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Home Based Care Guide for Outreach Workers

Tamil Nadu Family Care Continuum Program


























1


Foreword

Dr. S. VIJAYAKUMAR, I.A.S.,
Project Director & Member Secretary
Tamil Nadu State AIDS Control Society

Greetings from the Tamil Nadu State AIDS Control Society

According to the National AIDS Control Organization, approximately 50,000 children below 15
years are infected by HIV every year. In addition to those infected, children are affected both
directly and indirectly when one or both of the parents become HIV positive. To address this
staggering need, the national plan to address HIV/AIDS in India as articulated by NACP-III seeks
to strengthen family and community care through psycho-social support, counseling to adhere to the
prescribed ART regimen and education against stigma and discrimination associated with the
epidemic.

Understanding the need to address the epidemic through family and community support, NACP-III
has developed comprehensive guidelines on HIV care for each level of the health system; linkages
with social sector programmes for accessing social support for infected children and their families;
outreach and transportation subsidy to facilitate ART and follow up, nutritional, educational,
recreational and skill development support, and by establishing and enforcing minimum standards
of care and protection in institutional, foster care and community-based care systems.

Initiated in September 2005, Tamil Nadu State AIDS Control Society (TANSACS) through its
Tamil Nadu Family Care Continuum Program (TNFCC) successfully piloted a continuum of care
approach to care of HIV infected and affected children by addressing needs of children and parents
/ care givers, and promoting on-going linkages between clinical, community and home based
services. This has led to improved client tracking, comprehensive and uninterrupted services to
families; improved levels of adherence to antiretroviral drugs, especially women and children; and
successful linkages of clients to government schemes, of which they would otherwise be unaware.

Since its inception, TNFCC has successfully identified and registered around 16,000 people from
12000 families in 10 districts of Tamil Nadu; around 6,000 adults and children were started on ART
and the program caters to 1200 infected children and 12000 affected children. A unique feature of
the program is provision of effective pre-ART care to delay disease progression and maintain non-
ART status for a longer period, while ensuring timely initiation of ART when needed.

TANSACS acknowledges SAATHII for its technical assistance to the program, Duke University for
monitoring and evaluation, The Childrens Investment Fund Foundation for funding support, and all
the TNFCC-associated ART centers, field NGOs and hospital NGOs for effective implementation

This document provides an operational framework to guide outreach workers on the steps involved
in provision of quality home-based care in conformity to standards set by Indias National Control
Program (NACP III)





Dr. S. VIJAYAKUMAR, I.A.S.,
Project Director
Tamil Nadu State AIDS Control Society

2

Content


Background of TNFCC program 3
a. Mapping and Linkages 8
b. Client identification 9
c. Home visit 10
d. Exploring family status and needs identification 11
e. Providing psychosocial support 12
f. Addressing stigma and discrimination 14
g. Facilitating disclosure of HIV sero-status 15
h. Capacity building of clients 16
i. Care giver identification and training 18
j. Opportunistic infections / Symptoms identification, management and referrals 18
k. Adherence monitoring and counseling 20
l. Ensuring clients access to hospital services 21
m. Tracking clients progress 22
n. Facilitating formation of support group 23
o. Referral and linkages 25
p. Promoting positive speakers 26
q. Facilitating child focused intervention 27
r. Taluk Level Coordination meeting 27
s. Documentation 28
t. Key indicators tracked for monthly technical report and assessing program progress 29
u. Information sharing 30
v. Model curriculum for capacitating PLHIV and care givers 32
Annexure 1 (a r) 36



3

BACKGROUND OF TNFCC PROGRAM
Since September 2005, Tamil Nadu State AIDS Control Society (TANSACS) with
funding support from Childrens Investment Fund Foundation (CIFF) has been
implementing the Tamil Nadu Family Care Continuum Program (TNFCC) in ten districts
of Tamil Nadu. Technical Support partner NGO SAATHII (Solidarity and Action Against
the HIV Infection in India) provides technical, operational and logistic assistance and
internal monitoring support to the project. External Monitoring and Evaluation is being
conducted by Duke University.
TNFCC emphasizes comprehensive care of children infected and affected by HIV/AIDS
through a family-centered approach. The approach strives to improve quality of life in
HIV-affected families, encompassing health, nutrition, psychological, economic and social
domains, through active engagement of both government and non-government partners.
This multi-sectoral and comprehensive approach to family-centered care is consistent with
the mandate of Indias National AIDS Control Program and Guidelines for Care of
Orphans and Vulnerable Children.
To achieve its goal of preventing orphaning and enhancing quality of life for children and
parents from HIV-affected families, TNFCC addresses the following objectives:

To develop and evaluate a multi-sectoral model involving government hospitals,
NGOs, CBOs and positive networks in providing comprehensive continuum of
care and treatment including medical, psychosocial and nutrition services,
treatment of opportunistic infections and provision of antiretroviral therapy.
To develop and evaluate an integrated family-centered continuum of care and
treatment program for HIV positive families.
To integrate community-led treatment preparedness and literacy programs with
care and support services.
To evaluate the impact of nutrition support and counseling on reducing morbidity
and mortality in children and adults.
Scope and coverage
The project is being implemented in three government hospitals, attached to three of the
major medical colleges in the state. Each hospital serves a cluster of districts with one
hospital NGO designated in each cluster, and three or four affiliated field NGOs in the
districts belonging to the cluster; resulting in net program coverage of ten districts. Each
hospital runs a family-centered care program in partnership with NGOs and positive
networks, with technical assistance from SAATHII.
While private sector involvement in care and support has been low, it is an important aim
of the program to promote public-private partnerships for technical, implementing, and
monitoring assistance and in meeting the multifaceted needs of PLHIV.


4


Hospital and NGO Partners of the TNFCC program

Hospital Districts covered Hospital NGO
Field NGOs, CBOs
and Positive
Networks
Government Kilpauk
Medical College
Hospital, Chennai

Chennai cluster:
Chennai, Tiruvallur,
Kanchipuram and
Villupuram
Community Health
Education Society
(CHES)
South Indian Network
of Positive People
(SIP+), Madras Social
Development Society
(MSDS), and
Animators for
Community
Development (ACD).
Government Mohan
Kumaramangalam
Medical college
Hospital, Salem
Salem cluster:
Salem, Erode,
Dharmapuri, and
Perambalur
Young Women
Christian
Association
(YWCA), Salem
Young Women
Christian Association
(YWCA), Human
Integrated Life and
Learnings (HILLS),
SEARCH, and Indian
Development
Organization Trust
(INDO).
Government Medical
College Hospital,
Tirunelveli

Tirunelveli cluster:
Tirunelveli,
Tuticorin
Gramodhaya
Social Service
Society
Positive People
Welfare Society
(PWST+), St.Joseph
Leprosy Hospital
(SJLH)
Hospital activities
The three government medical college hospitals function as hospital program sites and are
responsible for coordinating and providing comprehensive care, support and treatment
services. These services are provided by the hospitals clinical departments, the ART
center having staff appointed by TANSACS and the staff of the hospital NGO.
For the ART center in each hospital, TANSACS has recruited and trained 2 ART medical
officers, 1-2 counselors, 1 lab technician, 1 pharmacist, 1 community care coordinator and
1 data entry operator as in any ART center.
5

TANSACS staff are supported by a trained NGO support team consisting of a project
coordinator, 1-2 counselors, 1-2 nutritionists, 1-2 nurse case managers, 2 nursing aids, 1
pharmacist, 1 accountant cum data entry operator and a sanitary workers. The NGO staff
varies according to the client load in each center and is gradually phased out as ART staff
is added and trained.


I. Flow chart describing Hospital Based Services:











































Patient Registration
Overview of program and
services to receive during
hospital visit

Counselling
Basic counselling, Report of CD4 test,
ART Preparation, Adherence
counselling, other issues like
disclosure, safe and safer sex issues,
positive living, partner testing,
children testing etc
Clinical Services
Physical exam, OI
Screening, Review of test
results, Prescriptions (As
per guidelines), other
medical referrals and
Lab
CBC, CD4 (as per
guidelines), Liver function
test and other need based
tests
Pharmacy
ART, Micronutrient
supplements, Other OI
drugs as per the
prescription

Nutrition services
Nutrition assessment,
counseling, diet
prescription, nutrition
demonstration,
Macronutrient supplements
Patient
Records/
Database
Info Sharing to
Field NGO
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FIELD-BASED SERVICES AND ROLE OF OUTREACH TEAM
Medical and nutritional services provided in the hospital are complemented by suite of
field-based services provided by the NGOs, with outreach workers playing a critical role.
These include:
Identifying HIV positive clients, motivating them for hospital registration and
monthly follow-up visits, and organizing support groups in their neighborhood
Identifying and training peer educators and caregivers
Providing home-based care which includes opportunistic infection diagnosis and
referrals, and ongoing adherence counseling
Referrals and linkages to various services such as housing, income generation,
legal services, welfare schemes, vocational training etc.
Providing child-related services
All services are provided by NGO-specific teams consisting of project coordinator, child
counselor, community health nurse and 8-10 outreach workers.
































7


II. Flow chart describing Field Based Services:


















































Mapping and
Linkages
Client
identification
and motivation
Enrolment
at the
hospital

Client wise
information
sharing to
hospital
Service
delivery at the
field level and
Documentation
TNFCC Field
component
Home based care for
consented clients
Child Focused
Intervention
Community sensitization
and resource
mobilization
Needs assessment
Psychosocial support
Linkages to other services
Self care training
Care giver training
OI identification,
management and training
Adherence counselling and
monitoring
Palliative care
Nutrition counselling
LSE / Recreation activities
Children support group
Children camp
Linkages to educational
support
Vocational training
Linkages to other services
Taluk level coordination
meeting
NGO coordination meeting
Resource mobilization
8

Activities of the outreach workers are itemized below:

a. Mapping and Linkages:

One of the first tasks undertaken by outreach workers is to carry out district-specific
mapping of demographic information, distribution of HIV in the population, service outlets
in government and NGO sectors, and resources available for people living with HIV
(PLHIV) in these sectors. Mapping helps the field teams to establish linkages with service
providers, create and strengthen referral systems, and develop strategies for increasing
access of PLHIV to the existing resources.


Steps:

i. The outreach workers make introductory visits to key stakeholders at district and
sub-district (taluk and block) levels, and elicit information on services and data
available with them.
ii. They also establish rapport with key stakeholders, introduce the TNFCC program,
and outline the needs of PLHIV that they could potentially fulfill.
iii. They then submit this information to their respective project coordinators, who
compile the district- and taluk- level directories and associated fact sheets
iv. Each outreach workers gets a copy of the resource directory to use as a reference for
their project activities, to strengthen referrals and linkages with government and
other service providers within their areas of operation.
v. The outreach workers periodically provide new data that the project coordinators use
to update the directories.

Tools used

Please refer to Annexure 1(a) for suggested Mapping formats developed by TANSACS
and SAATHII.

Expected Outcomes

The mapping exercises carried out by outreach workers are expected to lead to

Increase in clients identification and enrolment at the TNFCC center
Increase in referrals to various government and other services
Easy access to information for clients












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Tips for rapport building

Identify the most suitable
means of introduction
Confirm the identity
Disclose the purpose of initial
and follow-up home visits.
Explain the services provided
Engage in meaningful
conversation [enquire
wellbeing of family and
children]
Gain acceptance of client
[Follow principles of
counseling]
Develop trust building
Assure confidentiality
Identify core felt needs of the
client and start to address
them [e.g. educational needs
of children or nutritional
needs of the family]
Obtain consent for follow-up
of HBC visits and modality of
approach for follow-up visits-
time, venue-house/client
office/NGO office/common
meeting points etc.
b. Client Identification:

One of the key roles of outreach workers is to identify new HIV positive clients in their
areas of work. This enables them to draw all PLHIV in the area into the continuum of care
and positive prevention services, provide them with essential information pertaining to
their infection, and help to create support systems for the client within their families and
community.

Steps:

i. Outreach workers establish linkages with potential sources of HIV positive
individuals in their areas of operation, such as ICTCs, NGOs working in HIV
prevention, private health centers, private
labs, VHNs, Anganwadi workers, key
stake holders in the community etc.
ii. They introduce TNFCC program and the
various services provided at the hospital
and field level, so as to encourage these
stakeholders to refer PLHIV to them / to
the facility
iii. They collect names and addresses of
clients from the above sources, ensuring
confidentiality
iv. They then approach clients, build rapport
and motivate them to get enrolled at the
TNFCC center, by detailing the various
services provided by the hospital and the
NGO (Refer to tips for rapport building)
v. They provide newly identified clients
referral slips signed by themselves. These
slips contain the address of the hospital in
the relevant cluster, and provide a
mechanism for the hospital to track the
source of referral.
vi. They enter client details in the
identification and enrolment register
maintained at the community NGO
vii. They seek client consent for providing
home-based care services
viii. They provide feedback and updates to the
referring source on the clients

Tools used

Please refer to Annexure 1 (d, f) for formats of the Identification and Enrollment register
and Referral Slip





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Expected Outcomes

Client Identification by outreach workers is expected to lead to:

Effective linkages and referrals with various service providers
Increased enrolment at the hospital
Increased access to care, support and treatment services

c. Home visits

Initial home visits by outreach workers help to obtain client consent for subsequent visits.
If consent is obtained, home visits facilitate rapport-building with the clients and their
families, enable the outreach workers explore clients and family needs, and ensure access
to hospital and other required services. Such visits also help provide psychosocial support
and build skills for positive living, train client and caregivers in home-based care, and link
them to support groups and networks.

Steps:

The steps involved in home visits depend on the original source of referral of HIV-positive
clients.

Scenario A: Hospital referral to Field NGO

TNFCC-ART Centers provide the field NGO project coordinator (PCO) a list of clients
who have given consent to the ART counselor for home visits. Along with client consent,
the list also contains guidance provided by each client on directions to their residence, best
time and place to visit, and disclosure status to family. These data are extracted from client
case sheets and added to the list, which is maintained as an MS Excel spreadsheet. Field
NGO PCOs verify the data and share with outreach workers designated to work in the area
where the clients reside.

Scenario B: Referral from other sources like ICTC, Private practitioners, VHNs etc.

During the mapping process or subsequent visits, outreach workers obtain information on
new clients from ICTC, VHN, private practitioners and other referral sources. Information
from such sources is usually sketchy as compared to information available from TNFCC
ART Centers, with only the name and address provided, and other important information
such as disclosure status and guidance for approach unknown.

Scenario C: Leads on clients generated during community sensitization gatherings

As part of their community sensitization activities, outreach workers conduct taluk-level
coordination meetings on a quarterly basis. These meetings offer opportunities to sensitize
local communities on HIV issues, build local ownership in epidemic response, and
motivate uptake of counseling and testing. Following these meetings, community members
occasionally reveal information to the outreach workers on individuals in the area known
to be HIV-positive.

i. In all the scenarios described above, outreach workers need to take care to
maintain client confidentiality and privacy with respect to neighbors, and
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family members, especially when the clients have not disclosed status to their
family. For instance, residents in the locality might provide the location of the
client being sought out, but at the same time may be very curious to know the
reason for the visit. Sometimes the neighbors or the entire family might be
around when outreach workers interacts with the clients. In such cases,
outreach workers need to apply their skills and techniques to handle the
situations appropriately.

ii. Once the outreach workers have correctly located the client residence, they
confirm the identity, establish rapport with the client, explain the purpose of
the visit, and describe services provided through the program. The home visit
consent status is reviewed and confirmed during the visit.

iii. Once rapport has been built and consent for future visits confirmed, the
outreach workers provide home-based care to the client and family members
and ensure access to essential services

iv. If the given address is wrong or untraceable, or the clients are unwilling for
home based care, the outreach workers report this to the hospital during
information sharing sessions

Tools used

Please refer to Annexure 1(b, g) for formats of the Daily Diary and Home Visit Sheet.

Expected outcomes

Home visits by outreach workers are expected to result in

Enrollment at the TNFCC Centers in case of clients identified in the community or
through other service outlets
Working relationship with client and family members
Access to continuum of care services

d. Exploring family status and need identification

Exploring family status and identifying client needs helps to obtain clients demographic
details, disclosure status, issues related to stigma and discrimination, and family members
HIV status. Such information help understanding the felt needs of the client and their
families, and ensure need based intervention for the well being of client and their families.

Steps:

i. Outreach workers build trust, gain confidence and acceptance by the client/ and
family members
ii. Outreach workers explore and document the following details in the respective
registers
a. Family profile Size of the family
b. Education status (Including children)
c. Occupation status (assess possibilities of migration Permanent or
temporary, loss of job and reasons)
12

d. Family economic status
e. Disclosure status To whom disclosed and not disclosed
f. Partner / children HIV testing details
g. Stigma and discrimination self, family, neighborhood, work place,
community etc.
iii. Outreach workers assess the following needs of the clients and their families and
document them in the respective registers
a. Physical needs
i. Health needs
ii. Nutritional needs
b. Psychological needs
c. Social needs
d. Economic needs
e. Environment needs and
f. Education needs
iv. Based on this database the outreach workers plan need based interventions, like
referring the partner and children for testing, ensuring children education, referral
to government welfare schemes, and other essential services, addressing stigma
related issues, referral to counseling center etc.

Tools used

Please refer to Annexure 1 (d, e, f, g) for the formats of Identification and Enrolment
Register, External Referral Register, Referral Slip, Home Visit Sheet

Expected Outcomes

Availability of client and family profile including needs
Increased access to essential services ensured
Spouse and children testing is ensured
Support system for client within the family and community established

e. Providing psychosocial support

People living with HIV/AIDS and their family members undergo lot of emotional distress,
which increases their mental health problems. Further, having mental stress affects the
clients ability to cope with HIV, adhere to treatment including ART, and seek required
support. Providing counseling support to the client and their family by the outreach
workers helps to ensure clients and families cope with HIV and develop positive attitude
and outlook towards life. It further helps to build support system, coping skills, treatment
seeking behavior and increase access to services.









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Steps:

i. During home visit the outreach workers interact with client and their
families and assess the following key areas:

SL. Key areas Observations
1 Sleep
2 Appetite
3 Interest in daily activities
4 Cognitive orientation
(thoughts)

5 Socialization
6 Interpersonal skills
7 Self confidence
8 Self esteem and other emotional
areas like guilt, fear, angry, grief
etc.

9 Marital adjustment
10 Sexual life
11 Perception about life
12 Perception about future
13 Treatment seeking behavior
14 Substance abuse (Alcohol, drugs
etc.)

15 Coping skills
16 Others, please specify

ii. Outreach workers document the key observations in the home visit sheet
iii. Based on the assessment they identify the areas of support required and
provide appropriate counseling
iv. The counseling session (Key areas identified, intervention provided
including referrals) is documented in the home visit sheet
v. If the outreach workers feel they are unable to handle the issue they need to
discuss the case study with the Community Health Nurse, Child Counselor,
Project Coordinator, experienced outreach workers and seek their guidance
in handling the issue or request one of them to come for home visit in
handling the issue
vi. If the outreach workers feel the issue can be addressed only by the TNFCC
center then during the information sharing session the case study is
discussed with the concerned staff (Counselor, ART medical officer,
Nutritionist etc.) and documented in the case sheet and information sharing
sheet
vii. During the follow up visits the outreach workers assess the key areas and
track the progress and provide feedback to the field and hospital team during
fortnightly review meeting, case conferencing and information sharing
sessions.



14

Tools used:

Please refer to Annexure 1 (d, k, g) for the formats of Identification and Enrolment
Register, Information Sharing Sheet, and Home Visit Sheet

Expected Outcomes

Providing psychosocial support by the outreach workers expected to lead to

Resolve psychosocial issues of clients and family members
Provide referral services to clients and family members based on the areas
identified
Clients and family members develop coping skills and have access to services

Reading materials:
1. Living positively with HIV: A follow-up counseling toolkit on Mental Health by
TANSACS
2. National AIDS Control Organization, Counseling Training Module, 2006

f. Addressing Stigma and Discrimination:

Addressing stigma and discrimination issues by the outreach workers helps to identify the
reasons for stigma and discrimination in the family, community, work place etc., develop
client coping skills to handle stigma and discrimination issues, facilitate disclosure to
partner and family members, integrate client within the family, and community, ensure
access to stigma-free services

Steps:

i. Prior to home visits the outreach workers review the clients socio-
demographic details
ii. Outreach workers interact with client and family members and explore
stigma and discrimination issues with in the family and community
members
iii. Outreach workers assess the type of stigma (Self perceived stigma or
Enacted stigma) faced by the client and family members
iv. Based on the type of stigma the outreach workers develop strategies to
address stigma and discrimination and associated emotional problems
v. In case outreach workers are not able to handle this issue they need to seek
Project coordinator, counselor, and community health nurse guidance and
support or request one of them to come for home visit in handling the issue
vi. During the follow up home visits outreach workers track the clients progress
and provides required support to empower the client and the family
members
vii. The clients progress is shared during the field fortnightly review meeting,
through information sharing session and case conferencing





15

Tools used

Please refer to Annexure 1 (g) for the formats of Home Visit Sheets

Expected outcomes:

Addressing stigma and discrimination by outreach workers expected to

Document the reasons for stigma and discrimination all client and family members
Empower Clients and family members to handle issues related to stigma and
discrimination with in the family and community
Ensure access to essential services


Reading materials

Living positively with HIV: A follow up counseling toolkit on Stigma and
Discrimination by TANSACS

g. Facilitating Disclosure of HIV sero-status:

Due to multiple reasons such as stigma, discrimination, disruption of family relationships,
fear of separation from spouse etc., many clients face challenges in disclosing their sero-
status to the spouse, partners and family members. Facilitating disclosure by outreach
workers helps, to create support system for client within their family, ensure HIV
counseling and testing for spouse and children, ensure couples to practice safe and safer
sex practices. It also helps clients to access medical and other care, support services by
client/family members and receive timely and appropriate treatment and promote
adherence to medication, including ART

Steps

i. Outreach workers interact with the client and explore the reasons for not
disclosing the status
ii. They explain the advantages, disadvantages of disclosure to the clients and
make them understand its importance
iii. During the interaction the outreach workers identify the barriers for
disclosure and help the clients develop possible strategies for addressing the
barriers
iv. The outreach workers also explain forms of disclosure, steps in disclosure,
which further facilitates adoption of viable strategies by the client
v. If the clients request the outreach workers to be present during the
disclosure, the outreach workers are expected to comply and help the client,
spouse and family cope with the problems by providing appropriate
information and counseling
vi. During the follow up visits the outreach workers discuss with the client,
spouse, and family members about their concerns and need to plan
interventions based on that
vii. If the outreach workers are not able to handle the case they seek guidance
and support from project coordinator, child counselor, community health
nurse or hospital counselor or request one of them to come for home visit
16

Disclosure to children

Outreach workers are encouraged to seek guidance from child counselors in
facilitating disclosure to children.

The decision to disclose parents or childs HIV status to the child rests
with the parents or guardian
Disclosure may be partial: this means telling the child that his/her or the
parents medical condition requires special care while not naming
HIV/AIDS as the condition, and ensuring that all possible care is provided
to make them feel better
The time to disclose the status depends on
o Childs level of development and emotional maturity
o Readiness and comfort of parents / guardian
o The best time to tell the child her/ his sero-status is ten to eleven
years, as far as Indian setting is concerned above 12 years
The best place to disclose is at home
The child must be taught to keep the secret
viii. The out reach workers share clients progress during the field fortnightly
review meeting, information sharing session and case conferencing

Tools used

Please refer to Annexure 1 (d, g) for the formats of Identification and Enrolment Register
and Home Visit Sheet

Reading materials

1. Living positively with HIV: A follow- up counseling toolkit on Disclosure by
TANSACS
2. Protocol for child counseling on HIV testing, Disclosure and support by Family
Health International

Expected Outcomes

Facilitating disclosure of HIV sero-status by the outreach workers expected to lead to

Conducive and supportive environment for the client with in the family
Access to continuum of care services by client and family members

H. Capacity Building for clients:

With the advent of ART, HIV infection can be a chronic manageable condition. People
with HIV need support, information and capacity building to demystify myths and
misconception about HIV infection and lead a positive life. Capacity building for clients
by the outreach workers helps to instill hope and confidence to lead a healthy and positive
life, ensure access to care, support and treatment services, improve their quality of life and
sustain the efforts of the service providers


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Disclose to spouse / family and seek
support system
Get regular health care
Adhere to medicines and nutrition
supplements
Eat healthy and nutritious food
Maintain healthy habits
Do regular exercise and take adequate
rest
Maintain good personal and
environmental hygiene
Identify and treat infections promptly
Always adopt safe and safer sex
practices
keep self occupied
Be part of support group
Handle pets carefully
Cut down Stress
Seek spiritual support
Seek psychosocial support regularly
Steps
i. Outreach workers train all the clients registered under TNFCC program
during home visit on various components including basics of HIV/AIDS,
ART, self-care, management of OI,
nutrition, prevention of infections at
home etc. using the minimum
standards, training manual, home
care kit box and IEC materials
ii. Outreach workers document the
topics covered during the home visit
in the home visit sheet and updates
in the self care training register
iii. During follow up visit the outreach
workers assess the knowledge,
skills, health seeking behavior and
attitude through interaction with
clients, family members and
observation
iv. Based on the assessment the
outreach workers reinforce the
topics / information in the follow up
visits
v. Outreach workers track clients
progress and share the information
during the fortnightly review
meeting and through case
conferencing



Tools used

Please refer to Annexure 1 (d, i) for the formats of Identification and Enrolment Register,
Care giver training register.

Reading Materials

1. Caring for someone with HIV/AIDS A home based care handbook by I-TECH
2. Living Positively with HIV: A follow up counseling toolkit Facts You need to
know by TANSACS
3. ART and HIV Leaflet on ART developed by I-TECH
4. WHO flip chart Treatment literacy

Expected Outcomes:

Capacity building for clients by the outreach workers expected to lead to

Promote positive living among clients
Sustain health seeking behavior


18

I. Caregivers identification and training

Caregiver identification and training by the outreach workers helps to address stigma and
discrimination issues at the family level, facilitate better caring environment for the client
at the home level, ensure continuum of care at the home level, and capacitate caregivers in
providing home based care.

Steps:

i. Outreach workers identify primary caregiver with the help of the client.
ii. They train all the primary caregiver under TNFCC program on various home
based care topics including role of caregivers, basics of HIV/AIDS,
prevention of infections at the home level, Management of Opportunistic
Infections at the home level, nutrition, personal and environmental hygiene,
when and where to seek help, medicines to be taken by the client and the
possible side effects etc... using the home based care for care givers training
manual and IEC materials
iii. Outreach workers documents the topics covered during the home visit in the
home visit sheet and update in the caregiver training register
iv. During follow up visit the outreach workers assess the knowledge, skills,
attitude and problems faced by the caregiver through interaction with
caregivers and observation
v. Based on the assessment the outreach workers reinforce the topics /
information to the caregiver in the follow up visits
vi. On a periodic basis the outreach workers interacts with caregivers, identify
their problems including burn out and provides counseling or refer to project
coordinator /community health nurse/child counselor for counseling

Tools used

Please refer to Annexure 1 (i, g) for the formats of Care Giver Training Register, Home
Visit Sheet

Reading materials

1. Caring for someone with HIV/AIDS A home based care handbook by I-TECH

Expected Outcomes:

Care givers identification and training by the outreach workers lead to

Establish support system for client at the home level
Sustain the efforts of health care providers at the home level

J. Opportunistic infections / Symptoms identification, management and referrals,

Opportunistic infections / symptoms identification, management and referrals by outreach
workers helps to ensure early identification and treatment of opportunistic infections,
provide training / demonstration in managing opportunistic Infections / Symptoms at the
home level, provide appropriate referral for clinical care and capacitate client and
caregiver in opportunistic infection /symptom identification, management and referrals
19


Steps:

i. During the home visit the outreach workers assess the clients health status
using the following tool
S. No Presenting complaints Observations

1 Fever
2 Cold and cough
3 Tiredness and weakness
4 Nausea and Vomiting
5 Diarrhea
6 Skin problems especially
rash

7 Bed sores
8 Mouth and throat problems
9 Breathing difficulty
10 TB
11 STIs
12 HIV related pain
13 Swelling
14 Dental problems
15 Eye problems
16 Any other problems /
complaints



ii. Based on the nature and severity of complaints the outreach workers provide
training / demonstration on home management /seek guidance and support
from community health nurse through home visit / referral to hospital for
clinical care
iii. If the client needs palliative care the outreach workers go with community
health nurse to provide nursing care and project coordinator/ child counselor
for counseling
iv. Outreach workers documents the opportunistic infections / symptoms
identified and the interventions provided in the home visit sheet
v. During follow up visit the outreach workers tracks clients progress including
personal and environmental hygiene, health status, adherence to medicines,
access to hospital services and provides appropriate training / input
vi. Outreach workers train the caregiver / client in identifying the opportunistic
infections /symptoms, and management during home visits

Tools used

Please refer to Annexure 1 (i, g, f) for the formats of Care Giver Training Register, Home
Visit Sheet and Referral slip



20

Adherence calculation

ART Adherence % = No. of pills taken /
No. of pills to be taken * 100

Micro adherence % =No. of pills taken /
No. of pills to be taken * 100

Macro Adherence % = Total grams taken
/Total grams to be given * 100

(Or) Calculate the number of missed
doses (ART and Micro) and no of days
macro not consumed in the home visit
sheet and report in the appropriate
registers
Expected Outcomes:

Opportunistic infections / symptoms identification, management and referrals by outreach
workers lead to

Early identification of opportunistic infections and symptoms
Promote health seeking behavior
Ensure positive living
Sustain efforts of the health care providers at the home level

Reading Materials

1. Caring for someone with HIV/AIDS A home based care handbook by I-TECH

K. Adherence monitoring and counseling

Adherence monitoring and counseling by the
outreach workers help to monitor clients
adherence to ART, ATT, OI drugs including
prophylaxis, micro and macro supplements,
identify barriers for adherence and develop
appropriate strategy, ensure adherence to
medicines and nutrition, ensure access to
medical services and enhance quality of life

Steps

i. During home visit the outreach
workers monitor clients
adherence to ART, ATT, OI
drugs including prophylaxis,
micro and macro supplements
through pill count, health status assessment including CD4 status, weight
gain, Opportunistic Infections, interaction with client and caregivers, clients
access to medical services, etc.
ii. If the outreach workers come across poor adherence, missed doses, they
interact with the client and caregiver to identify the barriers and reasons for
poor adherence
iii. Based on the assessment the outreach workers provides counseling to the
client and caregivers on importance of adherence, strategies to overcome
poor adherence and build support systems to improve adherence
iv. During the information sharing the outreach workers shares the information
with the hospital team which help hospital team to focus on adherence
component during follow up visits
v. If the Outreach workers unable to address this issue they need to seek
guidance and support from community health nurse/ project coordinator/
child counselor or request one of them to come for home visit in addressing
the problem
21

vi. During follow up visits the Outreach workers track clients progress and
shares with the field and hospital team during fortnightly review meeting,
case conferencing and information sharing sessions
vii. Outreach workers documents the adherence status (For ART, Micro and
Macro % should be reported) in the home visit sheet and updates in the
CD4, ART register and monthly technical report

Tools used

Please refer to Annexure 1 (h, l, o, g) for the formats of Adherence Tracking, CD4, ART
Register, TB Tracking Sheet and Home Visit Sheet

Reading Materials

1. Treatment preparedness guidelines by NACO
2. Adherence to Anti retroviral therapy in Adults, A guide for trainers by Population
council, International center for reproductive health, coast province General
Hospital, Mombasa

Expected outcome

Adherence monitoring and counseling by the outreach workers expected to lead to

Ensure adherence to ART, ATT, OI drugs, Micro and Macro supplements as per
NACO standards
Strategies for addressing barriers incorporated in the follow up counseling
checklist

L. Ensuring clients access to hospital services

Outreach workers at the field level track clients hospital follow up status and ensure
access to hospital services on a regular basis. This activity facilitates tracking the reasons
for missed follow up, and lost to follow up, provide motivational counseling, treatment
education and ensure clients access to hospital services which includes and not limited to
routine clinical care, CD4 testing, counseling, nutrition counseling etc. Further it also help
to ensure pre-clients are not in lost to follow up category and ART clients in regular
monthly follow-ups


Steps:

i. Outreach workers with the help of patient wise data tracking system track
clients who are in missed and lost to follow up category
ii. During the home visit the outreach workers assess the reasons for missed
and lost to follow up
iii. Based on the assessment the outreach workers develop strategies to increase
health seeking behavior through motivation counseling, treatment education,
peer counseling, etc
iv. If the outreach workers not able to enhance health seeking behavior they
have to seek guidance and support from community health nurse/child
counselor / project coordinator and involve one of them in home visit.
22

v. During information sharing with hospital team outreach workers share the
reasons and seek guidance from the hospital team. If needed they request
one of the hospital team members to come for home visit.
vi. Outreach workers documents the reason, interventions provided, client
hospital visit status in the home visit sheet and patient wise data tracking
sheet
vii. During follow up home visit the outreach workers track client progress and
share with field and hospital team during fortnightly review meeting,
information sharing and case conferencing
viii. Outreach workers also provide supportive counseling and address the need
to ensure clients access to hospital service on a regular basis

Tools used

Please refer to Annexure 1 (g, r) for the formats of Home Visit Sheet and Patient Wise
Data Tracking sheet

Expected Outcome:

Ensuring clients access to hospital services by the outreach workers expected to lead to

Ensure all the clients enrolled in TNFCC ART centre access regular hospital
services
Document reasons for missed follow up / lost to follow up and address in follow
up counseling

M. Tracking clients progress

Outreach workers at the field level track clients clinical, psychological, social and
economic progress during home visit which helps to track client and family members
overall improvement, identify gap areas, needs and develop strategies to address identified
gap and needs, ensure access to care, support and treatment services. This facilitates
improving quality of life

Steps:

i. During home visit the outreach workers assess the following key areas and
document in the patient wise data tracking sheet and the respective registers

a. Family HIV status including Children
b. Disclosure status
c. Support system for clients with in the family
d. Children school going status
e. Environment and living condition
f. Psychological well being
g. Patients daily activities including work (Follow NACO WAB
guidelines)
h. Economic status
i. Discordant status track periodic HIV testing by negative partner
j. CD4 baseline count
k. Follow up CD4 due date
23

l. Follow up CD4 testing date and count
m. CD4 result collection status (Baseline and follow up)
n. Progress in weight
o. Progress in height (For children)
p. Hospital follow up status
q. client health status
r. Health seeking behavior
s. Adherence to ART, ATT, OI drugs, micro and macro
t. Safe and safer sex practices
u. Needs of client and family
v. Implementation of self care and caregiver training program
w. Participation in support group meeting
x. Follow-up of referrals and linkages

ii. Based on the assessment the outreach workers derives intervention strategies
which is followed up in the successive home visits
iii. The outreach workers document the intervention provided and follow up
status in the home visit sheet and update in the patient wise data tracking
sheet and the respective registers
iv. During information sharing with the hospital team the outreach workers
share client wise progress with the hospital team and update in the case sheet
v. Client wise progress is shared with the field and hospital team during the
fortnightly review meeting, case conferencing and NGO coordination
meeting


Tools used

Please refer to Annexure 1 (g, r, d, l, o, h) for the formats of Home Visit Sheet, Patient
Wise Data Tracking sheet, Identification and Enrolment Register, Adherence Tracking
Sheet, TB tracking sheet and CD4, ART register

Expected outcome:

Tracking clients progress by the outreach workers expected to lead to

Document clients progress
Ensure clients and families access to continuum of care services

N. Facilitating formation of support group

Facilitating formation of family support group (Including PLHIV (Adult and children),
caregiver, and affected children) by the outreach workers helps to form family support
group at the Taluk / Block level, create and strengthen support system for the clients,
children and caregivers, create a platform for information sharing among the clients,
children and caregiver, capacitate clients, children and caregiver on managing HIV and
create ownership and leverage community resources




24

Steps:

i. Outreach workers initiate the formation of family support group at the Taluk
/ Block level through explaining the purpose, activities and importance of
support group
ii. During the support group meeting the outreach workers train the support
group members (PLHIV (adult) and Caregiver) on various topics including
basics of HIV/AIDS, nutrition, importance of disclosure, managing
symptoms at the home level, personal and environmental hygiene, Basics of
ART, importance of adherence, welfare schemes, facilitation skills, legal
rights etc.
iii. Outreach workers facilitate sharing among the support group members to
ensure support system, develop coping skills and develop shared vision
iv. Outreach workers capacitate the support group members in planning and
facilitating the support group members to ensure sustainability
v. Outreach workers assist the support group members in planning and
conducting the support group meeting
vi. Outreach workers document the proceedings in the support group register
and on a periodic basis review the document to ensure all topics are covered
in the support group meeting
vii. During the review meeting the outreach workers shares the experience,
topics covered, resources mobilized, lessons learnt etc. during the fortnightly
review meeting
viii. Outreach workers ensure all the clients registered in TNFCC program are
linked with support group

Outreach workers to refer the child focused intervention guidelines developed by TA
team/TANSACS in conducting children support group

Tools used

Please refer to the Annexure 1 (n, p, i) for formats of Support Group Register, Children
Data Base and Caregiver Training Register

Expected Outcomes:

Facilitating formation of support group meeting by the outreach workers expected to lead
to

Form family support group at the Taluk / Block level
Establish support system for PLHIV established within the community level
Establish community ownership, resource mobilization and access to care, support
and treatment.

Reading materials

1. Living Positively with HIV: A Follow up Counseling Toolkit Facts You Need
to Know developed by TANSACS
2. Living Positively with HIV: A Follow up Counseling Toolkit Mental Health
developed by TANSACS
25

3. Living Positively with HIV: A Follow up Counseling Toolkit Telling Your
Partner developed by TANSACS
4. Living Positively with HIV: A Follow up Counseling Toolkit Stigma and
Discrimination developed by TANSACS
5. Living Positively with HIV: A Follow up Counseling Toolkit Safer Sex
developed by TANSACS
6. Living Positively with HIV: A Follow up Counseling Toolkit Disclosure
developed by TANSACS
7. Living Positively with HIV: A Follow up Counseling Toolkit Compendium of
Tools developed by TANSACS

8. Flip Chart HIV / AIDS udan Nambikkaiyodu Vazdhal Thodar Aalosanai
Karuvi Neengal Terindukollavendiya Unmaigal (Tamil) developed by
TANSACS

9. Flip Chart HIV / AIDS udan Nambikkaiyodu Vazdhal Thodar Aalosanai
Karuvi Mananalam (Tamil) developed by TANSACS

10. Flip Chart HIV / AIDS udan Nambikkaiyodu Vazdhal Thodar Aalosanai
Karuvi Thunaivarukku Arivithal (Tamil) developed by TANSACS

11. Flip Chart HIV / AIDS udan Nambikkaiyodu Vazdhal Thodar Aalosanai
Karuvi Kalangappaduthuthal and Verupadututhal (Tamil) developed by
TANSACS

12. Flip Chart HIV / AIDS udan Nambikkaiyodu Vazdhal Thodar Aalosanai
Karuvi Padukappudan Udaluravu (Tamil) developed by TANSACS

13. Flip Chart HIV / AIDS udan Nambikkaiyodu Vazdhal Thodar Aalosanai
Karuvi HIV Nilaiai Velipaduthuthal (Tamil) developed by TANSACS

14. Caring for someone with HIV/AIDS A home based care handbook by I-TECH

O. Referral and linkages

Outreach workers at the field level initiate referral and linkages to the client and the family
members based on the needs and issues identified. This activity helps to establish and
sustain linkages with NGOs, CBOs, government departments, and community
stakeholders. This further facilitates client and families access to other required services

Steps:

i. Outreach workers Identify various facilities available with in a
district/Taluk/ Block / village level (Health facility, ICTC center NGOs,
CBOs, government departments, lions club, rotary club, etc.) through
mapping exercise (refer to section a)
ii. Outreach workers establish linkages with various service providers which
enables to create and strengthen referral systems
iii. Based on the needs identified (Refer to section d) the outreach workers
details the services provided by the referral source to the client and provides
referral slip to the client / family member (If needed the outreach workers
26

accompanies or makes alterative arrangements like linking with other
clients/ peer educator etc.)
iv. Outreach workers also facilitate in obtaining required certificates such as
proof of residence, death certificate, income certificate, community
certificate, etc. from the government departments and key stakeholders
v. During follow up home visits the outreach workers ensures the client has
accessed the place and availed the services
vi. If the client has difficulty in accessing the services the outreach need to
facilitate and ensure the clients have access to services
vii. On a periodic basis the outreach workers meet the referral source, provide
feedback including appreciating their contribution and request for extending
continuous support
viii. The outreach workers documents the purpose of referral, and out come in
the home visit sheet and referral register
ix. Outreach workers collects supportive documents for those accessed services
and files it along with the referral register
x. During information sharing session the outreach workers updates the
hospital team about the services accessed by clients
xi. In the fortnightly review meeting and NGO coordination meeting the
outreach workers share the information with other staffs which facilitates
further linkages

Tools used

Please refer to the Annexure 1 (g, e, f) for formats of Home Visit Sheet, Referral Register,
and Referral Slip

Expected Outcome:

Referral and linkages by outreach workers expected to lead to

Ensure access to essential services
Establish community participation and ownership

P. Promoting positive speakers

Promoting positive speakers among the PLHIV helps to address stigma discrimination
issues within the family and community, create and sustain peer counselors who help in
increasing health seeking behavior, identify new clients, prevent new infections and
initiate advocacy issues and voice their rights

Steps:

i. During support group and home visit the Outreach workers identifies clients
who are open about their status and willing to be positive speakers
ii. Outreach workers builds clients knowledge and skills on positive speaking,
peer counseling skills etc. which facilitates becoming a positive speaker
iii. Outreach workers involve positive speakers in support group, Taluk Level
coordination meeting, District Level NGO networking meeting, peer
counseling etc. which ensures their participation and contribution
27

iv. Outreach workers documents the out come of involving positive speakers
and shares with other staff during the fortnightly review meeting and NGO
coordination meeting

Tools used

Please refer to the Annexure 1 (n, g, m) for formats of Support Group Register, Home
Visit Sheet, and Taluk level / NGO coordination meeting format

Reading Materials

1. Positive development: setting up self help groups and advocating for change, A
manual for people living with HIV Published by the Global Network of People
Living with HIV and AIDS in collaboration with Health Link
2. Lifting the burden of secrecy A training module for positive speakers By Asia
Pacific network of people living with HIV/AIDS

Expected Outcomes:

Promoting positive speakers by the outreach workers expected to lead to

Ensure Greater involvement of people living with HIV and AIDS in HIV
prevention, care, support, treatment and advocacy efforts.

Q. Facilitating child focused intervention

Outreach workers to refer the child focused intervention guidelines developed by TA
team/TANSACS.

R. Taluk Level Coordination meeting

Taluk Level coordination meeting serves as a platform to share issues, needs related to
HIV/AIDS in the community and build the ownership of the community members to
support families with People Living with HIV/AIDS and HIV/AIDS programs.

Steps:

i. Outreach Workers meet the key stakeholders at the community (Thasildhar,
Block Development Officer, political leaders (MLA, Chairman, Panchayat
Leaders, ward members etc.), service club president, Medical officer of
Taluk Level / Block level hospital, Industrialist, business community,
independent donors, SHG federation president, Faith based organization
leaders etc.), explains the objective, purpose of the meeting and invites them
to be part of the Taluk Level coordination committee. During the Taluk level
coordination meeting the Project coordinator / child counselor / outreach
workers
a. Brief the various activities of their organization and TNFCC
program
b. Sensitize the stake holders on HIV/AIDS
c. Present the issues / needs of People living with HIV, their families
especially children in their area
28

d. Detail the role of Taluk Level coordination committee members in
addressing these issues / needs and seek their guidance and support
e. The outreach workers document the proceedings of the meeting
including Taluk level committee members feedback, commitment
on support / addressing the expressed need
ii. The outreach workers in consultation with project coordinator implements
the suggestions / feedback and ensures regular follow up with the members
to mobilize resources and address key issues
iii. The outreach workers documents the outcome of Taluk Level coordination
meeting in the referral register / Taluk Level coordination committee
meeting minutes
iv. During the fortnightly review meeting and NGO coordination meeting the
outreach workers disseminate the experience, learning and outcome for
other to learn and implement

Tools used

Please refer to Annexure 1 (e, f, m) for formats of Referral Register, referral slip and Taluk
Level coordination committee reporting format

Expected Outcomes:

Formation and facilitation of Taluk Level Coordination Committee meeting by the
outreach workers expected to lead to

Sensitize community stakeholder on HIV and AIDS issues
Establish and sustain community support for PLHIV and families

S. Documentation

Documentation helps to capture the input, output, outcome and impact which help the
implementer to analyze the program progress and develop strategies.

Steps:

i. Outreach workers document the activities and input in the home visit sheet,
daily dairy, registers and formats
ii. The key output, and outcome are captured in the home visit sheet, daily
dairy, registers, formats and outreach workers wise data sheet
iii. Before consolidating the program data and documentation the project
coordinator validates the data with outreach workers, where the outreach
workers present supportive documents for each activities and data captured
iv. During the fortnightly review meeting and NGO coordination meeting the
outreach workers present their activities and key indicators in the program
v. Outreach workers with the help of project coordinator/child
counselor/community health nurse use the data, identify the gap areas and
develop strategies to enhance the quality of the program
vi. On a daily basis the outreach workers update all the registers and formats



29

Tools used

Please refer to Annexure 1 (a r) for formats of Daily Dairy, Resource Directory, Home
Visit Sheet, PLHIV identification and enrolment register, Caregiver Register, CD4, ART,
TB register, Support group register, External Referral Register / referral slip, HBC and
Children kit distribution register, Taluk level coordination meeting format, Information
Sharing Sheet, Outreach Workers Wise Data Sheet, Death register, Children Data Base,
Patient wise data tracking sheet

Expected Outcomes:

Documentation by the outreach workers expected to lead to

Systematically capture input, output, and outcome of the program
Enhance usage of data and establish documentary evidence for program
implementation

T. Key indicators tracked for Monthly technical report and assessing program
progress

The following key indicators are captured by the outreach workers in the specific reporting
formats and registers, which are used for tracking the program progress.

# of PLHIV identified
# of PLHIV registered (Adult)
# of CIA registered
# of families with children served
# of family members served
# of Affected children served
# of clients tested for CD4 baseline
# of clients received baseline CD4 test result
# of clients eligible for follow up CD4 testing (1, 2,3,4,5, etc.)
# of clients tested for follow up CD4 test (1, 2,3,4,5, etc.)
# of clients received follow up CD4 result
# of clients eligible for CD4 through baseline
# of clients eligible for CD4 through follow up CD4 test
# of clients eligible for CD4 based on WHO stage
# of clients initiated on ART
# of ART eligible clients not initiated on ART with reasons
# of clients initiated on Micro and Macro supplements
# of ART clients expected for hospital follow up
# of ART clients in regular follow up
# of ART clients missed follow up with reasons
# of ART clients lost to follow up with reasons
# of ART clients transferred out
# of ART clients reported death
# of Pre - ART clients expected for hospital follow up
# of Pre - ART clients in regular follow up
# of Pre - ART clients missed follow up with reasons
# of Pre - ART clients lost to follow up with reasons
# of Pre - ART clients transferred out
30

# of Pre - ART clients reported death
# of clients under home based care follow up
# of clients have disclosed their status to at-least one family member
# of concordant couples
# of discordant couples
# of discordant couple maintain discordance
# of discordant couple tested for HIV (Once in six months)
# of clients trained on self care
# of caregiver identified
# of caregivers trained
# of clients with TB
# of clients taking ATT
# of clients completed ATT
Clients ART adherence %
Clients micro and macro adherence %
# of clients provided counseling
# of clients received condoms
# of children referred for various services (vocational training, education support,
nutrition, institution care, etc.)
# of children tested for HIV
# of children not tested for HIV
# of children going to school
# of children know their HIV status
# of children know their parents status
Children orphan status (Both parents alive, single orphan, double orphan)
# of clients referred for various services (Government schemes, nutrition,
livelihood etc.)
# of children under institutional care, kinship care
# of clients referred for medical services
# of clients attending support group meeting
# of families received HBC and children kit
# of families using HBC and children kit
# of Taluk level coordination meeting conducted
# of members participated in the Taluk level coordination meeting

U. Information sharing

Information sharing by the outreach workers facilitates, hospital team track clients
progress at the field level including services provided by the field team, health seeking
behavior, adherence to medicines, health status, field team to update client wise
information to hospital team including the reasons for lost to follow up, missed follow up,
eligible not started on ART, adherence issues, family problems etc This further
facilitates hospital team and outreach workers to derive intervention strategies for
problematic clients and family members, build capacity of the outreach workers.

Steps

i. During the fortnightly review meeting the outreach workers submit the fortnightly
plan to the project coordinator which includes date for information sharing session
with hospital team
31

ii. The project coordinator prepare the outreach workers information sharing session
schedule and send it to ART center, TANSACS and Technical Assistance Team
iii. The outreach workers completes the client wise data in the information sharing
sheet and get approval from the project coordinator
iv. As per the plan the outreach workers go to the ART center with client wise
information
v. During the information sharing day the outreach workers
a. Assist the hospital team in case flow
b. Accompany clients for clinical referrals
c. Update the reasons for lost to follow up / missed follow up / eligible not
started on ART, such as
1. Migration (temporary/permanent)
2. not able to trace the clients due to wrong address
3. client not willing for treatment (ART)
4. clients not willing for home based care
5. Death
6. Taking treatment at other ART centers
7. Taking treatment at private settings and non-allopathic
practitioners, etc. with the help of hospital team

d. Request the hospital team to collect proper address or address the areas of
intervention required from hospital team such as treatment preparedness to
increase health seeking behavior, adherence to ART, OI medicines and
supplements, maintaining personal hygiene, disclosure to spouse,
motivating clients to bring spouse/ children for HIV testing, practicing
safe and safer sex etc. through one to one interaction with concern staff
with the case sheet or updating in the case sheet
e. Documents the areas of intervention expected from the hospital at the field
level through discussion with hospital team
f. Seek guidance from the hospital team to address key issues at the field
such as motivating clients for hospital follow up, counseling clients on
safe and safer sex practices, facilitating disclosure, nutrition counseling,
etc.
g. Get technical input
h. Review case sheet and collect data/information which is not mentioned in
patient note book and the information requested in previous information
sharing session
vi. After information sharing session the outreach workers take a photo copy of the
completed information sharing sheet and handover to the project coordinator for
further follow up and filing
vii. The ART medical officer review the process and outcome of information sharing
session, and provide feedback
viii. Before leaving the center the outreach workers sign in the information sharing
register maintained at the hospital and get signature from the ART Medical officer
/ ART Counselor
ix. During fortnightly review meeting the outreach workers update the process and
out come of information sharing to the field team




32

Tools used

Please refer to Annexure 1 (k) for formats of Information Sharing Sheet, Death Register
and Daily Dairy

Expected Outcomes:
Information sharing session by the outreach workers expected to lead to

Document reasons for lost to follow up, missed follow up, eligible not started on
ART by the field and hospital team
Track patient wise information
Develop strategies for individual clients and provide appropriate services
Build outreach workers capacity in handling technical issues at the community
V. Model Curriculum for capacitating PLHIV and caregivers

The following curriculum helps the outreach workers to plan the capacity building session
in a structured way and ensure minimum standards for all the PLHIVs and caregivers. The
outreach workers are expected to cover the proposed sessions for all the registered clients
and the identified caregivers.

a. Basics of HIV / AIDS

Objectives of the session:

By the end of the session clients and caregivers will be able to

Understand basic facts about HIV/AIDS including modes of transmission,
prevention and treatment
Dispel Common myths and misconceptions related to HIV / AIDS
Learn the importance of health seeking behavior

Content
a. What HIV and AIDS are
b. Functions of immune system
c. How does HIV affect the immune system
d. Importance of CD4
e. How HIV is transmitted
f. How HIV is not transmitted
g. Signs and symptoms
h. Treatment
i. Prevention
j. Myths and misconceptions about HIV/AIDS including information on
complete cure for HIV through alternative medicines
k. Link between health seeking behavior, positive living and HIV disease
progression

Materials required: Flip chart, pamphlets



33

b. Basics of Antiretroviral Therapy

Objectives of the session

By the end of the session the clients and caregivers will be able to

Understand basic facts about Antiretroviral therapy including when to initiate
ART, advantages, possible side effects, management of side effects, and
importance of adherence

Content

a. What are Antiretroviral therapy
b. Why Antiretroviral therapy are important
c. ART treatment preparation process/steps
d. When to initiate ART
e. Will ART cure HIV
f. How long ART has to be taken
g. Advantages of ART
h. What to do before initiating on ART
i. What are possible side effects of ART
j. How to manage side effects
k. What is adherence
l. Why adherence to ART is required
m. When to seek help

Materials required: Flip chart, pamphlets

c. Living positively with HIV

Objective of the session

By the end of the session the clients and caregivers will be able to learn and understand

HIV is a manageable infection
Important elements in the management of HIV infection

Content

a) What is positive living?
b) Why positive living?
c) Is it possible to lead a healthy life after HIV infection?
d) Important elements for living positively with HIV
I. Medication
II. Nutrition
III. Healthy habits
IV. Safe sex
V. Positive attitude
VI. Hygiene etc...
e) Importance of making will
Materials required: Flip chart, materials for demonstration
34

d. Nutrition and HIV

Objectives of the session

By the end of the session the clients and caregivers will be able to

Understand the importance of nutrition in managing HIV infection (Link between
nutrition and HIV)
Explain the various groups of food necessary for a balanced diet
Describe the importance of nutrition in delaying HIV disease progression
Describe the importance of food safety and hygiene

Content
a. Link between Nutrition and HIV
b. Component of food pyramid and its importance in daily diet
c. Food safety and hygiene
i. Importance of kitchen hygiene
ii. Personal and environmental hygiene
iii. Preparing food safely
iv. Storage of food
v. Storage of drinking water
e. Demonstration of low cost recipe including macro supplements
f. Importance of adherence to Macro and Micro
g. Importance of kitchen garden

Materials required: Flip chart and Raw materials for low cost recipe demonstration
session

e. Prevention of infection in the home

Objective of the session

By the end of the session the clients and caregivers will

Explain how to prevent infection at home
Understand the importance of hygiene
Demonstrate universal precaution methods
Know the method of using condoms and its importance

Content

a) What are personal and environmental hygiene?
b) Importance of personal and environmental hygiene in preventing infection
c) What are universal precautions?
d) Universal precaution methods
e) Importance of condoms in positive prevention
f) Steps and methods of using condoms

Materials: Flip chart, HBC Kit / materials for demonstration

35

F. Management of symptoms at home

Objective of the session

By the end of the session the clients and caregivers will

Identify symptoms of the various infections associated with HIV/AIDS
Learn and treat symptoms at home
Know when to refer/ go to the doctor

Content

a) How to identify symptoms at home
b) What to do at home
c) How to prevent
d) When to refer / go to the doctor

The clients and caregivers are expected to be trained on the following topics

Fever Tiredness and Weakness Respiratory problems
Diarrhea, Dehydration Skin Problems Pain, Anxiety, Depression,
Mental confusion, and
Dementia
Nausea and vomiting Mouth and throat problems TB
STIs

Materials: Flip chart, HBC kit and materials for demonstration























36

ANNEXURE 1 (a) MAPPING FORMAT

S.No Primary Divisions Secondary divisions Tertiary divisions
Home affairs Taluks
Assembly constituencies
Parliamentary constituencies
Panchayat unions
Town panchayats
Village panchayats
Revenue Firkhas
Revenue villages
Municipalities
Corporations
Courts
District Collectorate and other departments
BDO
DRDA
TADCO
etc, etc
Population of the Particular district Male
* urban, rural can also be some classifications Female
Transgender
Children (>12 yrs)
Sex ratio
Density of the population (Persons/sqm)
Caste/ Tribe
Literacy Male
* urban, rural can also be some classifications Female
37

Boys <12th std
Girls <12th std
Employment
Cultivators
Male
* urban, rural can also be some classifications
Female
Workers Male
Female

Labourers
Male

Female

Anganwadi workers
Male

Female

Village health workers
Male

Female

Multi purpose health workers
Male

Female

SSA Officials
Male

Female
Non workers
Male

Female
Schools Balwadis
* urban, rural can also be some classifications Anganwadis
Primary
Middle school
High School
Higher Secondary School
Schools for special children
Transit schools / Non formal schools
Arivozhi Iyyakam
Red ribbon clubs
38

Colleges Arts / Sciences
* urban, rural can also be some classifications Engineering
Teacher training colleges
Other professional colleges
Medical
Colleges with red ribbon clubs
Hospitals Govt. Hospitals
* urban, rural can also be some classifications Primary Health centres
SUB centres
Block Hospitals
Taluk Hospitals
Private Hospitals
RMPs / PMPs
Medical phramacy
Allopathic Practitioners
Siddha Practitioners
Unani Practitioners
Homeopathy Practitioners
Ayurvedic Practitioners
Naturopathy Practitioners
VCTC
PPTCT
STI clinics
Blood Banks
Clinical laboratory
ART services
ICTC
Other Services
39

Anganwadis
Village health centres
List of STI / HIV/AIDS treating doctors / clinics
Ngos- P & CST Intervention Programs
* urban, rural can also be some classifications Prevention Programs
STI clinics / HIV clinics
Care, Support and Treatment programs
Networks in the districts
Community care centres
Day Care centres
Palliative care
Deaddiction and Rehabilitation centers
Other NGOs and CBOs- Micro credit organisation
Welfare Services Family counselling centers
* urban, rural can also be some classifications Adopting centers
Orphanages
Short stay homes
Half way homes
Child helpline
Drop in centers
Creches
Old age homes
Vocational training centers
Bank schemes( private and nationalised)
Collecterate
Govt. loan schemes for women
Govt. loan schemes for youth
Govt. loan schemes for children
40

Govt. loan schemes for disabled
Sangams and clubs Youth groups
* urban, rural can also be some classifications Women groups
Men groups
Children clubs
Police boys clubs / Friends of police
Auto drivers associations
Lorry drivers associations
Aravanis Sangams
Red cross society
Blue cross society
Advocacy Advocates / Legal aid services
* urban, rural can also be some classifications Police stations (Women and general)
Industries Small scale
* urban, rural can also be some classifications Large scale
Industries having HIV workplace policy
The addresses and contact numbers of these organisations may be tapped down













41

ANNEXURE 1 (b) - DAILY DAIRY

N.G.O NAME:
DATE
ORW NAME
DESIGNATION
TIMINGS - ACTIVITIES

SUPERVISOR signature

ANNEXURE 1 (C) WEEKLY PLAN

WEEKLY PLAN
S/NO DATE PLACE OF VISIT
ACTIVITY
PLANNED OUTCOME FOLLOW UP/REMARKS

42


ANNEXURE 1 (d) IDENTIFICATION AND ENROLLMENT REGISTER
ORW Name : Identification & Enrolment register Block Name :
Month
:

S
n
o

F
a
m
i
l
y

N
o

Referre
d by
HIV
testing
done at
Date of
Identifi
cation
Date of
enrolme
nt
OP
No.
Name & Address with Contact
Number A
g
e

S
e
x


Marita
l
Status
E
d
u
c
a
t
i
o
n


O
c
c
u
p
a
t
i
o
n


M
o
n
t
h
l
y

i
n
c
o
m
e

s
t
a
t
u
s


No.
of
Chil
dren
S
p
o
u
s
e

s
t
a
t
u
s


Home
visit
Conse
nt
status
Other
Rem
arks
M
a
l
e

F
e
m
a
l
e




ANNEXURE 1 (e) EXTERNAL REFERRAL REGISTER

External Referral Register
S.NO
Pre
ART
/
ART
No Name Age Sex Date of referral Referred to Purpose Follow up comments Outcome Staff In-charge






43





ANNEXURE 1 (F) REFERRAL SLIP


















44

ANNEXURE 1 (g) HOME VISIT SHEET

Date of visit
Total Visit number:
OP NO: Name of the client:
Time: ________to__________
Family members present during the visit:
Purpose of present visit: ( Tick key three objectives for the visit)
Education/Training Psycho social support Follow up
Basic HIV education Counseling PLHA Motivation for CD4 test,
result collection and status

Inform about support
group
Counseling family
members
Referrals
Positive living Counseling spouse Adherence monitoring
Care givers training Counseling children OI identification and
management

Nutrition education and
demonstration
Facilitate disclosure Spouse and children testing
Home based care Others:
Condom demo /
distribution

45



Activities carried out Observations Follow up required






Needs of the client for follow up:
Next HBC follow-up:


ANNEXURE 1 (h) - ADHERENCE TRACKING REGISTER
ORW Name: Month:
SNO OP NO Name Age Sex ART No Regimen % Percentage









46



ANNEXURE 1 (i) CARE GIVER REGISRTER
ORW Name : CAREGIVERS REGISTER Block : Month :
S
n
o

OP No.
Famil
y No
Name of the PLHA
ART/not
on ART
Self care
training
Name of Primary
Caregiver
Relationshi
p
Address of the
Caregiver
Contact No
Participated
in training
program (In
home visit /
At training
program)
Remar
k




ANNEXURE 1 (j) DEATH REGISTER
ORW Name : DEATH REGISTER Block Name :
Month :
S
n
o

OP
No
Date of
Registr
ation
Expire
d date
Date
when
death
reporte
d
Name
A
g
e

S
e
x

ART
no.
(if on
ART)
CD
4
cou
nt
On
ATT/
Not
on
ATT
Reason for
not
starting
ART if
eligible
Last
home
visit
before
death
date
Place of
Death
Health
condition
at time of
Death
Date
when
the
patient
last
visited
the
ART
centre
Brief
on
Funeral
Assista
nce






47

ANNEXURE 1 (k) INFORMATION SHARING SHEET

Name: Information Sharing Sheet Month:
S
.

N
o
.

Date of
Regn.
Pre -
ART
No.
Name ART No
Next CD4
due date
Date of last
visit by the
client to the
Hospital
[Hospital
NGO]
Next visit
to
Hospital
Death details
Date / Reason
Report on progress
at home, issues to be
addressed at the
hospital - Field
team [ORW]
Report on
progress at
Hospital, issues to
be addressed at
home - Hospital
team










ANNEXURE 1 (l) CD4, ART REGISTER

CD4, ART register
S.
No
Block Pre
ART
No
Family
No
ART
No
Registration
Date
Name Sex Age Date of
baseline
CD4
test
CD4
count
Baseline
1st
follow
up
due
date
Tested
date
CD4
count 1st
follow
up
2nd
follow
up
due
date
Tested
date
CD4
count
2nd
follow
up
TB
status
ART
start
Date
Regimen











48

ANNEXURE 1 (m) TALUK LEVEL COORDINATION MEETING


Place/Venue :

Date : Time :

Target Group:

Participants:

Male: Female: Total

Programme Topic:
Facilitator:


Materials used:


Programme Narration:












Programme Objectives:
At the end of the training program participants will


Training Activities: (Methodology& strategy)
49






























Date of Submission :

Submitted by : Signature :


Training Content
:
Participant feedback:
Questions asked and feedback:
50

ANNEXURE 1 (n) SUPPORT GROUP REGISTER

Support Group Register
Meeting No: Date: Time:
Taluk / Venue: End:
Total Number of PLHA Member: Total Number of SG Family Member: Facilitator
New Male Female New Male Female
PLHA:
Old Male Female Old Male Female
Project Staff
Total Male Female Total Male Female Peer Edcuator:
External:
Number of PLHA Member Attended: Number of SG Family Member
attended:
Minutes of last
Meeting

New Male Female New Male Female Achieved:

Old Male Female Old Male Female Pending:

Total Male Female Total Male Female

Agenda of the Meeting

Details

Next Meeting: Time: Place: Facilitator:
Please get signature of all the SG
members


51


ANNEXURE 1 (o) TB TRACKING SHEET
Anti TB Treatment ( ATT) - Reasons and Feed Back Month:
ORW Name : Block Name:
Sno OP No. Name Sex
ART / Non-
ART
Number
Type of
ATT
(I,II,III,IV)
ATT
(Newly
Start)
ATT
(Regular)
ATT
(Completed)
ATT (Missed Reason)


ANNEXURE 1 (p) CHILDREN DATA BASE

Parent
OP
NO
Child
Name A
g
e

S
e
x


S
c
h
o
o
l

g
o
i
n
g

S
t
a
t
u
s

S
t
a
n
d
a
r
d

M
o
t
h
e
r

H
I
V

S
t
a
t
u
s






(
P
/
N
/
N
T
)

S
t
a
t
u
s

n
o
t

k
n
o
w
n

/

N
o
t

T
e
s
t
e
d

N
e
g
a
t
i
v
e

C
I
A
Children
OP No.
P
a
r
e
n
t

S
t
a
t
u
s









(
P
a
r
t
i
a
l

/

C
o
m
p
l
e
t
e
)

C
h
i
l
d
r
e
n

S
e
l
f


S
t
a
t
u
s

(
P
a
r
t
i
a
l

/

C
o
m
p
l
e
t
e
)

B
o
t
h

P
a
r
e
n
t

A
l
i
v
e

/

S
i
n
g
l
e

/

D
o
u
b
l
e

O
r
p
h
a
n


I
n
s
t
i
t
u
t
i
o
n
a
l

c
a
r
e


K
i
n
s
h
i
p

c
a
r
e

E
m
p
l
o
y
e
d

P
s
y
c
h
o
s
o
c
i
a
l

S
u
p
p
o
r
t

O
f
f
e
r
e
d

A
t
t
e
n
d
i
n
g

C
h
i
l
d
r
e
n

s
u
p
p
o
r
t

G
r
o
u
p

L
i
n
k
e
d

f
o
r

E
d
u
c
a
t
i
o
n
a
l

S
u
p
p
o
r
t

N
u
t
r
i
t
i
o
n
a
l

S
u
p
p
o
r
t

C
h
i
l
d

M
a
r
r
i
a
g
e

/

M
a
r
r
i
e
d


S
t
u
d
y

M
a
t
e
r
i
a
l

(
P
e
n
/

P
e
n
c
i
l
/
N
o
t
e
/
B
o
o
k
s
/

B
o
x

e
t
c
.
)

U
n
i
f
o
r
m

C
H
I
L
R
E
N
'
S


R
E
M
A
R
K

Education C A A C I A
Parent / Child
Self Status







52



ANNEXURE 1 (q) OUTREACH WORKER WISE TRACKING SHEET

Block / Taluk details
S
A
L
E
M

M
E
C
H
E
R
I

OMALUR
K
A
D
A
Y
A
M
P
A
T
T
I

M
A
G
U
D
A
N
C
H
A
V
A
D
I

V
E
E
R
A
P
A
N
D
I

K
O
N
G
A
N
A
P
U
R
A
M

E
D
A
P
P
A
D
I

T
H
A
R
A
M
A
N
G
A
L
A
M

A
T
T
U
R
V
A
L
A
P
A
D
I

A
.
P
A
T
T
A
N
A
M

P
.
N
.
P
A
L
A
Y
A
M

T
H
A
L
A
I
V
A
S
A
L

P
A
N
A
M
A
R
A
T
H
U
P
A
T
T
I

S
A
N
K
A
G
I
R
I

N
A
N
G
A
V
A
L
L
I

K
O
L
A
T
H
U
R

G
A
N
G
A
V
A
L
L
I

Y
E
R
C
A
U
D

TOTAL
REMARK
S
Name Of ORW

































No. of client enrolled by ORW till
date


No. of Clients referred by Hospital


Total No. of clients under follow
up


No. of Death


Transferred out


Migration


Not in Favour for house visit


Wrong address


Others


53

Total number of clients lost to
follow up


No. Of clients under follow up At
present


No. of Families under Follow up at
present


Number of clients expected for
hospital follow up this month


Number of clients visited hospital
this month


Number of clients missed follow up
in this month


No of clients done Base line CD4


No. of clients received Base line
CD4 report


No of clients done follow up CD4


No. of clients received follow up
CD4 report


No .of clients eligible for ART in
Base line


No. of clients eligible for ART in
follow up


No. of clients on Transfer eligible


Total No. of clients eligible for ART


No. of clients started on ART


No. of active clients on ART


Reason for not starting ART


54

a. ON ATT treatment


b. Not willing to start ART


c. CD4 increased and feels good
health


d. Having alcoholic and tobacco
habit


e. Migration


f. Taking ART in other centre
and private


g. On process


h. Death


Total number of clients not
started on ART


No. of Children infected with HIV


No. of Children affected with HIV


No. of Clients attended with M& E -
interview


No. of client pending for interview


M& E Home visits form due


No. of M& E HVF pending


No. of Taluk level advisory
committee conducted


No. of Care givers trained on HBC


55

No. of Support group meetings
conducted


No .of concordant couples


No. of discordant couples




ANNEXURE 1 (r) PATIENT WISE TRACKING SHEET
S
n
o
.

OP No. Name Sex
ART LFU / Non
ART LFU /
Eligible but not
ART started / ART
Missed / CD4 not
tested / Status not
disclosed etc
Reasons and Feed Back

(Address not clear, Migration, Death, Motivation, Out of Station(Area), Transfer out (Centre
Name), unwilling for HBC / Treatment, Not accepting the status , Regular Follow-up, Private
Treatment(Centre Name), Other District(Name), Other State(Name), Fear of Side Effects, etc.

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