Service | Description |
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HIV Testing and Diagnosis | HIV Testing: Screening of individuals for HIV using rapid diagnostic tests (RDT) or other lab tests can occur in various settings, including clinics, community outreach, or antenatal care. Linkage to Care: Once an individual tests positive, they are linked to HIV care services to ensure they begin receiving the necessary treatment and support. Pre-Test and Post-Test Counseling: Counseling is provided both before and after testing to help patients understand the testing process, their results, and the importance of treatment.
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Care and Treatment Enrollment | Patient Enrollment: After HIV diagnosis, the patient is enrolled into HIV care and treatment services. This step involves collecting demographic and health information and creating a patient record in the health system. Initial Assessment: A comprehensive medical assessment is conducted, including a physical exam, medical history, and baseline laboratory tests (such as CD4 count, viral load, and screening for opportunistic infections like TB).
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ART (Antiretroviral Therapy) Initiation | Treatment Plan: Based on the initial assessment, the healthcare provider initiates the patient on ART. The regimen is chosen based on clinical guidelines, the patient’s health status, and any existing conditions. Adherence Counseling: Patients are counseled about the importance of adhering to their ART regimen, potential side effects, and how to manage them. Continuous adherence support is provided throughout treatment. First Follow-Up Visit: After ART initiation, a follow-up visit is scheduled to assess the patient's response to treatment, check for side effects, and ensure adherence.
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Routine Clinical Monitoring | Scheduled Visits: Patients have regular clinic visits to monitor their health, ART effectiveness, and overall well-being. Routine lab tests, including viral load monitoring, are conducted to ensure the virus is being suppressed. Opportunistic Infection Management: Healthcare providers screen and manage any opportunistic infections (OIs) or co-infections, such as TB, that may arise. Mental Health and Psychosocial Support: Ongoing mental health screening is conducted to address any depression, anxiety, or other mental health concerns. Psychosocial support is provided as needed.
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Differentiated Service Delivery (DSD) | Tailored Care Models: Based on the patient’s stability (e.g., virally suppressed, adherent), differentiated service delivery models may be applied. Stable patients may need fewer clinic visits and may be eligible for multi-month dispensing of ART or community-based care. Appointment Tracking and Patient Tracing: Patients who miss follow-ups or ART pickups are traced through phone calls, community health workers, or home visits to encourage them to return to care.
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Viral Load Monitoring | Viral Suppression Check: Viral load is typically monitored 6 to 12 months after ART initiation and then annually for stable patients. The goal is to ensure that the patient’s viral load is suppressed, meaning the virus is effectively controlled by the ART regimen. Treatment Adjustments: If a patient’s viral load is detectable or increasing, the healthcare provider will assess the causes (e.g., adherence issues, drug resistance) and adjust the treatment plan accordingly.
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Management of Complications and Co-Morbidities | Co-Infection and Co-Morbidity Management: Patients are screened and treated for conditions such as tuberculosis (TB), hepatitis, and non-communicable diseases (NCDs) like hypertension and diabetes. Treatment of Side Effects: Providers manage any side effects from ART to ensure patient comfort and continued adherence.
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Retention and Long-Term Follow-Up | Patient Retention in Care: Efforts are made to keep patients consistently engaged in care, including reminders for appointments and refills. Differentiated service models may also help improve retention by reducing the burden of frequent clinic visits. Long-Term Monitoring: Ongoing monitoring includes annual viral load tests, routine check-ups, and continuous psychosocial support. Stable patients may receive services through community-based models to reduce the frequency of facility visits.
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Transitioning and Exit from Care | Transfer of Care: If a patient needs to transfer to another facility, proper documentation is created, ensuring continuity of care at the new location. Exit due to Death: In the event of death, a formal death report is completed, including details of the cause of death.
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Patient Education and Support | Ongoing Education: Throughout care, patients receive education on living with HIV, medication adherence, prevention of transmission, and overall wellness. Peer Support and Counseling: Peer support groups and counseling services are often provided to help patients cope with their diagnosis, adhere to treatment, and maintain mental and emotional well-being.
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