where the DTG dosages/formulations are not yet available, LPV/r
should be used - for children <20Kg. LPV/r is available in 3 different formulations
syrup, pellets and tablets and the formulation should be selected basing on the ability
of the child to take the formulation (pellets or tablets) as recommended.
• Prior to initiation with DTG, PLHIV should be screened for eligibility.
6.3.2.1 Dolutegravir (DTG)
➢ Step 1: Introduce the rationale for the introduction of DTG for 1st line ART.
The rationale for introducing DTG is High levels of pre-treatment resistance to NNRTI-
containing first-line, better efficacy, better tolerability, higher genetic barrier to
resistance. DTG is an acceptable alternative to EFV and NVP for use in 1st line regimens.
DTG is a once-daily, “best-in-class” integrase strand transfer inhibitor (INSTI). DTG is
currently available in country in 2 formulations: a FDC of TDF/3TC/DTG and singles of
DTG 50mg for adults and adolescents weighing ≥35kg. Formulations for children (25mg
and 10mg) tablets are expected to be available in 2020.
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6.3.2.2 Eligibility for DTG

➢ Step 2: Introduce participants to the information on eligibility for DTG use.
o Which patients are we starting on TDF/3TC + DTG at the facilities?
▪ All adults, adolescents and children including pregnant and breastfeeding
adolescent girls and women are eligible for DTG.
▪ However, there are some exceptions that are discussed below.
o Who should NOT be initiated or transitioned to DTG?
i. Clients with Diabetes
ii. Clients with 2 or more risk factors for hyperglyacaemia and a high baseline
RBS or FBS
➢ Step 3: Ask the participants to turn to page 143 of the Desk Job Aid or Page 145 of the
Consolidated Guidelines and review the screening algorithm for PLHIV initiating or
transitioning to DTG.
➢ Step 4: Review the dosing and dispensing guide on page 205 and 206 of the Desk Job Aid
(ARV dosing by formulation and weight range) or Annex 13 of the Consolidated
Guidelines with the participants.
o TDF/3TC/DTG should be taken once daily with or without food
▪ Patients should take ARVs at a convenient time daily to promote
adherence. It is preferable to take ART containing DTG in the morning to
minimize insomnia.
▪ TDF/3TC/DTG should be taken with water and swallowed without being
crushed or chewed
▪ If the patient misses a dose, it should be taken as soon as possible,
providing the next dose is not due within 4 hours. If the next dose is due
within 4 hours, the patient should not take the missed dose and simply
resume the usual dosing schedule.
o TDF/3TC/DTG comes in a pack of 30 tablets which will last a patient
approximately one month
o Co-Infected with TB: Patients on a DTG based regimen should take an extra-dose
of DTG (take the same weight appropriate dose twice a day) while taking
rifampicin containing TB treatment. Resume the usual daily dosing of DTG two
weeks after stopping Rifampicin.
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Appearance Available as single film coated pill formulation
Packaging Individual package contains 30 tablets
Storage Conditions DTG does not require refrigeration
6.3.2.3 Programmatic regimen substitutions in virally suppressed PLHIV on 1st line ART
➢ Step 1: Introduce the concept of programmatic regimen substitutions for children,

adolescents and adults who are virally suppressed on first line regimens. The ART
optimization process for adults, adolescents and children already on first line ART will
involve single or double substitutions of specific ARVs in order to align to the
recommended first-line regimens. Prior to ARV substitution the VL should be assessed
for all patients. If a VL result within the last 6 months is not available, a VL test should be
requested. Only clients with suppressed VL results (VL < 1000copies/ml) will have their
ART regimens optimized by drug substitution. If the VL is NOT suppressed (VL> 1000
copies/ml), ARV substitutions should NOT be done. These clients should be assessed and
managed as treatment failure. If the VL remains unsuppressed after IAC interventions,
the client should be switched to 2nd line ART. Note that for children and adolescents aged
less than 19 years on NNRTI-based first line regimen whose VL is not suppressed, switch
to second line ART without waiting for a repeat VL result but conduct IAC to improve
adherence to the new regimen.
➢ Step 2: Highlight the following recommendations for children with a non-suppressed
viral load:
o If the child is on an NNRTI regimen and VL is not suppressed, switch to 2nd
line immediately and do IAC simultaneously. Do not postpone switch.
o If the child is on a DTG or LPV/r-based regimen as part of first line ART,
conduct IAC and repeat VL after 3 months. DTG and PI have high resistance
barrier so poor adherence is a more likely cause for an unsuppressed VL than
resistance. If VL is still not suppressed after IAC interventions, switch to 2nd
line ART. For children and adolescents, this switch will be guided by an HIV
drug resistance test.
➢ Step 3: Have participants turn to page 144 of the Desk Job Aid (Recommended
programmatic drug substitutions in adolescents and adults) or Page 162 of the
Consolidated Guidelines and discuss ART drug substitutions in adults:
o Adolescents and adults on first line ART with a suppressed viral load result within
the last 6 months, should have their NNRTIs substituted with DTG.
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o Adults and Adolescents (≥ 30kg) on ABC shall have their ABC substituted with
TDF. Prior to the substitution ensure screening for TDF eligibility. Patients with
history of, or current renal impairment should be maintained on ABC.
o Emphasize that in pregnant and breastfeeding women. Do VL test at the 1st
ANC/PNC visit:
▪ Pregnant and breastfeeding women who are on EFV-based first-line regimens

and are virologically suppressed will remain on EFV400-based regimens
throughout pregnancy until 6-9 months post-partum when EFV400 should be
substituted with DTG if the VL within the past 6 months is suppressed.
▪ Pregnant and breastfeeding women who are on first line regimens containing
NVP, AZT or ABC and are virologically suppressed will remain on the same
regimens throughout pregnancy until 6-9 months post-partum when they shall
be transitioned to TDF+3TC+DTG if the VL within the past 6 months is
suppressed.
▪ Note: In case of a pregnant or breastfeeding woman on Abacavir consider the
possibility that she was given the Abacavir because of a contraindication to
Tenofovir. Screen the women carefully for eligibility for TDF before initiating
TLD.
o Alternative regimens will be used in case of contraindications to DTG as shown in
recommended 1st line table on page 142 of the Desk Job Aid or Page 148 of the
➢ Step 4: Have participants turn to page 145 of the Desk Job Aid (Recommended
programmatic drug substitutions in children) or Page 163 of the Consolidated
Guidelines and discuss ART drug substitutions in children:
o All children on NNRTI- based first line ART regimens with a suppressed viral load
result within the last 6 months, should have their NNRTIs substituted with DTG.
o In the absence of appropriate DTG formulations at the time of treatment
optimization, children <20Kg on EFV-based regimens who are virally suppressed
should be maintained on the same regimen until the appropriate dose of DTG is
available or until they attain weight of 20Kg when the EFV can be substituted with
DTG.
o Children <20kg on Nevirapine should be given a LPV/r-based regimen.
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o As children grow their LPV/r formulations should be appropriately adjusted from
syrups to pellets and finally to tablets. Changing formulation should be based on
the child’s ability to take pellets and tablets correctly.
o Children already on LPV/r-based regimens whose VL is suppressed should be
maintained on these regimens.
o AZT should be substituted with ABC.
o Alternative regimens will be used in case of contraindications to DTG or LPV/r as
shown in recommended 1st line table on page 142 of the Desk Job Aid or Page 148
of the Consolidated Guidelines.
Emphasize to the participants that this is important because:
• This will harmonize their treatment with the recommended regimen for that age
group and simplify forecasting and quantification.
➢ Step 5: Ask the participants to answer the following questions to check understanding.
o David is a one year old HIV positive baby. What ARV regimen would you start
him on?
▪ Answer: ABC/3TC/DTG
▪ In the absence of appropriate dosage, then the alternative regimen is
ABC/3TC+LPV/r.
o Owino is an 11 year old boy who weighs 20 kg and is ready to start ARVs. What
regimen would you give him?
▪ Answer: ABC/3TC/DTG
o Paul Mukasa is a 13 year old boy and 30 kg who needs ARVs. What regimen would
you start him on?
▪ Answer: TDF/3TC+DTG
o Nakato, a 3 year old HIV positive child weighing 18kg has been on
ABC/3TC/LPV/r pellets for the past 2 years. Her last viral load test was done 3
months ago and the next clinic visit is in one month’s time. What ART-related
interventions will you take
▪ Answer: Continue with the treatment, review VL results. If VL is
suppressed, continue the same regimen.
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6.3.3 ARV dosing, formulations and side effects
➢ Step 1: Take participants through the drug interaction with DTG and side effects of DTG.
Guide participants through the training slides on DTG drug interactions and side effects
as outlined below.
Table 15: DTG drug interactions
Drug family Interaction with DTG Action
Anti-TB medicines Rifampicin reduces DTG Adjust DTG dose to twice daily
levels to offset Rifampicin effects
Polyvalent cation products Reduce DTG levels Use DTG 2 hours before or 6
containing Mg, Al, Fe, Ca, Zn hours after the product to avoid
(e.g vitamin supplements and interaction
antacids)
Anticonvulsants (e.g Reduce DTG levels by 30- Use alternative anticonvulsants

Carbamazepine, 70% e.g Sodium Valproate
Phenobarbital and Phenytoin)
Table 16: DTG side effects
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6.3.3.1 Use of LPV/r formulations in Paediatric 1st Line ART regimens in Uganda (Syrup,
Pellets and Tablets)

➢ Step 1: Introduce the different LPV/r formulations syrup, pellets and tablets available for
HIV infected children. Emphasize that the decision to dispense syrup, pellets or tablets
should not be made basing solely on age of the child but on the individual child’s ability
to correctly take the formulations.
o Prior to dispensing pellets, there should be evidence that the pellets can be prepared
properly by the caregiver/s and the child can swallow them with soft food.
o Prior to dispensing tablets, there should be evidence that the child is able to swallow
whole tablets without crushing or chewing them.
➢ Step 2: Take participants through pages 146-148 of the Desk Job Aid to discuss how to
give LPV/r pellets.
➢ Step 3: Inform participants who should be started on LPV/r syrup using the information
below:
o Which patients should be started on LPV/r syrup?
▪ Newly initiating patients < 3 months
▪ Patients having difficulty swallowing LPVr pellets.
Which patients should NOT use LPV/r Syrup, pellets or tablets?

o Patients with hypersensitivity to LPV/r
o Patients taking other medications that are contraindicated with LPV/r
➢ Step 4: Together with the participants review the correct dosing of LPV/r, syrup, capsules
and tablets by weight band (Refer to pages 204 and 206 of the Desk Job Aid or Annex 13
of the Consolidated Guidelines).
➢ Step 5: Instruct participants to turn to page 147 in their Desk Job Aid (How to open LPV/r
capsules) in order to review correct administration of LPV/r pellets. First, walk
participants through the process of opening the capsules. Take participants through the
process of administering LPV/r oral pellets to children:
1. Open the tin, count and remove the exact number of capsules required for the
immediate dose as prescribed
2. Place the capsules on a clean surface and close the tin.
3. Hold the capsule on both ends and, twisting in opposite direction pull capsule apart.
4. Sprinkle the contents of each pellet over a small amount of breast-milk or soft food
5. This mixture should be swallowed immediately.
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Be sure to emphasize to participants that:
• Pellets MUST NOT be stirred, crushed, dissolved/dispersed in food, or chewed.
• Administration of the required dose should be followed by drinking water or
additional food to ensure that no pellets are left behind in the mouth
• No mixture of the pellets and food is to be stored for later use.
• The capsule SHOULD NOT be swallowed
• It is important to make sure the child has taken the entire dose of pellets by limiting
the food or breastmilk used to an amount the child is able to easily consume in one
swallow (e.g. 1 teaspoon), which may be followed by additional food or breastmilk
to ensure the full dose is ingested.
➢ Step 6: Review the counseling messages below with participants to ensure they can
properly counsel caregivers and answer any questions they might have. Walk participants
through the following messages that caregivers should be informed of:
• This is a new way of giving medicine that is better for their child
• The capsules must be opened and cannot be swallowed whole
• The pellets should be swallowed without chewing, crushing or dissolving
• Pellets can be mixed with a small amount of soft food or liquid (including expressed
breast milk)
• The full dose of pellets prescribed must be taken
• Pellets should be taken at the same time as other ARV medications prescribed
Note to facilitator
• You MUST demonstrate opening of the capsules and administration techniques to the
caregiver when prescribing LPV/r oral pellets for the first time.
• The recommended soft food should be one that does not require chewing to minimize
the chances of the child chewing or crushing the pellets.
• You must try to ensure ALL caregivers administering medications to the child are
adequately counselled on the administration of the pellets.
➢ Step 7: Take participants through the process of placing the first orders of LPV/r
formulations (syrup, pellets and tablets).
1. Determine the number of patients that require the LPV/r formulations (syrup, pellets
and tablets).
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• Determine the number of newly enrolled PLHIV in the different age groups of
children < 3 months, Children ≥3 months to <3 years, Children ≥3 years to <10
years.
2. Calculate quantity of LPV/r pellets to order
• From Open MRS/ART register, determine the ages of each of the patients
• Using the Dosing chart, determine the number of doses for each formulation
required per patient per day depending on the weight band dosing.
• Calculate total number of each formulation required per month for all patients
• Calculate total number of tins of for each formulation required per month
3. Place an order for LPV/r for each formulation by filling order form below
&2
n during 2
Cycle (≤ 60
Month
month
AMC =C/(2-
On-
of
stock during
of
of
+
in
Consumptio/
Month Cycle
Cycle
Adjustments
G/F
= (4 x F) - G
Pharmacy)
+ / - ) out
Adjusted
(Physical
Received
Quantity
Quantity
at start
Opening
required
PMTCT
Months
Balance
Balance
Closing
Drug Formulation
during
Hand=
(Month
Losses
Basic Unit
Count
Stores
Cycle
days)
Stock
Days
30/E)
ART
and Strength
Notes
2
2
A B C D E F G H I
ADULT FORMULATIONS
Tenofovir/Lamiv
udine/Efavirenz
(TDF/3TC/EFV)
300mg/300mg/60 Pack
2 0mg of 30
Zidovudine/Lam
ivudine/Nevirapi
ne
(AZT/3TC/NVP)
300mg/150mg/20 Pack
3 0mg of 60
Tenofovir/Lamiv
udine (TDF/3TC) Pack
4 300mg/300mg of 30
Zidovudine/Lam
ivudine
(AZT/3TC) Pack
5 300mg/150mg of 60
115
Abacavir/Lamiv
udine (ABC/3TC) Pack
6 600mg/300mg of 30
Atazanavir/Rito
navir (ATV/r) Pack
7 300mg/100mg of 30
Lopinavir/Riton Pack
avir (LPV/r) of
8 200mg/50mg 120
Dolutegravir Pack
9 (DTG) 50mg of 30
Efavirenz (EFV) Pack
10 600mg of 30
Nevirapine Pack
11 (NVP) 200mg of 60
Zidovudine Pack
12 (AZT) 300mg of 60
PAEDIATRIC FORMULATIONS
Abacavir/Lamiv
udine (ABC/3TC) Pack
1 120mg/60mg of 60
Zidovudine/Lam
ivudine/Nevirapi
ne
(AZT/3TC/NVP) Pack
2 60mg/30mg/50mg of 60
Zidovudine/Lam
ivudine
(AZT/3TC) Pack
3 60mg/30mg of 60
Lopinavir/Riton
avir (LPV/r) Pack
40mg/10mg of
pellets 120
116
Lopinavir/Riton
avir (LPV/r) Pack
4 100mg/25mg of 60
Efavirenz (EFV) Pack
5 200mg of 90
Nevirapine Pack
6 (NVP) 50mg of 60
Abacavir (ABC) Pack
7 60mg of 60
6.3.4 Prescribing ARVs for children, adolescents and adults
Introduction: The focus of this session is to introduce the revised ARV dosing chart for children,
adolescents & adults. This session is designed to be interactive and to get participants to practice
how to use the revised ARV dosing chart.
Key Questions:
1. How do we prescribe appropriate doses of each formulation for children, adolescents and
adults?
➢ Step 1: Review key steps to prescribing ARVs by asking participants to tell you what the
steps are for:
o Adults and adolescents
o Children
Once a patient has been identified as eligible for ART and prepared to initiate treatment,
there are three steps to prescribing ARVs:
1. Identify the proper regimen to prescribe, based on the national guidelines
and clinical condition of the patient.
2. Select which ARV formulations to use, based on the regimen selected.
Emphasize the benefits of using FDCs.
3. Prescribe the right dose.
Use the ARV dosing chart to prescribe the proper amount of each formulation, based on
the patient’s weight.
Emphasize the importance of taking weight and referring to the ARV dosing chart
while prescribing ARVs for children at all clinic visits.
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➢ Step 2: Give each pair of participants the ARV Dosing Chart or ask them to refer to the
ones on pages 205 – 206 in the Desk Job Aid (ARV dosing by formulation and weight
range) or Annex 13 of the Consolidated Guidelines and review it in detail.
➢ Step 3: Ask participants to work in pairs to answer the following questions using the desk
job aid. Using the job aid to answer the questions helps them familiarize with the tool and
increases their chances of using it thereafter. After answering the questions, ask different
pairs to share their answers with the whole group.
1. David is 6 month old HIV-positive baby whose weight is 7kg who went through PMTCT
(mother received ART and the baby was given Nevirapine for 6 weeks). You would like
to start David on ABC/3TC/LPV/r. What dose would you prescribe?
a. Answer: ABC/3TC (60/30) - 1.5BD and LPV/r-1.5 mls
How much of each formulation would you dispense for 30 days?
b. Answer: ABC/3TC (60/30) – 90 tablets LPV/r-45 mls
2. Owino is a 11 year old boy who weighs 20 kg and is ready to start ARV’s. You would like
to initiate him on ABC/3TC+ DTG. What dose would you prescribe?
a. Answer: ABC/3TC (120/60) - 3 OD and DTG (10mg)- 3 OD.
How much of each formulation would you dispense for 30 days
b. Answer: ABC/3TC (120/60)- 90 tabs and DTG (10mg)- 90 tabs
6.3.5 Follow-up and Monitoring of ART Patients
Introduction: This chapter provides guidance on how to and when to use clinical assessment and
laboratory monitoring tests to monitor response to ART, ART side effects and toxicity, and how
to diagnose ART treatment failure.
Key Questions:
1. Why do we monitor response to ART?
2. How do we monitor response to ART?

➢ Step 1: Ask participants to tell you why we monitor patients on ART. As they brainstorm,
refer to the following answers to ensure all have been mentioned.
The purpose of monitoring patients on ART is to assess:
o Response to ART and diagnose treatment failure
o Safety of the medicines- side effects and toxicity
o Adherence to ART
118
➢ Step 2: Ask the participants to tell you how they would monitor the clients on ART?
6.3.5.1 Clinical Monitoring
➢ Step 1: Briefly review the components of a comprehensive clinical assessment of PLHIV

Components
• Demographics (age, sex etc.)

• Symptom Screen and Advanced Disease Pathway-ask all patients all questions
• Screen for signs and symptoms of Hepatitis B and C infections, malaria, and other
infections
• Screen for pregnancy (women of reproductive age)
• Screen for co-morbidities
• Screen for STIs
• Screen for symptoms of depression
• Obtain previous history of ART
• Obtain previous history of chronic illnesses (hypertension, DM, COPD, kidney disease)
• Obtain a list of current medication(s)
• Screen for side/adverse effects of medications.
• Establish family planning methods currently in use
• Assess development, sexual awareness and behavioral issues in adolescents
• Assess school attendance (children of school-going age)
• Determine progress with disclosure if not done already
• Perform nutritional assessment: weight and height in all patients, plus mid-upper arm
circumference (MUAC) in children 6-59 months
• Assess growth and development in children under 5 years; monitor for changes
• Ensure examination of vital signs, skin, eyes, oropharynx (presence of thrush), lymph
nodes, lungs, heart, abdomen, genital tract (for STIs), extremities, nervous system
• Determine WHO clinical staging
6.3.5.2 Laboratory Monitoring
Viral load monitoring

Uganda adopted viral load monitoring as the preferred approach for monitoring response to ART
and to diagnose/confirm ART treatment failure. Compared to clinical or immunological
monitoring, virological monitoring:
119
• Provides an early and more accurate indication of treatment failure and the need to switch
from first-line to second-line drugs, hence reducing the accumulation of drug resistance
mutations and improving clinical outcomes.
Instruction for facilitators:
➢ Step 1: Review viral load monitoring frequency with participants and the viral load
algorithm on pages 153 and 154 of the Desk Job Aid (Viral load algorithm for children,
adolescents and adults including pregnant and breastfeeding women) or Page 151 of
the Consolidated Guidelines.
o Frequency of viral load
▪ Adults: the first VL test should be done at 6 months, then at 12 months
after ART initiation, and thereafter, every 12 months, if it is suppressed. If
not suppressed, follow the algorithm listed below.
▪ Children and adolescents under 19 years of age: the first VL test should
be done at 6 months after initiating ART, then at 12 months after ART
initiation, and if it is suppressed, do VL every 6 months.
▪ Pregnant and breastfeeding women:
• If newly initiating ART, follow the standard algorithm like adults;
do VL at 6 and 12 months after ART initiation, then every 6 months
if they are suppressed, till cessation of breastfeeding. If non-
suppressed, follow VL algorithm and IAC flow chart.
• If already on ART, a VL test is done at ANC 1, irrespective of when
the last VL test was done, then every six months until cessation of
breastfeeding.
▪ Emphasize that pregnant and breastfeeding women will be monitored 6 monthly

and not every 12 Frequency of viral load monitoring
▪ Frequency of viral load monitoring

▪ The following criteria were added to the previous
▪ After every switch in treatment (after failure): The VL test should be done at 6
months after a switch to second- and third-line ART.
▪ Third line ART patients: The VL test should be done every 6 months. If a VL >1000
copies is detected (un-suppressed VL) then genotype testing is recommended.
➢ Step 2: Review the procedure of what to do when viral load is not suppressed (VL >1000
copies per ml). For non-suppressed PLHIV, the following should be done:
120
o Contact the patient to return to facility within one week after facility receives
results.
o Ensure that facility ART team holds case discussions on patients with non-
suppressed VLs to determine possible causes of non-suppression.
o Discuss results with the patient and assess for barriers to adherence.
o Do intensive adherence counseling support monthly for three months
o Repeat VL test one month after the last (3rd) intensive adherence counseling session
(the repeat viral load test should be done within 6 months of the last unsuppressed
VL test).
o If the repeat VL is suppressed, follow the standard algorithm.
o If repeat VL is not suppressed, and the ART team is confident that the patient is
adherent, then the patient is failing on the current ARV regimen and should be
switched.
➢ Step 3: Review the 10 point change package for non-suppressed clients which is on page
155 of the Desk Job Aid (When viral load is NOT suppressed) or Page 152 of the
➢ Step 4: Take participants through the non-suppressed cascade which ART clinic staff must
track monthly.
The cascade is based on cohort of patients who were non-suppressed 6 months prior to reporting
period.
Non suppressed Completed IAC Got a 2nd VL Non-suppressed Switched to

test at 2nd test next line
regimen
CD4 monitoring
Although CD4 cell count is no longer the mainstay for ART response monitoring and is not a
precondition for initiating ART, it is still recommended in the following scenarios:
121
- At baseline when initiating ART. (Baseline CD4 helps to screen for risk for opportunistic
infections, e.g. cryptococcal infection in patients with CD4 less than 100 cells/mm 3.
-ART patients with VL >1000 copies/ml and/or WHO clinical Stage 3 or 4 disease
-PLHIV who are on treatment or prophylaxis for cryptococcal infection to inform decision on
when to stop fluconazole.
Other laboratory tests

Other laboratory tests should be done when clinically indicated.
➢ Step 1: Ask participants to turn to pages 149-151 and 156 of the Desk Job Aid or Pages
153-154 of the Consolidated Guidelines and discuss the other follow up laboratory tests
that could be done to monitor response.
➢ Step 2 Ask participants to turn to page 157 of the Desk Job Aid (Monitoring patients
initiated or transitioned to DTG) or Page 155 of the Consolidated Guidelines and discuss
the monitoring algorithm for severe adverse events for clients initiated or transitioned to
DTG. Highlight the importance of monitoring clients on DTG for hyperglycaemia
especially those ate high risk:
o Age ≥ 45 years
o BMI≥ 24 kg/m2
o History of hypertension
➢ Step 3: Ask participants to turn to page 158 of the Desk Job Aid (Genotype testing) or
Page 152 of the Consolidated Guidelines and discuss genotype testing and the
recommended targeted approach:
The following categories of patients will receive Genotype testing to identify optimal ART
regimens:
o All children <15 years failing on 1st line ART:
▪ Children exposed to both AZT/3TC and ABC/3TC NRTI backbone and are
failing on their first line ART treatment.
▪ Infants born to mothers failing treatment (first, second or third line)
▪ Children receiving Lopinavir/ritonavir or Dolutegravir on first-line ART
and who have a repeat viral load result >1000 copies/ml following
intensified adherence counselling.
o Patients failing on a PI-based regimen irrespective of line of care.
o Patients with a prior exposure to a PI and failing on a DTG based regimen and vice
versa.
o All patients failing on their second line ART.
o All patients failing on their third line ART.
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Note to facilitator
• Ask participants to work in pairs to answer the following questions using the desk job aid.
Using the job aid to answer the questions helps them familiarize with the tool and increases
their chances of using it thereafter.
• After answering the questions, ask different pairs to share their answers with the whole
group.
Question: Patrick is 1 year old boy who is HIV positive by DNA PCR. He is enrolled into HIV
care today.
• What baseline tests would you do?
o Answer: Hb and CD4 count
• He is initiated on ART, when would you do the next monitoring tests?
o Answer: 6 months
• What tests would you do?
o Answer: Do viral load.
6.3.5.3 What to expect in the first months of ART
➢ Step 1: Review the following information with participants. Emphasize that although
ART is a lifelong commitment, the first months of therapy are especially important.
• Clinical and immunological improvement and viral suppression are expected when
individuals adhere to ART.
• Opportunistic infections (OIs) and immune reconstitution inflammatory syndrome (IRIS)
may develop, as well as early adverse drug reactions, such as drug hypersensitivity,
especially in the first three months of treatment.
• ART significantly decreases mortality overall, but death rates are also highest in the first
three months of ART. These complications are most common when the people starting
ART already have advanced HIV disease with severe immunodeficiency (very low CD4
cell counts) and existing co-infections and/or comorbidities, severely low hemoglobin, or
are severely malnourished/ low body mass index.
• Poor adherence in this period is also associated with the risk of early treatment failure and
rapid development of drug resistance.
• ARV drug toxicity.
123
6.3.6 Switching ARVs in children, adolescents and adults
Key Questions:
1. What is switching an ARV regimen?
2. How do we decide to switch 1st line to 2nd line?
Proposed time: 20minutes
Instructions for facilitator

➢ Step 1: Ask the participants what they understand by the following terms:
o ARV Substitution
o Switching a regimen (Note: Be sure to clarify the difference between “substitution” and
“switching”)
o Treatment failure
Refer to information in below as you discuss answers
Substitution is the process of replacing one ARV drug with another in situations such:
• Toxicity/ side effects
• Development of OI like TB, Hep B, etc
• Change in treatment guidelines (remind participants that its critical to ensure that the
patient is virologically suppressed before ARV substitutions. A recent VL (within past
6 months) must be reviewed and if unavailable, repeat the VL before substitution).
Switching an ARV regimen is:
• The process of replacing 2 or more ARV drugs due to treatment failure
Parameters to assess ARV Treatment Failure include:
• Clinical
• Immunological
• Virological
6.3.6.1 Making the decision to switch from 1st line to 2nd line or 3rd line ARV Regimens
Instructions for facilitators: As you introduce the new guidelines for switching to 2nd or 3rd line
ARV regimen, ask participants to refer to page 159 of Desk Job Aid (Criteria for switching ART
regimen due to treatment failure) or Page 163 of the Consolidated Guidelines for the guidelines
on when to switch an ARV regimen.
124
➢ Step 2: Introduce the new guidelines for switching from 1st line to the 2nd line or 2nd to 3rd
line ARV regimen. Go through the process of switching with the participants using page
160 of the Desk Job Aid (Prior to switch).
o An individual must have been on ART for at least six months before you can
determine that a regimen has failed (remind the participants that it is important to
differentiate between IRIS and treatment failure)
o Before switching therapy, it is essential to assess and address adherence issues.
o Following a 1st VL >1000 copies/ml, carry out 3 IAC sessions. Repeat VL test after
IAC, if still >1000copies/ml→ switch ART:
• Emphasize that even if the viral load drops at the 2nd VL test (following IAC), if it is still
>1000 copies/ml, the patient’s ART should be switched.
o Genotype testing according to guidelines to determine optimal regimens
• Emphasize that
o If the child is on an NNRTI regimen and VL is not suppressed, switch to 2nd line
immediately and do IAC simultaneously. Do not postpone switch.
o If the child is on a DTG or LPV/r-based regimen as part of first line ART, conduct
IAC and repeat VL after 3 months. DTG and PI have high resistance barrier: poor
adherence is a more likely cause for an unsuppressed VL than resistance.
➢ Step 3: Tell participants that even patients on 2nd line regimens can get treatment failure.
Ask them to refer to the desk job aid on when to switch for the criteria for switching from
2nd to 3rd line ARV regimens.
When to switch from 2nd to 3rd line ARV regimen

Switching Considerations
Determining treatment failure among patients on 2nd line regimens should be guided by ARV
resistance testing page 158 of the Desk Job Aid and results should be interpreted in view of
the first line ART regimen.
6.3.6.2 2nd Line ARV regimen for patients Failing on 1st Line
Key Questions:
1. What 2nd line ARV regimens are used in Uganda?
2. What 3rd line ARV regimens are used in Uganda?
Proposed time: 20 minutes
Instructions for facilitator: Inform participants that:
125
• Second line ART for adults, adolescents and children will be either PI-based or DTG-based
depending on what anchor ARV was used in the first line regimen. The choice of the NRTI
backbone for the 2nd line regimen will also depend on what was used for the 1st line NRTI
backbone.
• All 3rd line regimens are to be guided by resistance testing.
➢ Step 1: Ask the participants to turn to page 161 of the Desk Job Aid (2nd and 3rd line ART
regimens) or Page 167 of the Consolidated Guidelines and review the 2nd and 3rd line ARV
regimens with them. Emphasize the need to consider previous regimens in selection of
optimal 2nd and 3rd line regimens.
➢ Step 2: Now ask the participants to turn to page 162 of the Desk Job Aid (Recommended
programmatic regimen substitutions in adults on 2nd line ART with suppressed VL) or
Page 168 of the Consolidated Guidelines and review the recommended programmatic
drug substitutions in virally suppressed patients on 2nd line ART. The discussions should
be guided by the recommendations below:
• Adults on ATV/r or LPV/r-based 2nd line regimens who are virally suppressed (basing on
VL result within the past 6 months) and who did not receive DTG in their 1st line regimens
should have ATV/r or LPV/r substituted with DTG.
• Pregnant and breastfeeding women on ATV/r or LPV/r-based 2nd line regimens who are
virally suppressed and who did not receive DTG in their 1st line regimens should be
maintained on the same regimens. At 6-9 months postpartum, if their VL is suppressed
(basing on VL result within past 6 months), ATV/r or LPV/r should be substituted with
DTG.
➢ Step 3: Emphasize that although simplification of regimens (once-a-day dosing) is a main
goal of ART optimization, children and adolescents who are virally suppressed and stable
on 2nd line regimens containing twice-daily LPV/r will be maintained on their regimens so
as to preserve their options for 3rd line regimens. Drug substitutions may be considered
on a case by case basis especially in children and adolescents in whom twice-daily dosing
may hinder adherence.
126
6.3.6.3 What 3rd line ARV regimens are used in Uganda?
Formulation of 3rd line regimen will be guided by resistance testing. Have participants review
the 3rd line decision making flow chart on page 163 of the Desk Job Aid (3rd Line Decision-
Making Flowchart) or Page 169 of the Consolidated Guidelines.
Note to facilitator
Finally, emphasize to participants that they should: Always consult and discuss a case with
a colleague before substituting a drug or switching the regimen
6.3.6.4 Case study practice to check understanding of participants.
Ask participants to work in pairs and use their desk top job aide to answer the following
questions, one at a time as you read them. Participants should give answers to one question at a
time and then proceed to the next.
1. Pat, an 8 year old boy has been on ABC/3TC/EFV for 3 years now. He has been adherent
and doing very well until 1 month ago when he developed skin rashes and pneumonia.
His viral load is unsuppressed (5000 copies/ml) after intensive adherence intervention.
From this information do you think Pat is failing on his first line regimen?
a. Answer: Yes - Duration on ART >24 weeks, Adherent-Yes, Clinical failure- yes,
virological failure-Yes
2. If yes, which regimen would you switch him to?
a. AZT + 3TC + DTG
b. Alternative regimen: AZT+3TC+LPV/r
6.4 Pharmacovigilance
Introduction: Pharmacovigilance (PV) encompasses activities relating to the detection,

assessment, understanding, and prevention of adverse effects of medicines or any other medicine
related problems. The latest guidelines recommend heightened pharmacovigilance, to ensure
safety of all ARVs and other medications within the population.
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6.4.1 Detection, management and reporting of adverse effects of medications
Key Questions:
1. What procedures should be followed to detect and report adverse effects?
2. How are adverse effects investigated and managed?
➢ Step 1: Define drug toxicities/adverse events and describe the importance of PV

highlighting the following:
o Toxicities or adverse drug reactions refer to unintended harmful events due to

exposure to medicines.
o Toxicities many occur at any time during treatment. They may be mild to severe and
should be anticipated and monitored in a timely manner to avoid severe morbidity
and mortality outcomes.
o Adverse drug reactions may negatively affect treatment uptake, adherence and
retention in care.
➢ Step 2: Ask the participants to turn to page 164 of the Desk Job Aid (Pharmacovigilance)
or Page 173 of the Consolidated Guidelines and discuss the steps and flow of information
in PV. Use the diagram to highlight specific roles and responsibilities of the health
workers and other stakeholders.
➢ Step 3: Discuss the process of screening and investigations for the different types of PV:
o Ask the participants to turn to page 165 of the Desk Job Aid (Screening tool for
Active Pharmacovigilance) or Page 176 of the Consolidated Guidelines and
review the Screening tool to be used to screen for side effects. Explain that the
health worker must inquire about all the symptoms on the checklist and record
them appropriately in all forms of PV at every visit.
o Emphasize that there are different methods of PV. The method approved for all
HIV and TB implementing site is Active Pharmacovigilance.
➢ Step 4: Discuss the steps of reporting with Active PV. Ask participants to turn to page 166
of the Desk Job Aid (Methods of PV) or Page 173 of the Consolidated Guidelines for the
discussion.
➢ Step 5: Discuss the laboratory monitoring schedules for active pharmacovigilance in both
non-sentinel and sentinel sites on pages 167 and 168 of the Desk Job Aid or Pages 177-178
of the Consolidated Guidelines.
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6.4.2 Managing ARV Drug Toxicity
Instructions for facilitator

➢ Step 1: Review the following information on managing ARV drug toxicity with
participants. Emphasize that at every clinic visit healthcare workers should assess
patients on ART for ARV side effects and toxicities as well as toxicities from other
medications the client may be taking. If the patient has side effects or toxicity do the
following:
o Determine the seriousness of the toxicity.
o Evaluate concurrent medications and establish whether the toxicity may be
attributable to an ARV drug or drugs, or to a non-ARV medication taken at the
same time.
o Consider other disease processes. Not all problems that arise during treatment are
caused by ARV drugs.
o Manage the side effects and toxicities according to severity.
o Report the event using the National DrugAuthority (NDA) adverse drug reaction
form.
➢ Step 2: Review the management of ARV side effects and toxicities on pages 169 of the
Desk Job Aid (Management of ARV side effects and toxicities) or Pages 178-179 of the
Consolidated Guidelines with the participants. During the discussion highlight that
symptoms and laboratory test results should be used to grade the severity of the drug
toxicity/adverse drug reactions and that the severity grading should guide the
management. Refer the participants to Chapter 9 Pharmacovigilance of the Consolidated
Guidelines 2020 for details of symptom and laboratory test severity grading.
➢ Step 3: Ask the participants to turn to pages 170-172 of the Desk Job Aid (Toxicities/side
effects of ARVs and recommended substitutions in adults, adolescents, and children)
or Pages 157-160 of the Consolidated Guidelines and review the side effects/toxicities and
the presenting symptoms of commonly used ARVs. Guide the participants on identifying
the appropriate management and ARV substitution.
➢ Step 4: Ask the participants to turn to pages 173 of the Desk Job Aid (Management of
Hyperglycaemia following DTG initiation) or Page 181 of the Consolidated Guidelines
and discuss the management of hyperglycaemia following initiation of DTG. Reiterate the
importance of screening and monitoring clients on DTG for hyperglycaemia.
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MODULE 7. Service Delivery Models
7.1 Differentiated Service Delivery
Introduction: To achieve the UNAIDS 95–95–95 targets, Uganda adopted innovative and efficient
strategies to deliver HIV & TB prevention, care, and treatment services to address the needs of
different sub-populations of clients under HIV care. These programmatic adaptations are called
“differentiated HIV and TB service delivery models.” This section presents the recommended
differentiated care models for HIV testing services and care and treatment for PLHIV & TB for
adoption by the facilities and communities managing PLHIV. The details on how the
differentiated care models will be implemented in Uganda are described in the Implementation
guide for differentiated service delivery models of HIV and TB services in Uganda.
Key Questions:
1. What is Differentiated Service delivery (DSD)?
2. Why DSD?
3. How is DSD implemented?

➢ Step 1: Ask participants to turn to page 175 of Desk Job Aid (Differentiated Service
Delivery) or Page 184 of the Consolidated Guidelines and discuss what DSD is. The
following should be highlighted:
Differentiated service delivery refers to various ways of providing HIV prevention, care
and treatment services that are tailored to the needs and preferences of PLHIV with the
aim of maintaining good clinical outcomes and improving efficiency in service delivery.
➢ Step 2: Ask participants to discuss why differentiated service delivery is needed.
Highlight the following:
o Undifferentiated HIV service delivery is characterised by:
▪ Limited access to HTS by high risk and vulnerable sub-populations who do
not frequent facilities
▪ Partial integration of services
▪ Low HTS yield in some populations
▪ Overcrowding of clients on clinic days
▪ Delays in service delivery
▪ Monthly refills for all clients
▪ Repetitive and unnecessary clinic visits for stable clients
▪ Inappropriate mixing of clients and services e.g. adolescents and adults; weak
and stable patients
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▪ Untailored group counselling and health education due to the mix of clients
▪ Excessive workload for health workers
o Benefits of differentiated service delivery
Differentiated HIV Testing Services
▪ Promote targeting to maximize the yield with focus on the high risk and
vulnerable sub populations.
▪ Encourage adapting service delivery to the needs and preferences of patient
groups and the constraints of services providers
▪ Increase access and utilization of HTS by addressing specific barriers,
bottlenecks or requirements of a sub population of individuals to enable them
to know their HIV status
▪ Support linkage to treatment and prevention services
▪ Promote integration of HIV testing and screening with other health service
▪ Encourage decentralization of HIV testing services
▪ Encourage and supports task-shifting
Differentiated Care and Treatment Services
▪ Optimize staff workload
▪ Promote service delivery cost-efficiency
▪ Ensure reduced frequency and burden of travels to facilities, providing clients
more opportunities to engage in other activities (e.g. household activities,
IGAs)
▪ Create opportunities for tailored counselling and health education
▪ Promote improved client clinical outcomes
▪ Empower clients to take care of their treatment and care needs
▪ Encourage and supports task-shifting
▪ Lead to improved client and health worker satisfaction
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7.1.1 Building Blocks for DSD
Instructions for faciliators:

➢ Step 1: Ask the participants what the the building blocks of DSD are. Note the responses
and then go through the DSDM building blocks diagram and clarify. Refer to page 175 of
the Desk Job Aid (The 4 Building blocks of DSDM) or Page 184 of the Consolidated
Guidelines.
7.1.2 Elements of differentiation in Uganda
➢ Step 2: Review page 176 of the Desk Job Aid (Elements of differentiation in Uganda) or
Page 185 of the Consolidated Guidelines.
Inform the participants that to provide client-centered care, there is a need to consider the
following:
o The clinical characteristics of the client (stable, unstable or complex)
o The sub-population (e.g., adults, children and adolescents, pregnant and breastfeeding
women, key populations, men)
o The context (e.g., urban/rural, unstable context, epidemic type)
This allows the building of appropriate models of HTS and HIV treatment and care using the
building blocks described earlier.
7.1.3 Two services for adopting Differentiated Models
Introduction: The two services for adopting differentiated models are:

1. Differentiated HIV testing services
2. Differentiated HIV care and treatment services
➢ Step 1: Have participants review the recommended differentiated HIV testing services
models and approaches on page 177 of the Desk Job Aid Recommended Differentiated
HTS Models and Approaches) or Page 186 of the Consolidated Guidelines. Emphasize
the following:
Differentiated HIV testing services are service-delivery models that are adapted to
address the specific barriers or bottlenecks of a subgroup of individual clients to enable
them to know their HIV status. Differentiated HTS will facilitate early diagnosis of as
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many people as possible aiming to maximize yield, efficiency, cost-effectiveness and
equity.
The recommended models and approaches for differentiated HTS:

1. Facility-based HTS shall include provider-initiated HTS (i.e. Routine HTS, Testing after
using screening tool, Diagnostic HTS and index client HTS) and client-initiated
counselling and testing (i.e.at OPD and other testing points or Health Facility based Drop
in Centres).
2. Community-based HTS shall include provider-initiated HTS (i.e. Home-based HTS,
Snowballing and HTS in education establishments for sexually active youth) and client-
initiated counselling and testing (i.e. outreach/mobile HTS and HTS at Community Drop-
in Centres).
➢ Step 2: Have participants review the client categories for differentiating HIV Care and
Treatment on pages 178-179 of Desk Job Aid (Client categories for differentiating HIV
Care and Treatment) or Page 187 of the Consolidated Guidelines
o Emphasize criteria for categorizing clients into stable or unstable/complex.
*All stable clients transitioned to new regimen due to policy changes (e.g. ART optimization)
shall be retained in their current DSD approaches if all other factors stay constant however
pharmacovigilance MUST be emphasized. See section on DSD implementation in the context of
ART optimization for details.
o For a client to be stable, must meet all the above criteria for stable clients.
o Clients with uncontrolled chronic co-morbidities (e.g. Hypertension, Diabetes,
Cardiac diseases, and renal diseases) should be considered unstable until control
is achieved.
o Pregnant women can fall in either stable or unstable/complex categories,
depending on their characteristics. They are, however, differentiated to only
facility-based approaches.
o Health workers may take into consideration other issues not included in the lists
above, e.g. psychosocial problems/issues, family support, etc. to determine
whether a client is stable or not.
➢ Step 3: Have participants review the recommended differentiated care and treatment
service delivery models and approaches on page 180 of Desk Job Aid (Recommended
Differentiated HIV Treatment and Care Models and Approaches) or Page 188 of the
Consolidated Guidelines. Emphasize the following:
o Differentiated HIV care and treatment: Refers to a strategic mix of approaches to
address the specific requirements of a subgroup of clients living with HIV. It
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includes approaches aimed at modifications of client flow, schedules and location
of HIV treatment and care services for improved access, coverage, and quality of
care.
o The recommended models and approaches of differentiating HIV treatment and
care include:
o Facility model (i.e. Facility Based Individual Management (FBIM), Facility
Based Groups (FBG) and Fast Track Drug Refills (FTDR))
o Community model (i.e. Community Drug Distribution Points (CDDP) and
Community Client Led ART Delivery (CCLAD))
➢ Step 4: Have participants review the recommended differentiated care and treatment
service delivery models and approaches for various age groups as well as for specific
populations and circumstances (pages 181-182 of the Desk Job Aid) or Page 189 of the
Explain the eligibility for each of the models by the various populations and emphasize
that children should ideally receive care together with their caregiver for convenience.
Likewise, both caregiver and child should return to the facility models if either of them
becomes unstable and is referred to the facility for care.
1 and 2, Stable children 2 - <10years can join FTDR or CDDP if their parents/care
givers are stable and choose to join these approaches.
3 and 4, Stable adolescents 10 – 14years can join CCLADs or CDDP if their
parents/care givers are stable and choose to join these approaches.
3, Stable adolescents (10 – 14years) can be CCLAD members if their parents/care
givers are stable and choose to join CCLADs but they cannot pick drugs on behalf
of the other members. The responsibility of picking drugs will be for the
parent/care giver in a given CCLAD group.
5 and 6, Stable adolescents 15 – 19years can join CCLADs or CDDPs if they choose
to.
5, Adolescents 15 – 19years can form an adolescent only group if they choose to.
➢ Step 5: Reiterate and define the eligibility criteria for multi-month dispensing. (page 185
of the Desk Job Aid) or Page 188 of the Consolidated Guidelines. Emphasize the follow.
This is defined as prescriptions for 3- or 6-months. Previous guidelines recommended 3
months prescriptions for stable clients on stable approaches i.e. FTDR, CDDP and
CCLAD. These guidelines recommend the introduction of 6 months prescription for high
risk clients in whom frequent drug pickups may compromise their adherence to ART.
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Only stable clients will be considered for 6-month refills of ART in addition to meeting all
the following criteria:
• ≥15 years
• Not pregnant or breastfeeding
• Repeat VL not due in less than 6 months
• Not TB/HIV co-infected
• No regimen switch or substitution in the last 6 months
• Completed INH prophylaxis
Six-month refills can be provided through FTDR or CDDP approaches.
➢ Step 6: Highlight the current recommendations for early differentiation: At 6 months after
initiation of ART, a client can be classified as stable and qualify to be differentiated into
approaches for stable clients in the facility and the community.
➢ Step 7: Discuss DSD implementation in the context of ART optimization. (page 186 of the
Desk Job Aid) or Page 190 of the Consolidated Guidelines. Emphasize the following:
All stable PLHIV transitioning to other regimens due to policy changes (e.g. ART
optimization) shall be retained in their current DSD approaches if all other factors stay
constant. Efforts should be made to strengthen pharmacovigilance in all DSD models and
approaches. The following are recommended as health workers optimize ART for the
PLHIV enrolled onto FBIM, FBG, FTDR and CCLAD:
o Providing one-month refill at regimen change
o Providing patient education about side effects and when to return to facility
o Scheduling a clinical review one-month post regimen change
o If no major concerns are identified during the clinical review one-month post
regimen change, stable clients can resume multi-month refills (MMRs)
Clients enrolled onto Community Drug Distribution Point (CDDP) approach shall have
their regimen optimization done as follows:
o Regimen change done by clinician at the CDDP
o Patient education about side effects and when to return to facility provided at the
CDDP
o 3-months refill provided
o Clinical review scheduled at 1 month after regimen change at the facility.
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o If no major concerns identified the client is referred back to the CDDP for the next
scheduled visit.
o If no major concerns are identified during the clinical review one-month post
regimen change, the client is referred back to the CDDP for the next scheduled
visit.
➢ Step 8: Discuss the procedures for provision of TPT in Community DSD approaches:
(pages 183-184 of the Desk Job Aid) or Pages 190-191 of the Consolidated Guidelines.
Emphasize the following;
• TPT initiation
o TPT should be initiated by a clinician regardless of which DSD approach the client is on.
Efforts should be undertaken to have baseline tests done (i.e. LFTs) prior to initiation of
TPT.
o TPT should be initiated at the health facility for all clients receiving ART services through
FBIM, FBG, FTDR and CCLAD.
o For clients enrolled onto CDDPs, TPT should be initiated from the CDDP during the
clinicians visit. Efforts should be undertaken to have baseline tests done (i.e. LFTs) at the
time of initiation of TPT.
o Patient education about side effects and when to return to the facility should be provided
at the time of TPT initiation regardless of DSD approach.
TPT and ART refills should be aligned
• Monitoring clients on TPT
o Clinical monitoring of clients on TPT should be done at every clinical encounter regardless
of DSD approach the client is on:
▪ Monitoring can be done through history taking and physical examination for signs
suggestive of hepatic injury (i.e. Yellowing of eyes, body itching, body rash)
▪ Monitoring can also be done through follow up phone calls to the clients. During
the phones calls health workers should explore for signs of liver injury, adherence
to treatment and provide client education.
▪ LFTs should be done at baseline and at 3 months
o Clients in more intensive approaches (i.e. FBIM and FBG) should be reviewed every
month for TPT and ART toxicities
• Clients in less intensive approaches (i.e. FTDR, CDDP and CCLAD) should be reviewed
at least once every three months. Review at 3- and 6-months post TPT initiation should
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happen at the facility for clients enrolled onto FTDR and CCLAD. Review at 3- and 6-
months post TPT initiation for clients enrolled onto CDDP should happen at the CDDP.
➢ Step 9: Highlight Differentiated HIV services for special subpopulations. (Page 192 of the
Consolidated Guidelines. Emphasize the following:
o Group ANC and PNC for AGYW

o Adolescent peer programming e.g. Young people and adolescent peer support (YAPS)
o Key populations
➢ Step 10: Highlight managing special situations. (page 187 of the Desk Job Aid).
Emphasize the following:
Managing transitions from PMTCT to ART and from paediatric/adolescent groups to

adult clinics
o These clients should be automatically transitioned to the adult ART
models/approaches and supported appropriately
Managing clients who do not qualify for specific models and yet demand for them
o Clients should be managed on individual basis.
Managing clients who transfer in
o Transfers in clients should be managed as if they were new in care
Managing clients who falter or drop out of a specific differentiated service delivery model
o These automatically revert to the comprehensive approach and are closely
monitored until they become stable
Couple enrolment into DSDM
o If stable and disclosed to each other, they should receive care under the same
model. This allows each one to alternately pick drugs for the other.
Managing a TB/HIV co-infected client
o TB/HIV co-infected clients are initially managed in the facility and can only join or
re-join community care and treatment approaches if they have completed
intensive phase and are sputum negative. Regardless of which HIV Care and
Treatment approach they are receiving care from, their appointments for HIV and
TB clinical reviews and ART and anti-TB medicine refills must be aligned.
Managing clients whose regimen has been changed due to policy changes
o All stable clients transitioned to new regimen due to policy changes (e.g. ART
optimization) shall be retained in their current DSD approaches if all other factors
stay constant however pharmacovigilance MUST be emphasized.
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7.1.4 How to introduce Differentiated Service Delivery Models
Instructions for facilitators: Inform partiicpants that during and immediately following the
training of health care workers on DSD, MoH recommends the stepwise approach detailed in
below to be followed in their facilities to introduce differentiated models of service delivery. This
approach will facilitate effective implementation and coordination of DSDM.
➢ Step 1: Refer to page 189 of the Desk Job Aid (How to introduce DSDM in your health
facility) or Pages 192-194 of the Consolidated Guidelines to facilitate the discussions
below and to page 190 of the Desk Job Aid to discuss the roles and responsibilities of
health workers in DSDM.
Table 17: Stepwise approach to introduce differentiated models of service delivery

Step 1: Establish a committee to coordinate DSDM activities
1. Strengthen an existing committee to undertake DSDM activities. At a minimum they
should include;
• ART In Charge
• HTS Focal Person
• HMIS/Data Clerk
• Logistics Focal Person
• QI Focal Person
• PMTCT/EID Focal Person
• Community Representative (Health Assistant, CDO, VHTs, CHEWs)
• TB Focal Person
• Laboratory Focal Person
NOTE:
✓ This team should be supervised by the Health Facility In Charge
2. To ensure buy-in and facilitate quick and easy DSDM implementation in the facility, the
established committee will be in charge of coordinating the development and
implementation of the work plan
Step 2: Conduct assessments to;
1. Determine the current practices i.e. what models and approaches are being implemented
in the facility and community based on the building blocks and the elements.
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2. Define the priority sub populations receiving services in your facility and communities.
These will be the populations for whom both HTS and Care and Treatment services will be
differentiated.
3. Determine the characteristics of each of the identified sub populations above.
4. Engage with community members and volunteers.
5. Determine the challenges by service providers in delivering different services to specific
groups.
Step 3: Review results from the various assessments to determine the appropriate model(s)
and approach(es) for your facility both HTS and Care and Treatment
Step 4: Assess resource needs
The approaches do not require additional resources in the run phase. However, they will
require upfront investments. The facility needs to have a clear understanding of resource
requirements before starting. Resources may include human resources, extra
materials/equipment, and financial support.
Step 5A: Devise a clear work plan and implement selected model(s), with key milestones.
Designate responsible persons
Step 5B: Implement and Monitor the model(s)
1. Refer to details for each model and approach on how to implement (Differentiated HTS
and differentiated HIV Care and Treatment sections)
2. Utilize relevant SOPs, job aides, tools and registers for each model
3. Monitor set indicators for each model and approach (Refer to M&E section)
4. Review progress through CMEs, review meetings, etc.
5. Identify areas for improvement and use QI approach to address them (Refer to QI section)
6. Assess impact of the QI interventions and make necessary adaptations
7. Report (Refer to M&E section)
NOTE:
✓ At the end of each month report how many new approaches (by model) have been
formed
Step 6: Document best practices
Documentation for best practices should be detailed enough, addressing aspects such as:
✓ Processes that were undertaken
✓ Structures/systems that were developed and/or strengthened
✓ Positions that were designated for key DSD activities
✓ Resources used, including how they were mobilized - from who or which organization
and whether they fostered TB/HIV collaboration efforts
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✓ Networks that were developed – within the community, across facilities etc. and how
this was done
✓ Successes attained
✓ Challenges encountered and how they were addressed or attempted to be address (if
the challenges still exists); etc.
Refer to the Implementation guide for Differentiated Service Delivery for HIV and TB Services in
Uganda for details.
7.2 Working with community structures to optimize delivery of HIV services

Introduction:
Health facilities should establish collaborations with the existing community structures in order
to realize the desired outcomes in the various areas including identification of positives, linkages
to prevention, care and ART services, retention in care, viral load suppression as well as reduction
in morbidity due to opportunistic infections. The community structures will play a key role in
completing the continuum of care by increasing demand, uptake and continuous utilization of
HIV prevention, HTS, care and treatment services both in facilities and community.
Key Questions:
1. What are the community structures and community intervention points?
2. What are the examples of community structures?
3. What are the roles of a healthy worker in community –facility linkages?
4. What are the considerations for establishment of collaboration between community
structures and health facilities?
5. What are the roles and responsibilities of stake holders in implementation of community
level activities?

➢ Step 1: Ask participants to brainstorm what community structures are? Emphasize that
Community organizations are formal or informal groups of people based in or around a
“community” and are organized in some way, usually having some structure, rules or
legal entity but sometimes being just an informal association.
Community intervention point is a geographical location in which interventions/services are

offered /implemented outside of the health facility.
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➢ Step 2: Ask participants to brainstorm on community structures they have in their
respective communities. Refer to the facility-community collaboration framework on page
191 of the Desk Job Aid or Page 199 of the Consolidated Guidelines and share examples
below:
• Non-Government organizations(NGOs)
• Community Based organizations(CBOs)
• KP Civil Society organizations (CSOs)
• Faith Based Organizations(FBOs)
• PLHIV Networks
• Peer support groups
• Adherence support groups
• Family support groups
• Academic institutions
• Government bodies e.g., Police, courts of law
• Legal service organizations
• VHTs and CHEWS
• OVC service organizations
• Agricultural service organizations
➢ Step 3: Ask participants to brainstorm the role of health workers in community –facility
linkages? Emphasize the framework and roles for health workers (Pages 192-193 in the
Desk Job Aid) or Pages 200-202 of the Consolidated Guidelines.
• Map community structures or community intervention points/groups within its
catchment area
• Establish an effective collaboration with selected community structures or
intervention points to offer HIV services along the 95; 95; 95 cascade
• Select the community structures depending on the gaps and needs identified in the
HIV services program at the health facility.
• The community structures will work with a designated focal person at the health
facility to ensure successful and completed bi-directional referrals and linkages are
happening between facilities and communities
➢ Step 4: Discuss the key considerations in establishing a facility-community linkage as

follows:
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• The process will be participatory involving all relevant stakeholders at the district
level including: the Health facility staff, the DHT, the DCDO, and other stake holders
in the districts
• The district’s health and community development offices will spearhead the planning,
coordination, monitoring and supervision of the implementation of the facility-
community linkages.
• Establishment of clear roles and responsibilities of all actors at all levels including
MOH, ADPs, District local governments, health facilities, implementing partners and
the community-based institutions.
• The community-based services will be integrated into the existing health services to
avoid duplication of services
➢ Step 5: Ask participants about the roles and responsibilities of stakeholders in

implementation of community level activities. Emphasize the following:
District roles and responsibilities
• With support from IPs, the districts’ health and community development offices will
spear head planning, coordination, monitoring and supervision of the implementation
of the strategy.
• Regularly update CSO directories.
• Be responsible for local resource mobilization for integration of community-based care
into the district’s HIV/AIDS programming.
Implementing partners roles and responsibilities

• Support implementation of standard package of services described in the strategy
• Strengthen district’s coordination and supervision activities to ensure facility-
community collaboration.
• Provide Technical Assistance (mentorships and coaching) to ensure the Districts,
facilities and the CBOs collaborate to offer community-based services.
• Strengthen collaboration between the DOVCC activities for effective coordination and
implementation of the community-based services.
• Print, distribute & mentor on the required community data collection & reporting
tools. Working with local government, will support the collaboration between the
Government community structures (CHEWS/VHTs) and the CBOs.
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MODULE 8. Integrating Continuous Quality Improvement into HIV
Care Services
Time 20 minutes
Key Question:
What are the HIV service delivery gaps for improvement?
➢ Step 1: Ask the participants to turn to page 194 of the Desk Job Aid (Integrating CQI into
HIV services) and review the steps to use CQI to improve HIV service delivery gaps.
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MODULE 9 Logistics Management

Begin the overview with facilitator’s introductions and opening remarks. Be sure to give some
background on facilitator’s experience in logistics management including working contacts.
Note to facilitator
Participants are encouraged to ask questions during the session. If it is a question that needs
to be addressed later or that may need some research done before an answer is given, it should
be placed in the parking lot.
9.1 Principles of Logistics Management
Time: 25 Minutes
Learning Activities Summary

Title Type Time
8.1.1. Logistics Management and the Six Rights Interactive lecture 5. mins
8.1.2. The major concepts in logistics Interactive lecture 5 mins
management
8.1.3. The Logistics Cycle Interactive lecture 10 mins
8.1.4. Importance of good logistics Interactive lecture 5 mins
management
9.1.1 Logistics Management and the Six Rights
Instructions for faciliators:
➢ Step 1: Explain what logistics management involves:

• Logistics management involves planning, implementing, and controlling the efficient
forward, and reverse flow and storage of goods and related information between the point
of origin and the point of consumption in order to meet the customer's needs.
• Allow the participants to brainstorm on the six logistics rights:
1. The RIGHT goods
2. In the RIGHT quantities
3. In the RIGHT condition
4. Delivered to the RIGHT place
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5. At the RIGHT time
6. For the RIGHT cost and to the right customer.
• Emphasize the importance of the six rights. These rights provide goals for us to aim at in
managing commodities.
9.1.2 Major Concepts in Logistics Management
➢ Step 2: Emphasize to participants that is important for them to understand the 3 major
concepts in logistics management and their application. For each of these concepts ask
participants to demonstrate each of these concepts with examples.
• Average Monthly Consumption:
o The quantity of medicines calculated to be consumed by patients per month for a
particular drug.
o Calculation of AMC depends on whether there was a stock out or not.
o Consumption determines how much we order for patients therefore it is very
important to consider the number of days when the product was stocked out.
When there is no stock out
AMC = Quantity issued to patients in Month 1 + Quantity issued to patients in Month 2
When there is a stock out

Quantity issued to patients in Month 1 Quantity issued to patients in Month 2
AMC = ( x 30) + ( x 30)
No.of days product was in stock in Month 1 No.of days product was in stock in Month 2
• Stock on hand: The quantity of usable medicine that is available to be given to patients.
Emphasize to participants that expired or damaged medicines are not usable and are
therefore not stock on hand.
• Losses: The quantity of stock removed from the store for reasons other than consumption
by clients at the facility eg due to expiration, theft, damage.
• Adjustments: These can be positive or negative:
o Positive: Quantities of product received from any source other than the central
warehouse eg borrowing from another facility.
o Negative: quantities of products that are issued to another facility (not consumed
at the facility).
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9.1.3 The Logistics Cycle

➢ Step 3: Reference the above image to explain the logistics cycle to participants. This cycle
is applicable to logistics systems that manage health commodities as well as those that
manage a mix of products. The logistics cycle illustrates the relationship between all the
activities in a logistics system. All the activities are important however for purposes of
this roll out we are shall concentrate on the highlighted components.
• Product selection: Products should meet needs of majority of the patients and should be
based on standard treatment guidelines and Essential Medicines Lists. Standard treatment
guidelines are adopted from WHO recommendations. Uganda has adopted majority of
the recommendations released by WHO in 2015.
o Remind participants that product selection is very important . If the right products
are selected, then customers receive what is needed however if the wrong products
are selected then the customer’s needs are not met. We must however take into
account the capacity of our systems and also balance those needs to their costs and
also the ability to manage the products.
▪ Example: Cold chain for products that require cold chain (Kaletra syrup)
• Quantification and procurement:
o Estimating the quantity of the selected products required to ensure an
uninterrupted supply for patients.
o Both exisiting and new active clients should be considered when making orders.
o Place orders with the relevant warehouse using the order and delivery schedule.
o Inform participants that ARVs are not charged to their credit line for essential
medicines. Ordering for HIV commodities will be discussed later in the module.
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• Inventory Management: Inventory management consists of receiving, storing, issuing
and maintaining adequate levels of stock. All products should be received by the medicine
store staff and witnessed/verified by the relevant persons in the administration and
community where appropriate.
o Dispensing points within the HF must request from the store using requisition and
issue vouchers.
o Inform participants that there is a logistics maual called ‘Management of Medicines
and Health Supplies’ that will provide more detail on logistics management. Copies
of the EMHS manual will be provided to the participants.
o Inform participants that you will go through inventory management later in the
module.
• Serving Customers: Ask: How would participants like to be served when they go to buy
airtime?
o Emphasize that customers want to find the right product in the right quantities
and quality at the shop that they have gone to to purchase a product. Relate this
to serving patients.
o Describe rational medicines use: patients receive medications appropriate to their
clinical needs, in doses that meet their own individual requirements, for an
adequate period of time
o Correct prescription, dispensing and patient adherence support rational drug use
9.1.4 Importance of good Logistics Management
➢ Step 4: Ask participants to brainstorm on the importance of good logistics management.

From all that has been discussed above, what happens if logistics management of health
commodities is not done correctly? What have participants seen at their facilities?
• Emphasize that availability of medicines improves patient health outcomes and prolongs
life. However, poor logistics management leads to:
o Stock outs (when patients leave a HF without the prescribed medicines because it
is not available at the time): Patients may therefore get drug resistance, treatment
failure, poor retention in care.
o Expiries (expiry date = when the manufacturer cannot guarantee the quality, safety
and the efficacy of the medicine and cannot take responsibility of any problem that
may result from its use): Wastage of financial resources and inadequate space for
other commodities.
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9.2 Inventory Management
Time: 30 Minutes
Facilitator Preparation
• Ensure all the tools (Stock cards, transaction vouchers) and practical materials are printed
before hand
• Ensure that all exercises are printed and included in training materials

Title Type Time
a) Inventory management Interactive lecture 5 mins
b) Completing a stock card Practical session 15 mins
c) Conducting a physical count Interactive lecture 10 mins
Materials needed: Pen, calculator, Transaction vouchers, delivery notes, Requisition and Issue
Voucher
Exercises will be done individually.
9.2.1 Inventory Management
Instructions for facilitators: Guide participants through the following discussion topics and
information.
➢ Step 1: Ask: what is inventory management? Ask participants what they would do to
manage their stock if they had a shop
o All the procedures that are used to maintain adequate stock of each item at the
facility
o Involves activities in ordering, receiving, storing and issuing commodities
o Record keeping and good storage practices are key
• What logistics management information tools do we use at the health facility to track all
the information we need to maintain adequate stock? Make sure participants mention the
following:
o Stock card and stock book,
o Requisition and issue vouchers,
o Invoices and delivery notes,
o Temperature monitoring charts,
o ARV dispensing log,
o ARV and eMTCT Medicines Report and Order form,
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o Patient registers.
• Encourage participants to refer to the manual ‘Management of Medicines and Health Supplies’
for good storage practices.
9.2.2 Completing the Stock Card
Instructions of Facilitators:
➢ Step 2: Ask participants what a stock card is and when it is used.

• It is a logistics tool that tracks the characteristics, quantities and movement of
commodities in a store. Each product in the facility should have a stock card.
• The stock card is used:
o Each time drugs are received and issued
o When doing a physical count
o When losses and adjustments need to be made
• Take participants through each section of the stock card. The key points to emphasize
when completing a stock card are:
• Stock cards are kept in the facility’s store next to the product. If space is inadequate, put
them in a box file.
• Have a separate stock card for similar items such as:
o Same medicines with same strength and same dosage form but with different pack size
should have the same stock card. This will help in its utilisation; otherwise, it may be taken
as completely different medicines with associated confusion. Different strengths or
weights or volumes (e.g., Efavirenz 600mg and Efavirenz 200mg) Different formulations
(e.g., Nevirapine syrup 10mg/ml and Nevirapine 50mg tablet)
• Write in the generic name, dosage form and strength of the drug. e.g.
Generic Name Dosage form Strength
Efavirenz and not Stocrin Tablet 600mg
Nevirapine 100ml Suspension 10mg/ml
Efavirenz Tablet 200mg
• All transactions (receipts and issues) on the stock card should be in packs and not pills,
tablets or mls.
• Clearly indicate expiry dates, batch numbers when doing a physical count, issuing to a
user unit, and when receiving a product from the central warehouse
• Losses and adjustments:
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o What are losses and adjustments? Ask participants to define these as they were
covered in the principles of logistics management.
• There are two types of adjustments namely:
• Positive adjustment: indicate as a positive number e.g +10 packs
• Negative adjustment: indicate as a negative number e.g -20 packs
• Losses: indicate as a negative number e.g -30 packs
• Remarks - Indicate any reasons for loss, damage or adjustments
Practical exercises on completion of the Stock Card

Note to Facilitator
Each person should do the exercise individually then ask volunteers to attempt the exercises
for everyone
Exercise 1: On 31st July 2015, the storekeeper of Adilang Health Centre III code number R13
located in Agago HSD in Pader district; Mr. Peter Okello carried out the physical count for the
ARVs, provided by NMS. The result for TDF/3TC/EFV 300/300/600 mg (fixed dose combination)
Batch no. G66004 was 100 packs with an Expiry date of December 2017.
• During the month of August and September of 2015, the following transactions occurred
at the store: 2 of Aug 2015, 10 packs were issued to the dispensary on requisition and issue
voucher number 10. On the 10th of Aug 2015, Peter issued 20 packs to the dispensary on
voucher number 11 and 20 packs for an outreach to Patongo HC III on voucher 30. On the
20th of Aug 2015, he issued 5 packs on voucher 12 to the mother-baby care point. On
September 7th he issued 20 packs to mother-baby care point on voucher 17 and 29th of
September he issued 15 packs to the dispensary on voucher 13 and received 200 packs
from NMS on the same day with voucher number GN007.
• A completed stock card is shown below. Identify the issues in this stock card
• Answers:
i. No physical count was done at the end of July
ii. Financial year was not indicated
iii. Outreach issues were not indicated. This could lead to audit issues
iv. NMS receipt is not correct. It is 200 and not 180. This could lead to audit
issues.
v. The calculations are wrong. This will lead the facility to show a higher
closing balance than what they have on the order form which will result in
a stock out
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• During the stock take for 30 September 2015, Peter discovered 20 packs of
TDF300mg/3TC300mg/EFV600mg had an expiry date of 30th August 2014. He also found
an open carton containing 50 packs of TDF300mg/3TC300mg/EFV600mg. The rest had an
expiry of date of December 2017.
• What is the opening and closing balance for the cycle?
• Opening balance: 100 packs
• Closing balance: 240 packs
• What inventory management issues arise from this facility?
• Expired stock indicates poor inventory management
• ‘Discovery of stock with shorter shelf life than those being issued to dispensing
points’ shows lack of ‘First Expiry First Out’ principle which indicates poor
inventory management.
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HMIS FORM 015: STOCK CARD
Health Unit Name: Adilang HC III Health Unit Code: R13

Financial Year: _______________________________
Item Description (Name, formulation, strength): Pack Size: Item

Tenofovir/Lamivudine/Efavirenz tablets 300/300/600mg Pack of 30 Code No:
Special storage conditions: Dry conditions

Unit of Issue: Pack of 30. Maximum Stock Level: 4 months Minimum Stock Level: 2
months
Date To or Vouche Quantit Quantit Losses/ Balance Expiry Batc Remar Initia
From r y y out Adjustmen on date h ks ls
number in ts Hand No.
2/8/15 Dispens 10 10 90 P.B
10/8/1 ary
Dispens 11 20 75 P.B
5
21/8/1 ary
MB 12 5 70 P.B
5
7/9/15 point
MB 17 20 40 P.B
29/9/1 point
Dispens 13 15 25 P.B
5
29/9/1 ary
NMS GN007 180 205 P.B
5
30/9/1 PC +50 255 P.B
5
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9.2.3 Conducting a Physical Count
Materials needed: Red pen, calculator and a ruler
➢ Step 3: Ask participants what is the purpose of a physical count?

• Verify the stock level of medicines and health supplies, especially when handing over
• Verify and determine quantities to order or when receiving stock from warehouses or
other sources
• Verify the accuracy of stock-keeping records
• Detect losses of medicines and health supplies in the store
• Ensure all stock in the store is usable (not damaged or expired)
• Determine whether the stock will be used up before the expiry date or if you need to
redistribute.
When should a physical count be conducted?
• Once a month, at the same time every month and just before writing orders
Who should participate in conducting a physical count?
• Storekeeper, facility in-charge, pharmacist /pharmacy technician, if available
What are the steps in conducting a physical count? (Ask participants to briefly describe how they
would count products in the store)
• Set a date for the physical count. Select the physical count team. Participants should be
selected from the facility. The storekeeper and pharmacist/pharmacy technician, if
available, should be members of the team.
• Prepare the store, make sure cartons are neatly stacked and partial cartons are visible.
• Count unopened/complete cartons first. Multiply the number of cartons by the number of
units in the carton. This will give the total number of medicine/item units in the carton.
• Count open cartons. If an open carton contains unopened boxes, count the boxes and
multiply the number by the number of units in a box. This will give the total number of
the item units in the unopened boxes.
• Count all the units that are in open boxes.
• Add up the total units from the unopened cartons, unopened boxes, open boxes on
shelves, in drawers, dispensing points etc. This will give the total number of units of the
items available in the store and dispensing facility, known as the actual quantity on hand.
• On the stock card for the item, draw a line with a red pen through the next row of the
stock card after the last calculated stock balance.
• Record the date of the physical count in the next row; fill in the actual stock on hand under
the stock balance column.
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• Calculate any losses or adjustments and indicate comments under the remarks column.
• Write your initials after conducting the physical count. Draw another line under the row.
This differentiates the physical count from the routine entries on the stock card.
When is this task completed?
• All products in the store have been counted and recorded on the stock card
• Losses/adjustments have been calculated, recorded and explained if applicable
9.3 Good Dispensing Practices
Time: 15 Minutes
Facilitator Preparation
• Ensure tools (e.g. ART dispensing log) and practical materials are printed beforehand
• Ensure that all exercises are printed and included in training materials

Title Type Time
8.3.1. Good dispensing practices Interactive lecture 5 mins
8.3.2. Completing the ARV dispensing Interactive lecture 10 mins
log
Materials needed: Pen, calculator, Patient prescriptions, dispensing log
9.3.1 Good dispensing practices

➢ Step 1: Ask participants the importance of good dispensing:
o To ensure that the right form of the drug is given to the right patient in the right
dosage and quantity with the right instructions in the right packaging.
o Steps in good dispensing and key issues in dispensing: Ask participants to
describe the process they go through when dispensing drugs to patients. Ensure
that all the key issues are emphasized
➢ Step 2: Read and understand the prescription:
o Make sure you understand what has been written on the patient card.
o It MUST include patient name, age, diagnosis, date, drug name, dosage form,
strength, dose, frequency and prescriber signature (recognise it)
o If you cannot read what has been written check with a colleague or ask the
prescriber
o NEVER guess a drug name and other details
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o Understand the dose –check Uganda Clinical Guidelines and the national ART
dosing chart.
o Check that the medicine and dosage are appropriate for the patient. Contact
prescriber if you think it needs to be changed –NEVER change without consulting
with the prescriber.
➢ Step 3: Collect the medicines
o Keep the lids on all containers. If more than one medicine has been prescribed,
close one container before opening another container.
o Read the label- don't find the medicine based on colour of tablets or form of
container
o Read the generic name
o Check expiry and quality of medicine -don't dispense if something is wrong, (look,
smell, cloudy etc)
➢ Step 4: Label the medicine
o Write the label before packaging
o Patient may not remember how to take the medicine– Write it down
o Information on the label; Generic name of the medicine, dosage form, Strength,
Quantity of the medicine, Instruction on how to use the medicine, Name of patient,
Date supplied
➢ Step 5. Calculate, then measure or count the correct quality of medicine
o It is important to measure or count the quantity accurately
o Ensure patient gets full course for treatment duration
o It will enable you to check compliance later
o Use counting trays, spoons or spatulas. Do not use your bare hands
➢ Step 6: Package the medicine
o Ensure medicine is packed in appropriate container to avoid contamination and
maintain effectiveness
o Use dispensing envelopes for loose tablets e.g. Cotrimoxazole 960mg
o Never mix medicines in the same container
➢ Step 7: Re-read the prescription and check what you have dispensed
o Check the prescription that you are dispensing for correct medicine, dosage form,
strength, quantity, check label
➢ Step 8: Deliver and counsel the patient on the medicines
o Explain the instructions for taking/giving the medicines
▪ Ask the patient to tell you how they are going to take it (open ended
question)
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▪ Information to be provided include dose, indication, frequency, duration,
indication, interactions with food, other medicines and alcohol, side
effects, contraception, paediatric dosing (how to measure syrups) and
storage
▪ If a dose is less than a whole tablet, show the patient how to divide the
tablet. If it should be mixed with food, show how to crush the tablet and
mix it with food. This is common for pediatric medicines.
9.3.2 Completing the ARV Dispensing Log
Purpose and content
The porpose of this content is to ensure that the participants understands;
• The data elements of the dispensing
• New changes in the dispensing log
• how to fill an ARV dispensing log
• how to enter the different formulations in an ARV dispensing log
• how to calculate;
o Page totals
o Balance on hand
o End of month consumption summaries.
Session objectives
By the end of this session, the participants should be able to;
• List the data elements of an ARV dispensing log
• Identify the changes in the ARV dispensing log
• Appropriately fill the ARV dispensing log
• Enter different formulations in the dispensing log
• Calculate;
o Page totals
o Balance on Hand
o End of month consumption summaries

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Time Topic and Activity Aids Trainer
5 minutes Elements of the ARV dispensing log Power point
10 minutes Changes in the dispensing Power point
30 minutes (Group exercise and presentation) filling an Copies of dispensing

ART dispensing log logs
10 minutes Filling the ARV dispensing log Power point
10 minutes Entering dispensed medicines in the ARV Power point

dispensing log
10 minutes Calculating page totals Power point
10 minutes Calculating Balance on hand Power point
10 minutes Calculating monthly consumption Power point

summaries
95 min (1hr 35mins) – Total Time
➢ Lecture: Elements of the ARV dispensing log (5 minutes)
Continue with the PowerPoint presentation by elaborating and describing in detail the elements
of the ARV dispensing log.
➢ Lecture: New changes in the ARV dispensing log (10 minutes)
Continue with the PowerPoint presentation by bringing out the new changes to the ARV
dispensing log and explain the reason for the changes.
➢ ACTIVITY 1 – How to fill an ARV dispensing log (30 minutes)
Give them 30 minutes to complete the exercise below on how to fill an ARV dispensing log.
Scenario
On 1st July 2018 in Asuret H/C III, 10 clients (ADULTS) with patient number AS-001 to AS-010
received two month refills of TLE, 30 (patient number AS-11 to AS-40) clients received one month
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refills of TLD, 10 (AS-50-1S-60) received 2 month refills of AZT/3TC/NVP 300/300/200mg and
Cotrimoxazole 960mg 60 tablets each.
On the same day, 3 patients (Patient number AS-009, AS-010, AS-08) received fluconazole 200mg
tablets refills for 2 months each. Additionally, the nurse working in the dispensary received; 100
tin of TLE, 108 tins of TLD, 50 tins of AZT/3TC/NVP 300/300/200mg and 10 tins of fluconazole
200mg tablets from the store in the morning. Before receipt from the store, there was 10 tins of
TLE, 8 tins of TLD, 20 tins of AZT/3TC/NVP 300/300/200mg.
Use the information provided to completely fill the day’s transactions in the ART dispensing log.
➢ Lecture: filling the ARV dispensing log (10 minutes)
Continue with the PowerPoint presentation by elaborating how best to fill the ARV
dispensing log.
➢ Lecture: Entering dispensed medicines into the ARV dispensing log (10 minutes)
Given that the log is used both for ARVs and other OI medicines, it is critical that you take
the participants through how the different formulations are entered.
➢ Lecture: Calculating page totals (10 minutes)
Take the participants through how page totals are calculated at each end of the dispensing
day.
➢ Lecture: Calculating balance on hand (10 minutes)
Continue with the power point and take the participants through how to calculate balance
on hand given the new changes in the ARV dispensing log.
➢ Lecture: Calculating end on month consumption summaries (10 minutes)
Continue with the power point and take the participants through how to come up with
monthly consumption summaries given the new changes in the ARV dispensing log.
9.4 Completing ARV and eMTCT Medicines Report and Order Form
Purpose and content
The porpose of this content is to ensure that the participants understands;
• the elements in the ARV order and report form
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• changes in the ARV order and report form
• how to fill an ARV order and report for
Session objectives
• Appreciate the changes in the new ARV order and report form
• Correctly fill in the patient numbers
• Understand the different data element of the ARV order and report form
• Order using the updated ARV order and report form
Time Topic and Activity Aids Trainer
5 minutes Changes in the ARV order and report form Power point
30 minutes Different sections in the order and report Power point

form
10 minutes (Plenary) discussing the different elements Power point

of ARV order and report form
40 minutes Filling the ARV order and report form Power point/report
forms
40 minutes Activity 3; how to fill an ARV Order and Order and report form
report form
20 minutes Filling in the patient summary section Power point
5 minutes Order submission Power point
140 min (2hr 20mins) – Total Time
➢ Lecture: Changes in the ARV order and report form (5 minutes)
Continue with the PowerPoint presentation and explain the changes to the ARV order
and report form
➢ Lecture: Different sections in the ARV order and report form (30 minutes)
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Continue with the PowerPoint presentation and explain the different sections of the ARV
order and report form.
➢ Activity 2: Plenary; Different elements of the ARV Order and report form; (10 minutes)
Looking at the order form

▪ What data elements are collected?
▪ What is the use of this data?
➢ Lecture: Filling the ARV order and report form (40 minutes)
Continue with the PowerPoint presentation and take the participants through how to fill the ARV
order and report form.
Completing the ARV order and report form

• Kakuuto health centre III, a government facility in Rakai district is preparing their bi
monthly report and order for ARVs for the period of 1 November 2016 to 31 December
2016 on 17thJanuary, 2017
1. Is the facility’s report and order form in time for the warehouse’s order deadline?
Answer: No, deadline is 16th January therefore this report is late.
2. List the tools and corresponding information we shall obtain from them to complete the
order
Answer: Refer to table on sources of information needed to complete the ARV
order form.
• On October 31st2016 Kakuuto HCIII took stock of their ARV medicines and the following
drugs were available in the store:
TDF300mg/3TC300mg/EFV 600mg 400 packs, AZT300MG/3TC150/NVP200mg 100 packs,
AZT300mg/3TC150mg 0 packs, TDF300mg/3TC300mg 0 packs, Efavirenz 600mg were 100
packs, Nevirapine 200mg were 210 packs, ATV/R 400mg were 140.
AZT60mg/3TC30mg/NVP50mg were 15, AZT60mg/3TC30mg were 0 packs,
ABC60mg/3TC30mg were 0, Nevirapine 50mg were 10 , EFV 200mg 70 packs , LPVr
40/10mg 11, Nevirapine 10mg/ml 5 bottles. Cotrimoxazole 960mg were 0 packs and
fluconazole200mg were 13, cotrimoxazole 120mg – 5 packs
The closing balances for the previous cycle were;
TDF300mg/3TC300mg/EFV 600mg 100 packs, AZT300MG/3TC150/NVP200mg 10packs,
AZT300mg/3TC150mg 1000 packs, TDF300mg/3TC300mg 10 packs, Efavirenz 600mg
were 200 packs, Nevirapine 200mg were 21 packs, ATV/R 400mg were 100.
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ABC60mg/3TC30mg were 0, Nevirapine 50mg were 10 , EFV 200mg 10 packs , LPVr
40/10mg 20, Nevirapine 10mg/ml 5 bottles. Cotrimoxazole 960mg were 0 packs and
fluconazole200mg were 13, cotrimoxazole 120mg – 5 packs
The following drugs were received from NMS in the period November and December
2016.
TDF300mg/3TC300mg/EFV 600mg 20. AZT300MG/3TC150/NVP200mg was 50 packs.
AZT300mg/3TC150mg 100packs. TDF300mg/3TC300mg 150 packs. Efavirenz 600mg was
45 packs. Nevirapine 200mg was 30 packs. ATV/R 300/100mg was 20.
AZT60mg/3TC30mg/NVP50mg was 20. AZT60mg/3TC30mg was 30 packs.
ABC60mg/3TC30mg was 10. Nevirapine 50mg was 0. EFV 200mg 30 packs. LPVr 40/10mg
10. Nevirapine 10mg/ml 5 bottles. Cotrimoxazole 960mg were 30 packs and
fluconazole200mg was 10,
The following consumption was also recorded in the review period:

In ART clinic:
TDF300mg/3TC300mg/EFV 600mg 130 , AZT300MG/3TC150/NVP200mg were 100 packs,
AZT300mg/3TC150mg 60 packs, TDF300mg/3TC300mg 140 packs , Efavirenz 600mg were
50 packs while Nevirapine 200mg were 110 packs. While ATV/R 400mg were 40.
ABC60mg/3TC30mg were 10, Nevirapine 50mg were 10 , EFV 200mg 10packs , LPVr 40/10
1pack, Cotrimoxazole 960mg were 19 packs, cotrimoxazole 120mg 2 pack and
fluconazole200mg were 20.
In Mother-baby care point:
Nevirapine 10mg/ml 5 bottles. TDF300mg/3TC300mg/EFV 600mg 20, cotrimoxazole
960mg 1pack, cotrimoxazole 120mg 1 pack
The store manager also noted that 40 packs AZT300mg/3TC150mg and 10 packs of EFV
200mg were expired at the end of November. Patient numbers were as shown in the table
below:
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Tell the participants to use the information provided to fill an ARV order form and report for the
period. Areas of emphasis should be AMC, closing balance, months of stock and quantities
require for each commodity.
➢ Lecture: Filling in the patient summary section (20 minutes)

Take the participants through the patient section.
ART patients
• Tell the participants that for first line regimens they have to;
o Fill in the number of existing patients at the start of the cycle being reported on for
all first line ART regimens. This data can be got form the ART register or Open
MRS.
o Fill in the number of new patients enrolled on all first line ART regimens during
the cycle being reported on. This data can be got from the adherence counselling
register or the pre-ART register.
The numbers of paediatric patients should be filled in by age, i.e. 0-<3 years, 3-<10 years, 10-
<15 years less than 35kg and 10-<15 > 35kg. This data can be obtained from Open MRS or the
ART register.
• Additionally, inform the participants that for second line patients, they should;
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o Fill in the number of existing patients at the start of the previous cycle for all
second line ART regimens. This data can be obtained from Open MRS or the ART
register.
o Fill in the number of new patients enrolled on all second line ART regimens during
the previous cycle. This data can be obtained from the Non-suppressed viral load
register, or the ART register, or Open MRS.
The numbers of paediatric patients should be filled in by age, i.e. 0-<3 years, 3-<10 years,
10-<15 years less than 35kg and 10-<15 > 35kg. This data can be obtained from Open MRS
or the ART register.
For Patients with opportunistic infections the participants should know that they need to;
• Fill in the numbers of patients treated with drugs for opportunistic infections by age
group (Adults, Children), in the previous cycle. These include cotrimoxazole and
dapsone. For fluconazole, fill in the number of patients by condition, i.e. Acute
cryptococcal meningitis, maintenance therapy for cryptococcal meningitis and esophageal
candidiasis.
Note:
o All calculations are automatically generated in WAOS.
o Remarks: Explain any sudden changes in consumption and patient numbers.
Note to Facilitator
The task is complete when all sections of the form have been accurately filled and when a copy
of the report has been entered into the web-based system if a facility has computer and internet
connectivity, or a paper copy sent to the DHO Office for entry into the web based system. A
hard copy should be filed at the facility.
➢ Lecture; Submitting the ARV and Report and Order Form (5 minutes)
Continue with the power point and explain to the participants the different warehoused and the
category of facilities tagged to each of them.
Tell the participants to note that:

• Orders are submitted according to the delivery schedule of the individual warehouse.
Refer to the Warehouse Delivery Schedule. Every facility should have a copy.
• All order forms should be submitted to warehouses using the Web-based ARV Ordering
System (WAOS) https://hmis2.health.go.ug .
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• If the facility does not have internet capacity or a computer, submit the order to the district
biostatistician/MMS or implementing partner supporting the facility who will enter it into
WAOS.
9.5 Ordering for third line ARVs
Purpose and content
The purpose of this content is to ensure that the participants understand the current ordering
mechanisms for 3rd line ARV medicines;
Session objectives
• Order for 3rd line ARVs
• Approptiately report patients on 3rd line ART
Time Topic and Activity
30 minutes Ordering for 3rd line ARVs
➢ Lecture; Ordering for 3rd line ARVs (30 minutes)
Proceed with the power point and tell the participants that ordering and reporting for third line
ARVs is currently restricted to regional referral hospitals and centres of excellence. This means only
referral hospitals and centres of excellence will be ordering and reporting on the consumption and
usage of third line ARVs through WAOS. The referral hospitals and centres of excellence will use
the standard ARV ordering and reporting forms to order and report on third line ARV following
the bi-monthly ordering and reporting cycle. This should be done alongside other ARVs. Orders
should be submitted through the web-based ARV ordering and reporting system (WAOS) before
the order deadline.
Inform the participants that the regional referral hospital will be responsible for issuing third line
ARVs to all lower level health facilities having third line patients within the region even when their
other ARVs are provided through a different warehouse.
Once resistance results and regimens prescribed have been communicated to the regional referral
hospital and the responsible implementing partner, the regional referral hospital should use the
issue and requisition voucher to send third line ARV to the parent facility.
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The implementing partner should facilitate the movement of the ARVs from the RRH to the lower
facility. The RRH should consider ARVs issued to the lower level facility as consumed and
therefore should proceed and update the stock card. This information should be used to prepare
the next ARV order and report.
Additionally, inform the participants that once the third line ARVs have reached the lower facility
where a third line patient has been accessing care, the received quantity of medicine should be
entered into a stock card. The facility should then follow the issuing procedures prescribed in the
MOH medicines and health supplies management manual 2012. Once the medicine is dispensed
to the patient, the dispensing log should be updated immediately.
Refer to Page 196 of the Desk Job Aid.
Lower facilities are currently not authorized to order for third line ARVs through WAOS. The
regional referral is responsible for consolidating all orders for them. Lower facility requiring 3rd
ARVs should send a copy of page 2 and patient summary page of the order form to their
respective regional referrals.
9.6 TLD transition
Purpose and content
The purpose of this content is to ensure that the participants understand;
• That the ordering and reporting for TLD is not differet from the rest of the ARVS
Session objectives
• Incorperate TLD and DTG in facility orders
• Appropriately understand how to account for existing patients transitioned to TLD
10 minutes Ordering for TLD and DTG 50mg
30 minutes TLD Transitioned and new clients

reporting
165
➢ Lecture: ordering for TLD and DTG 50mg tablets (10 minutes)
Tell the participants that ordering for TLD will be in the same way as that of the other ARVs.
Tell them that:
• Initial supply received through the implementing partner will be captured in the
quantities received cell in the ART order form (Column B) when placing orders for the
next cycle
• Order DTG 50mg single formulation for TB co-infected patients . Remember TB patients
on TLD regimen require an additional dose of DTG 50mg
➢ Lecture: TLD Transitioned and new client reporting (30 minutes)

Tell that participants that:
• All existing patients transitioned from other regimens during the previous cycle
should be entered as new patients on the regimen
• All new patients initiated on TLD should always be entered as new patients on the
regimen
NB: To avoid double reporting care must be taken for transitioned patients numbers not to be
captured as existing patients in their previous regimen
9.7 Dispensing of medicines to patients under DSD
Purpose and content
The porpose of this content is to ensure that the participant understand how to;
• Outline the different DSDMs
• Account for drugs dispensed through the different DSD models
• Tools for ARV accountablity
Session objectives
• Outline the different DSDMs
166
• Account for drugs dispensed through the different DSD model
• List the ARV accontability tools for DSD
5 minutes Different DSD models
30 minutes Accounting for DSD ARVs
10 minutes Tools for DSD ARV accountability
➢ Lecture; Different DSD models (5 minutes)
Help the participants to outline the different DSD models;
• Facility Based Individual Management Model (FBIM)

• First Track Drug Refills (FTDR)
• Facility Based Groups (FBG)
• Community Client Led Arm (CCLAD)
• Community Drug Distribution Point (CDDP)
➢ Lecture; Accounting for DSD ARVS (30 minutes)

Tell the participants that accountability for drugs dispensing for clients under the different arms of
service delivery are key. Using the power point, take the participants through how to account for
drugs dispensed through DSD
➢ Lecture; Tools for DSD ARV accountability
Using the power point guide the participants through the different tools that are used for ARV
accountability under the differentiated service delivery models. Tell them that they include:
• Dispensing logs
• CCLAD monitoring forms
• ARV medicine return forms
9.8 Filling the Viral Load, EID and SCD Commodities Order Form
Case scenario to practice filling the order form:

• You are in Kijura HC IV served by Kabarole Hospital Hub under MIT as the Implementing
partner. You received VL testing supplies on the 1st January 2016 which were to take you
167
through 2 months. It is February 28th 2016 and you are preparing supplies order and
report to sent to UNLHS.You hold a forecasting meeting and realize that in December
2015 the facility received 2 registers of the VL/CD4 register, 2 copies of the VL request
forms, and 2 DBS kit. Since the last supply of VL commodities, you enrolled 100 clients in
the HIV clinic and started 200 clients on ART. The sister in-charge of the ART clinic
informs you that 300 patients will need a 1st VL test March and April 2016 to clear the
backlog and among those who have been undergoing intensive adherence counselling, 50
will need a repeat VL in the same period. The laboratory technician who is monitoring the
stocks of VL supplies informs you that at the beginning of January 2016 the facility had 1
register of the VL/CD4 register with 2 pages remaining, no copy of the VL request forms,
and no DBS kit and had no supplies in store apart from the request forms which were in
the clinicians’ rooms and the a few filter papers in the phlebotomy room. The HMIS focal
person informs you that you offered VL testing to 150 patients. And for the two months
because of on-going onsite mentorship no forms of filter papers were spoilt during sample
collection. Using this information, make a supplies request to UNHLS.
168
Annex 1: NDA ADR form
169
Annex 2: Viral Load, EID and SCD Commodities Order Form
Description UOM Opening Quantity Consumption Losses/adjustment Maximum stock Total closing Quantity to Comments
balance at received during the s (+/-) during the required based on balance order for (E-F)
start of during the reporting period – reporting period the clients who (Physical count)
reporting reporting number of clients need a test in the
period period offered VL test next 2 months
A B C D E F G I
DBS COMMODITIES
1 DBS kits 50
(specify VL,
EID, Sickle cell
in the
comments
column
2 Cryogenic 100
tubes
3 VL load 50
request forms
HMIS TOOLS
1 CD4/VL daily 1
activity
register (HMIS
095a)
2 DBS dispatch 1
books
Total number of clients on ART (Active on ART)

Number of clients due for 1st VL in next 2 months (have never had a VL before and are due for a VL in the next 2 months)
Number of clients due for a routine VL in next 2 months (formerly suppressed on previous VL test)
Number of clients who require a repeat VL after IAC in the next 2 months
Total number of clients who are due for a VL in next 2 months
170
MODULE 10. Introducing Changes in HIV Care Tools
Module focuses on two tracks – Introducing the changes in HIV HMIS tools as well as tracking
roll out of the revised guidelines
10.1 Introducing Changes in HIV HMIS Tools

Brief introduction: Ministry of Health conducted a thorough review of the HMIS. The revised HIV
HMIS tools included elements to document the changes brought about by the revised guidelines
for prevention and treatment of HIV. These changes are reflected in the pre-primary, primary and
secondary tools. The electronic medical records system (Uganda eMR) has also been changed to
capture data based on the revised pre-primary and primary tools.
Instructions for facilitators: Introduce the cross cutting changes in the recording and reporting
tools
Cross cutting changes to the revised HIV HMIS tools include: -
HIV tools assigned new HMIS

Passport Number and
codes in the format HMIS ACP
Refugees Identification
0XX e.g. HMIS ACP 003 – HIV
Number can be recorded as
Care/ART card
the other unique identifiers
register, HMIS ACP 003 –

HIV Care/ART card
National Identification Clients categorised as either National (N),

Number (NIN) adopted as Refugee (R), must hold refugee
one of the client unique identification card or Foreigner (F) – Non
identifiers Ugandan and doesn’t have a refugee status
Categorisation of clients
register, HMIS 003 –special categories of register,
ACPunder priority HMIS
populations e.g.–AGYWs,
ACP 003 Persons
HIV Care/ART
with Disabilities,
HIV Care/ART Uniformed
card forces, etc. card
171
Each section of the revised guidelines is integrated with steps followed in documenting the changes
using the revised HIV HMIS tools.
Routine HIV programme performance monitoring reports – Health Unit Outpatient Monthly
Report (HMIS 105) and Health Unit Quarterly Report (HMIS 106a), were also changed to track
performance as per the new changes in the revised guidelines. Overall, two major changes were
adopted: - Reporting HIV prevention
and care service numbers by
5-year age bands
Reporting HIV prevention

and care service numbers by
client category – National,
Refugee and Foreigner
172
For HMIS 105, the key changes introduced included;
• HIV Testing Services (HTS)

o Reporting service numbers by Entry points, Approach of testing, Key/Priority
populations
o Assisted Partner Notification cascade
o HIV self-testing cascade
• MCH and PMTCT
o ANC 8th visit
o TB screening in ANC
o Hep B cascade
o Viral load cascade for ART-K
o Outcomes of HIV exposed infants
For HMIS 106a, the key changes introduced included;
• Advanced disease cascade

• Cryptococcal Antigen (CrAg) cascade
• TB Preventive Therapy (TPT) cascade
• Differentiated services delivery models
• Age specific cohort analysis (Children 0-9, Adolescents 10-19 and Adults ≥20 years)
• Quarterly HIV care status – LTFU, Died, TO
• Outcomes of follow up/tracing of lost/LTFU
• Cause of Death
• Viral load cascade, including the Non-suppressed viral load cascade
• Community – Facility referrals
• Pre Exposure Prophylaxis (PrEP)
Standard Operating Procedures (SOPs) have been developed to guide documentation, recording,
summarising and reporting based on the revised guidelines.
10.2 Tracking guidelines roll out

Rolling out of the revised guidelines at health facilities and training of Health workers to ensure
effective utilization of the guidelines will be tracked using the training reports that will be entered
into the online training database.
Instructions for facilitators: Display the standard Guidelines training report template and the
online database and describe how these are completed and the channel of submission
173
• For each training conducted at National, regional, district and health facility, the team
leader compiles training report summarising;
o Training details
o Health facility details
o Participants details, including performance in pre and post test
o Summary of participants trained in Comprehensive HIV prevention, care, treatment
and support
o Key observations, challenges and recommendations
• Completed training report is used by the Team leader to enter training details in the online
database using a googleforms based link
• Signed off training report is submitted to MoH-ACP (National level training);
Implementing Partner (in case of a regional training) or City/Municipality/District Health
Office (in case of the district or health facility training)
Data will be summarized as follows; weekly for the first three months and bimonthly thereafter.
Summaries generated will be disseminated to key stakeholder to provide an update on the roll out
of the guidelines.
Instructions for facilitators: Introduce the cross cutting changes in the recording and reporting
tools and to guide how to monitor implementation of the revised guidelines and program
performance, and to provide a framework for assessing the impact of the guidelines.
174
Post training mentorship and supportive supervision will be conducted to assess and support health
facilities provide the HIV/AIDS services as per the revised guidelines, as well as identifying
challenges encountered during utilization of the revised guidelines;
• Post training mentorship – conducted one month after roll out of the revised guidelines at
health facility
• Supportive supervision – 3 months from onset of site based roll out and 1-month after
completion of national roll out of site based trainings.
Instructions for facilitators: Introduce the key changes that will be monitored/tracked during the
supportive supervision visits at the health facilities
Display Annex 15 of the Guidelines
175

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MINISTRY OF HEALTH

NATIONAL TRAINING CURRICULUM FOR ROLL OUT OF

STD/AIDS Control Programme

1.2 Biomedical HIV Prevention interventions ........................................................................ 26

MODULE 2. HIV Testing Services ................................................................................................. 36

2.3 What are the HTS Protocol? ............................................................................................... 38

2.4 Targeted HIV testing .......................................................................................................... 39

2.6 HIV Testing Services Algorithm ........................................................................................ 43

2.7 What is Assisted Partner Notification (APN)? ................................................................. 44

3.2 Introduction to adherence .................................................................................................. 58

3.5 Adherence Support............................................................................................................. 65

3.8 Module 3 Practice case studies to check participant understanding .............................. 68

4.2 Services for non-pregnant adolescent girls and women .................................................. 72

4.3 Services offered during pregnancy.................................................................................... 73

4.5 Services offered during the postpartum period ............................................................... 76

4.6 Care of the HIV-exposed infant/child ............................................................................... 76

4.7 Community eMTCT............................................................................................................ 77

MODULE 5: Maternal, Infant and Young Child Nutrition.......................................................... 79

5.2 Infant and Young Child Feeding ....................................................................................... 80

5.3 Nutrition assessment, counselling and support for PLHIV ............................................ 82

5.4 Management of Malnutrition............................................................................................. 84

6.2 Diagnosis, Prevention and Management of Co-morbidities and Co-infections ............ 86

6.3 Antiretroviral therapy for people living with HIV .........................................................106

9.2 Inventory Management .....................................................................................................148

9.5 Ordering for third line ARVs ............................................................................................164

9.6 TLD transition ....................................................................................................................165

9.7 Dispensing of medicines to patients under DSD.............................................................166

MODULE 10. Introducing Changes in HIV Care Tools ..............................................................171

A) TRAINER OF TRAINERS SCHEDULE

9.30-10.00am Pre-test Service delivery:

Differentiated Service Delivery

Working with Community Structures to

10.30am Tea break Tea Break Tea Break

1.00-1.30pm Lunch break Lunch break Lunch break

3.00-5.00pm HTS HIV Care and Support for PLHIV

5.00pm Trainers’ meeting Trainers’ meeting Trainers’ meeting

Module Reference Changes

ART regimens for TB/HIV co-infected patients initiating Second-line ART

Children ≥ 20Kg- <30Kg

After TB treatment the regimens should be optimized.

Training Manual Management of Cryptococcal Meningitis

Children ≥ 20Kg- <30Kg

Training Manual Eligibility for DTG:

Training Manual Recommended programmatic drug substitutions in adults and adolescents

Training Manual Recommended programmatic drug substitutions in children:

Training Manual Children with a non-suppressed viral load

• All children failing in 1st line ART:

Adults and adolescents ≥ 30Kg, including pregnant and breastfeeding women

All 3rd line regimens to be guided by resistance testing

Training Manual Programmatic drug substitution in 2nd line regimens

Six-month refills can be provided through FTDR or CDDP approaches.

TPT and ART refills should be aligned

b. Monitoring clients on TPT

Proposed Time: 2 hours and 30 minutes

Instructions for Facilitator:

Table 2: Services for Behavioral Change and Risk Reduction

Provide socio- • Build a lifestyle of prevention among young people

1.2 Biomedical HIV Prevention interventions

Instructions for facilitator:

1.2.1 Condom programming

Instructions to the facilitator:

Note: After the discussion, summarise as follows;

o Adults and youth engaged in multiple sexual partnerships.

Facilitator's Manual 2020 July 2020 Final

Facilitator's Manual 2020 July 2020 Final

Client Name Health Worker Name _____

Signature or thumb print Signature or thumb print ___