1. IMAI Training

2. Training Methods No PowerPoint; no specialists No PowerPoint; no specialists Skills-based learning Skills-based learning Patient monitoring forms Patient monitoring forms Patient education materials Patient education materials Exercises and drills Exercises and drills Expert Patient-trainers Expert Patient-trainers

3. Active training with cases, interaction, clinical team building

4. What is the Expert Patient-Trainer? A person living with HIV/AIDS (PLHA) and/or on ART A person living with HIV/AIDS (PLHA) and/or on ART Trained to role-play a patient in specific HIV cases that were often (but not necessarily) similar to their own life experience Trained to role-play a patient in specific HIV cases that were often (but not necessarily) similar to their own life experience Trained to assess the important skills that the health worker should acquire from the clinical or aid training courses Trained to assess the important skills that the health worker should acquire from the clinical or aid training courses Trained to give appropriate feedback to the health worker after the role-play, which allowed the health worker to practice these skills Trained to give appropriate feedback to the health worker after the role-play, which allowed the health worker to practice these skills

5. Role of the Expert Patient-Trainer in IMAI Worked in the skill stations as patients in a clinical encounter related to Chronic HIV Care/ART where the health workers would interact with them through their cases and practice important skills. Worked in the skill stations as patients in a clinical encounter related to Chronic HIV Care/ART where the health workers would interact with them through their cases and practice important skills. Simulated role-plays with the course facilitators in the classroom, so health workers could learn training material and important clinical health worker - patient interactions through the demonstrations Simulated role-plays with the course facilitators in the classroom, so health workers could learn training material and important clinical health worker - patient interactions through the demonstrations Shared personal experiences with HIV/ART with the course participants pertaining to topics discussed within the classroom environment Shared personal experiences with HIV/ART with the course participants pertaining to topics discussed within the classroom environment

6. CASE 8 You are a 47 year-old man, who tested HIV+ two years ago. You are a very heavy drinker and do not go to the clinic regularly. You come to the clinic today because you want ART. This is your first visit. You are a 47 year-old man, who tested HIV+ two years ago. You are a very heavy drinker and do not go to the clinic regularly. You come to the clinic today because you want ART. This is your first visit.

7. IF ASKED: You are not taking any medications You are not taking any medications Clinical Review: You do have a pain in your mouth when eating. You do not have any problems swallowing. You also have an itching rash around your nose and eyes. You do have a poor appetite and problems with sleeping. Clinical Review: You do have a pain in your mouth when eating. You do not have any problems swallowing. You also have an itching rash around your nose and eyes. You do have a poor appetite and problems with sleeping. You do not practice safer sex You do not practice safer sex You do not work but are able to do some things at home when you are motivated You do not work but are able to do some things at home when you are motivated You feel very lonely. Your wife and baby boy died last year, and you are living with friends. You feel very lonely. Your wife and baby boy died last year, and you are living with friends.

8. ________CUT HERE________ Physical Exam: Current weight 65kg (last visit 8mo ago-77kg); Patient has white patches in his mouth which when checked can be scraped off and 1-2 mouth ulcers which are not deep or extensive. He also has a scaly rash around his nose and eyes. Physical Exam: Current weight 65kg (last visit 8mo ago-77kg); Patient has white patches in his mouth which when checked can be scraped off and 1-2 mouth ulcers which are not deep or extensive. He also has a scaly rash around his nose and eyes.

9. Case #8 Observer: Health Worker: GOODOKNOT GOOD NOT DONE GENERAL  Respectful  Simple words  Listened to patient  Made sure patient understood ASSESS  Asked why came to the clinic?  Reviewed symptoms on H10  Look: physical exam ADVISE  Talked about prevention  On correct treatment  On adherence AGREE  On treatment plan  Involved patient

10. ASSIST  Provided treatment options  Helped solve treatment problems  Provided psychological support ARRANGE  Follow-up date(s)  Support Group  Referral/Support outside clinic  Provided treatment plan  Completed patient card CASE-SPECIFIC QUESTIONS Classified patient in clinical stage 3? Patient’s functional status—Ambulatory Patient TB Status—No Signs Gave treatment for thrush (painful white sore in mouth) and seborrhoea? Discussed about ART and drinking problem Advised on how to address the drinking problem? Referred to TASO for drinking problem? Linked to community support organization? Discussed Septrin?

11. CASE 33 You are a married woman. You have tested HIV+ 2 months ago. You are on treatment for TB of the lungs, but otherwise are feeling quite healthy. Your husband is a policeman, but he has not been working for several months now, because he is too sick. You think he has HIV as well. You are a married woman. You have tested HIV+ 2 months ago. You are on treatment for TB of the lungs, but otherwise are feeling quite healthy. Your husband is a policeman, but he has not been working for several months now, because he is too sick. You think he has HIV as well.

12. If asked You are managing the TB drugs well. You are managing the TB drugs well. Two days ago, you told him about your positive test. He became very angry and beat you. He does not want you to come to the clinic anymore. So you have to invent a story and come secretly. Two days ago, you told him about your positive test. He became very angry and beat you. He does not want you to come to the clinic anymore. So you have to invent a story and come secretly.

13. Case specific questions Checked adherence to TB drugs? Checked adherence to TB drugs? Discussed benefits and difficulties of disclosure? Discussed benefits and difficulties of disclosure? Discussed safety? Discussed safety? Offered counselling for partner? Offered counselling for partner? Advised on the importance of attending clinic regularly? Advised on the importance of attending clinic regularly? Discussed peer support? Discussed peer support? Discussed community support? Discussed community support? Arranged follow up appointment next week? Arranged follow up appointment next week?

14. EPT Challenges Enthusiasm Enthusiasm Intimidation Intimidation Stigma and discrimination Stigma and discrimination Illness Illness

15. Training plan—efficient, rapid, capable of supporting continuous training Group work: 10-12 participants 2 facilitators Expert patients Card sorts Skill stations Video cases, exercises (group) Outpatient clinical practice for Acute Care Inpatient clinical practice

17. ScheduleDay One Monday Day Two Tuesday Day Three Wednesday Day Four Thursday Friday 8:30 – 10:30Welcoming and opening Introduction of participants Course objectives and introduction to training materials Administrative arrangements The situation of the HIV/AIDS epidemic in Ethiopia (Assegid) 7. Prophylaxis therapy 8. Adherence preparation 14. Special consideration during pregnancy and post- partum period 15. Special considerations in children 3. OI's of the neurological system 4. OI's of the GI system (persistent diarrhea) OFF 10:30 – 11:00 Tea/coffee Break 11:00 – 12:30 Pre-test First level session 1. Introduction to good chronic care; sequence of care 2. Introduction to HIV/AIDS and OIs; WHO Clinical staging 3. HIV and antiretroviral drugs 9. First line ARV regimen in uncomplicated cases 10. Four first-line ARV regimens 16. Monitoring patients on ART (30) Post-test 5. OI's of the mouth and throat (30) 6. OI's of the skin (30) OFF 12:30 – 1:30Lunch break 1:30 – 3:304. Adherence and drug resistance 5. Assess and provide clinical care 11. Managing side effects and new developments 12. ART initiation and follow- up of patients 13. Integration of prevention and treatment Skill stations7. ARV drugs 8. Excluding OI's OFF 3:30 – 4:00Tea/coffee break 4:00 – 5:306. Introduction to Patient monitoring: HIV care/ART card Skill stations Second level session 1. HIV and TB 2. OI's of the respiratory system Skill stationsOFF Home Facilitators’ Meeting

18. Week 1: Chronic HIV Care with ART MondayTuesdayWedThursFridaySaturday Basic ART Clinical Course Nurses, Midwives, Medical Assistants, Pharm techs Clinical Team Building Patient Monitoring Basic ART Clinical Course Clinical officers, Health officers ART Aid Course PLHA, other lay providers, Nursing or Health Assistants, or Nurses Basic ART Clinical Course Medical Officers/Doctors Second Level ART Clinical Course Medical Officers/Doctors

19. Week 2: Acute Care and Options MonTuesWedThursFri Short Acute Care/OI Course Nurses, midwives Optional:  Acute Care: STI  TB care with TB-HIV co-management  Patient monitoring: registers, reports  PMTCT: antenatal and post-partum care, continuity of care and records  IMCI-HIV short course  Provider-initiated testing and counselling  PMTCT: reproductive choice, FP Short Acute Care/OI Course Clinical Officers, Health Officers Second level OI Course Medical Officers/doctors  PMTCT: Infant feeding counselling

20. Continuous Training Schedule Week 1 Group 1 Group 2 Group 3 Group 4 Week 2