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HIV/AIDS 2014 national guidelines on
national guidelines on HIV/AIDS C ARE AND SUPPORT 2014 i National Guidelines on HIV/AIDS Care and Support 2014 ii National Guidelines on HIV/AIDS Care and Support 2014 iii National Guidelines on HIV/AIDS Care and Support 2014 TABLE OF CONTENT FOREWORD.............................................................................................................................i ACKNOWLEDGEMENTS ...................................................................................................iii TABLE OF CONTENT ..........................................................................................................iv LIST OF CONTRIBUTORS.................................................................................................vii EXECUTIVE SUMMARY.....................................................................................................ix LIST OF ABBREVIATIONS ..................................................................................................x CHAPTER 1: INTRODUCTION.........................................................................................01 1.1 BACKGROUND ...........................................................................................................01 1.2 SITUATIONAL ANALYSIS OF HIV/AIDS CARE AND SUPPORT IN NIGERIA...01 CHAPTER 2: CONCEPTUAL FRAMEWORK FOR HIV/AIDS CARE AND SUPPORT ...............................................................................................................................03 2.1 Introduction....................................................................................................................03 2.2 Definition .......................................................................................................................03 2.3 Guiding principles of HIV/AIDS Care and Support ......................................................03 2.4 Components of HIV/AIDS Care and Support programming and relevant interventions.. ..03 2.5 Eligibility for HIV/AIDS Care and Support ..................................................................04 2.6 Providers of Care and Support services .........................................................................05 2.7 HIV/AIDS Care and Support settings............................................................................05 Chapter 3: DELIVERY OF HIV/AIDS CARE AND SUPPORT SERVICES..................06 3.1 Continuum Of Care........................................................................................................06 3.2 Comprehensive Package Of Care And Support Interventions .......................................06 3.2.1 Medical Services .....................................................................................................06 3.2.2 Supportive services .................................................................................................06 3.2.2.1 Socio-economic services......................................................................................07 3.2.2.2 Psychological services .........................................................................................07 3.3 Care And Support In The Health Facility.......................................................................07 3.4 Community Based Care And Support Of PLHIV..........................................................07 3.5 The Minimum Package Of Care And Support Interventions For PLHIV......................08 3.6 Minimum Package Of Care And Support For PABA ....................................................08 3.7 Support Group Systems .................................................................................................08 CHAPTER 4: POSITIVE HEALTH DIGNITY AND PREVENTION (PHDP)..............10 4.1 Introduction....................................................................................................................10 4.2 Definition .......................................................................................................................10 4.3 Components of the key Elements of Positive Health, Dignity, and Prevention.............10 4.3.1 Health promotion and access ..................................................................................11 4.3.2 Sexual and reproductive health and rights ..............................................................11 4.3.3 Prevention of transmission ......................................................................................11 4.3.4 Human rights, including stigma and discrimination reduction ...............................12 4.3.5 Gender equality .......................................................................................................12 4.3.6 Social and economic support ..................................................................................12 4.3.7 Empowerment .........................................................................................................12 iv National Guidelines on HIV/AIDS Care and Support 2014 4.4 Measuring Impact ..........................................................................................................12 4.5 Minimum PHDP Services for PLHIV............................................................................12 CHAPTER 5: HIV/AIDS CARE AND SUPPORT SERVICES FOR SPECIAL POPULATIONS .....................................................................................................................13 5.1 Definition of Special Populations ..................................................................................13 5.2 Care and Support Services of the HIV Positive Child ...................................................13 5.3 Comprehensive Package of Care for HIV Positive Children.........................................13 5.4 Care and Support Services for Vulnerable Children (VC).............................................14 5.5 Care and Support Services for Women Living With And Affected by HIV/AIDS........15 5.6 Care and Support Services for PLHIV in Times of Civil Strife and Conflict................15 5.7 Care and Support Services for other Special Populations..............................................16 CHAPTER 6: POLICY AND PROGRAMMING ISSUES IN HIV/AIDS CARE AND SUPPORT SERVICES ..........................................................................................................17 6.1 Governance ....................................................................................................................17 6.1.1 Policy, Guidelines and Regulations ........................................................................17 6.1.2 Leadership, Coordination And Collaboration .........................................................17 6.1.3 Community Participation And Ownership..............................................................18 6.1.4 Financing Care And Support Services ....................................................................18 6.2 Human Capacity Development ......................................................................................18 6.3 Administration of HIV/AIDS Care and Support Programmes......................................19 6.3.1 Medical services....................................................................................................19 6.3.2 Psychological Services .........................................................................................19 6.3.3 Socio-economic empowerment.............................................................................20 6.4 Monitoring and Evaluation (M&E) ...............................................................................20 6.5 Logistics Management ...................................................................................................20 6.6 Advocacy, Sensitization and Mass Mobilization ...........................................................20 CHAPTER 7: Nutrition For People Living With HIV .......................................................21 7.1 The Link between Nutrition and HIV/AIDS..................................................................21 7.2 Nutrition Challenges of PLHIV in Nigeria ....................................................................21 7.3 Recommended Nutrient Requirement using Local Food Sources................................. 22 7.4 Nutritional Care and Support for adults living with HIV/AIDS....................................22 7.5 Nutritional Care for HIV positive pregnant women/adolescents...................................22 7.5.1 Safe Food Handling Practices .................................................................................22 7.6 Infant Feeding Options for HIV Positive Women & Adolescents .................................23 7.6.1 Exclusive Breastfeeding..........................................................................................23 7.7 Nutritional Care for PLHIV Taking Medication or Herbal/Local Remedies ................23 7.8 Nutritional Assessment Counselling and Support (NACS) ...........................................23 7.8.1 Components of NACS ............................................................................................24 7.8.1.1Assessment............................................................................................................24 7.8.1.2 Counselling ..........................................................................................................24 7.9 Outcomes of Assessment ...............................................................................................24 7.9.1 Anthropometric .......................................................................................................24 7.9.2 Nutritional Literacy.................................................................................................25 7.9.3 Referral criteria .......................................................................................................25 7.10 Nutritional Support for PLHIV ....................................................................................25 v National Guidelines on HIV/AIDS Care and Support 2014 CHAPTER 8: MONITORING AND EVALUATION OF CARE AND SUPPORT SERVICES..........................................................................................................................26 8.1 Introduction....................................................................................................................26 8.2 Responsibility for Monitoring and Evaluation Activities ..............................................26 8.3 Data Quality ...................................................................................................................27 8.4 Data Collection and Reporting Tools .............................................................................27 8.5 Supportive Supervision ..................................................................................................27 8.6 Data Reporting and Information flow ............................................................................28 Appendix 1: Indicator Tables.......................................................................................29-32 vi National Guidelines on HIV/AIDS Care and Support 2014 LIST OF CONTRIBUTORS NAMES NAME OF ORGANIZATION NAMES NAME OF ORGANIZATION Dawodu Yemisi APIN Dr. Akudo Ikpeazu NACA Ify Onwuatuelo APIN Dr. Daniel Egbule NACA Isah Ahmed APIN Dr. Emmanuel Agogo NACA Isah Mohammed APYIN Dr. Maryam Al-Mansur NACA Odeh F. Odeh APYIN Dr. Priscilla Ibekwe NACA Maria Jones ASHWAN Dr. Yinka Falola-Anoemuah NACA Assumpta Reginald ASWHAN Ikeotuoye Olumaobi NACA Helen Aphan ASWHAN Hasiya Bello Raji NACA Dennis Onotu CDC Aishatu Garba NAPEP Dr. Obinna Ogbanufe CDC Ukowu Judith NAPEP Steven Batanda CIHP Dr. Emeka Asadu NASCP Uduak Akpan CIHP Mr. Zeni Franklin NASCP Walter Ogwuocha CISHAN Ombugadu Obadiah NASCP Yakubu Adamu DoD Humphrey Ubanyi NEPWHAN Rev. Dr. L.U. Ogbonnaya Ebonyi State University Martins Akinbode NEPWHAN Dr. Azuogu Ben FETH Abakiliki Ukoli Patricia NEPWHAN Dr. Catherine Gana FHI360 Victor Omoshehin NEPWHAN Dr. Olufunlola Adedeji FHI360 Edward Ogenyi NEPWHAN Moyosola Abass FHI360 Amina S. Abdullahi NHRC Tanto Jobokyamba FHI360 Fatima A. Shamaki NHRC Ude Emmanuel Emeka FMARD Mallam Doma NINERELA+ Bridget Onyebuchi FMOH Gem Suleh SMEDAN Roselyn E. Gabriel FMOH Abdulmalik Muhammad SURE-P MCH Mrs. Gloria Onwuzirike FMWASD Irene Dunkwu SURE-P MCH Dr. Kate Anteyi HHSS FCT Tejiri B. Lookey SURE-P MCH Ella Aishatu Asabe Gomwalk IHVN TB/Network Dr. Kwame Ampomah UNAIDS Dr. Anthony Okwuosah IHVN Asuquo Francis UNFPA Juliet Nyior IHVN Dr. O. Omosehin UNFPA Dr. Oche Agbaji JUTH Dr. Biola Davies UNICEF Ijeoma Olso Effanga MSH Dr. Emeka Okechukwu USAID Michael Dibor MSH Dr. James Ezekiel USAID Ogunmodede Mathew MSH Dr. O. Oguniran WHO Dr. C. D. Ndukwe NACA Dr. M. Kamal NACA vii National Guidelines on HIV/AIDS Care and Support 2014 NAMES NAME OF ORGANIZATION NAMES NAME OF ORGANIZATION Azua Grace General Hospital Gboko Samaila Garba Amana Rural Health Audu Rebecca Otukpo LGA Benue State Gladys Ihunda NASCP FMOH Aja Catherine U. FETHA Bilkisu Jibrin NASCP FMOH Emilia Iwu IHVN Rev. Sr. Cecilia Azuh Catholic Archdiocese of Abuja Charity Maina IHVN Dr. Abiaziem Grey AIDS Health Care Foundation Agada Godswill CIHP Fakande Ibiyemi Living Hope Care Dr. Ngozi Ifebunandu FETHA Abakaliki Ejike Fidelis Min. of Education Bar. Jumai Danuk J. V. Danuk& Co Abatur Charity Fed. Med. Centre, Makurdi Dr. Alabi Olubunmi Wuse District hospital Fintirima Sambo Donga NASCP FMOH Tsambi Yusuf MSH Abuja Isa Abdulalhi NASCP FMOH Dr. Ochigbo Sunny UCTH Calabar Dr. Stephen Oguche JUTH Jos Dr. Nwoye Boniface FHI 360 Samuel Ajayi UATH ,Gwagwalada Dr. J. O. Abah FMC Makaurdi Dr. Amana Effiong MSH Abatur Charity Suteryo FMC Makurdi Dr. Adekoya Peters Prosamtas Consult Dr. Anne Ojimba FMC Asaba Dr. Anya Chukwuemeka CIHP, Nyanya Dr. Nneka Chukwurah NTBLCP/FMOH Prof. Olaitan Soyannwo UCH, Ibadan Anyanyo Ifeyinwa FHI 360 Scholastica Ode Hope Alive Foundation Anaeme Afam SMOH Awka Biaratu Abubakar NEPWHAN Gombe State Enegela Joseph CCCRN Dr. Ofondu Eugenia FMC Owerri Antha Nwandu CCCRN Onyedum Cajetan UNTH Enugu Dr. Muktar Muhammad FGH Tunji Odedola GAPRI Odume Bertrand CDC Dr. Deborah Odoh NASCP FMOH Patrick Akande APIN Stanis-Ezeobi Winifred CCFN Hamza Shuaibu USAID Dr. Bolaji Olufunke FMC Ido-Ekiti Ezeugwu Ngozi UniJos Akolawole Franca IHVN Owhonda Golden RSMOH Ikechukwu Michael BMSH PH Dr. Maryam Muktar-Yola National Hospital Ginika Egesimba MSH Ukwuoma Petrus FHI 360 Ashie Mary CIHP Barango P. CHAI Linda Ikechukwu Springs of Life Dr. Femi Adeyemi UNICEF Dr. Hadiza Khamofu FHI 360 Dr. Odafe Solomon CDC Dr. Felix Iwuala ARFH Dr. Bakunowa G Bello NPHCDA Adegbite Dr. Chris Obanubi FHI 360 Communication for Development Centre Odo T. I. FMWASD Godson Ogbuji FML Dr. Amuh Onyinye Bwari Town Clinic Dr. Uba Sabo NASCP FMOH viii National Guidelines on HIV/AIDS Care and Support 2014 executive summary T he National Guidelines for HIV/AIDS Care and Support offers general recommendations for the Care and Support of persons living with HIV/AIDS, persons affected by HIV/AIDS and service providers. It provides a general overview of the status of HIV/AIDS Care and Support in Nigeria with emphasis on progress made thus far. The document has six chapters that address the key components of HIV/AIDS Care and Support thus providing an implementable framework for the effective delivery of HIV/AIDS Care and Support services. The first chapter outlines the current situation of Care and Support services in Nigeria. It outlines the achievements and scope of these guidelines. Chapter 2 of the document presents the conceptual framework for HIV/AIDS Care and Support which it defines as 'the holistic and comprehensive client-focused care provided by a multidisciplinary team at all stages of the HIV/AIDS infection'. It outlines the basic principles that should guide the implementation of Care and Support services, eligibility criteria, providers of service, outlets for Care and Support services and the fundamental needs of the PLHIV. Chapter 3 of the document deals with delivery of Care and Support services, and clearly describes in details the component services of a comprehensive package of Care and Support services. It outlines services that should be on offer at health facilities and those that ought to be provided in the community. HIV/AIDS Care and Support services are divided into three main components: - Medical, Psychological and Socioeconomic. In addition, this chapter defines the minimum package of Care and Support services that should be offered to the PLHIV in the facility and in the community. Chapter 4 defines Positive Health Dignity and Prevention and prescribes its minimum package of interventions for PLHIV. It provides a set of interventions for health promotion, access to treatment, sexual and reproductive health, prevention of transmission of HIV/AIDS and STIs, protection of human rights including stigma and discrimination reduction, gender equality, socioeconomic support and empowerment of PLHIV. Chapter 5 provides recommendations for the Care and Support of special populations, which include women living with, and affected by HIV/AIDS, PLHIV living in conflict zones, and children rendered vulnerable by HIV/AIDS. It also explains why these individuals require special attention and highlights special interventions necessary to reduce the burden of HIV/AIDS on them. Chapter 6 describes policy and programming for HIV/AIDS Care and Support and focuses on governance and administration of the implementation of Care and Support. It outlines the specific roles of key stakeholders including government, NGOs, and service providers in ensuring compliance with guidelines, provision of services, and effective monitoring and evaluation. Chapter 7 speaks to the nutrition of the person living with HIV/AIDS and aptly describes the relationship between nutrition and HIV/AIDS. It speaks to the goals of nutrition counseling and recommends nutrient requirements for the PLHIV Chapter 8 addresses monitoring and evaluation of the entire care and support programme with the overall purpose of measuring programme results at all levels and guide towards achieving goals and strategic objectives. ix National Guidelines on HIV/AIDS Care and Support 2014 list of abbreviations AIDS ANC ART ARV BMI BF CBO CD4 CHAI CHEW CHO CPT CSO CXR DNA DCT DOT DQA FBO FHI 360 FMOH FP GBV HAART HBC HCT HIV IDUs IEC IGA IMAI INH IPT IPTp ITF ITN KAP LACA LC LGA LLITN LMIS MARPs M/C/S MDG M &E MSM MTCT MUAC NACA NAPEP NDE Acquired Immune Deficiency Syndrome Antenatal Care Antiretroviral Therapy Anti-Retroviral Body Mass Index Brest Feeding Community Based Organization Cluster of Differentiation 4 Clinton Health Access Initiative Community Health Extension Worker Community Health Officer Cotrimoxazole Preventive Therapy Civil Society Organization Chest X-Ray Deoxyribonucleic Acid Data Capturing Tools Directly Observed Treatment Data Quality Assurance Faith-Based Organization Family Health International 360 Federal Ministry of Health Family Planning Gender Based Violence Highly Active Antiretroviral Therapy Home-Based Care HIV Counselling and Testing Human Immunodeficiency Virus Intravenous Drug Users Information Education and Communication Income Generation Activities Integrated Management of Adolescent and Adult Illness Isoniazid Isoniazid Preventive Therapy Intermittent Preventative Treatment in Pregnancy Industrial Training Fund Insecticide-Treated Net Key Affected Population Local Government Agency for the Control of AIDS Local Councilor Local Government Area Long Lasting Insecticide Treated Nets Logistics Management Information System Most At Risk Populations Microscopy/Culture/Sensitivity Millennium Development Goals Monitoring and Evaluation Men who have sex with Men Mother- to- Child Transmission of HIV Mid-Upper Arm Circumference National Agency for the Control of AIDS National Poverty Elimination Programme National Directorate of Employment x National Guidelines on HIV/AIDS Care and Support 2014 NEPWHAN NGO NPA OIs OR OVC PABA PCR PrEP PEP PEPFAR PHC PHDP PLHIV PMTCT PPP RH SACA SMEDAN SOP STIs Network of People Living with HIV/AIDS Non-governmental Organization National Plan of Action Opportunistic Infections Operational Research Orphan and Vulnerable Children People Affected by AIDS Polymerase Chain Reaction Pre- Exposure Prophylaxis Post Exposure Prophylaxis President's Emergency Plan For AIDS Relief Primary Health Care Positive Health Dignity Prevention People Living With HIV/AIDS Prevention of Mother-to-Child Transmission Public Private Partnership Reproductive Health State Agency for the Control of AIDS Small and Medium Enterprises Development Agency of Nigeria Standard Operating Procedure Sexually Transmitted Infections xi National Guidelines on HIV/AIDS Care and Support 2014 CHAPTER 1: INTRODUCTION 1.1 BACKGROUND are and Support means different things to different people, ranging from offering medical treatment for illness, assisting people overcome challenges or simply showing empathy and consideration to persons in need. C In the context of HIV/AIDS, Care and Support means catering to needs of people living with HIV/AIDS and providing appropriate support for persons affected by it. HIV/AIDS is unique in the sense that in addition to physical illness, the infection is associated with social issues that significantly affect wellbeing of the PLHIV, their families and the community in which they live. For this reason, Care and Support for persons living with HIV/AIDS should address challenges that are associated with the disease and these could be medical, psychological or socio-economic problems. HIV/AIDS also exerts a significant toll on families and communities of persons living with HIV/AIDS and as such, Care and Support should include interventions that address the needs of this group. Before discovery of Antiretroviral Therapy (ART), symptomatic HIV/AIDS infection was rapidly fatal and the management of HIV/AIDS was limited to palliative care for the terminally ill, which consisted almost entirely of management of pain and the more common symptoms of terminal disease. The very short intervening period between the emergence of symptoms and death, usually six months, contributed to the dearth of Care and Support services for PLHIV in that era. Stigma and discrimination resulted in minimal community support for PLHIV and in many cases, being HIV positive was a taboo. Antiretroviral Therapy has altered the natural course of HIV/AIDS and transformed a rapidly fatal disease to a chronic disease and as a result rather than dying, persons living with HIV/AID encounter the challenges and other burdens associated with long term HIV/AIDS infection. Every PLHIV in Nigeria should receive support to cope with the burden of the infection. It is the responsibility of government and all groups engaged in providing such services to act within the purview of their individual mandates to ensure that PLHIV access Care and Support services suitable to their needs in a sustainable manner. These guidelines for HIV/AIDS Care and Support provide general guidance for the design and implementation of interventions that address the medical, psychological and socio-economic impact of HIV/AIDS on the PLHIV, their families and communities. 1.2 SITUATONAL ANALYSIS OF HIV/AIDS CARE AND SUPPORT IN NIGERIA The arrival of Antiretroviral Therapy in Nigeria received great excitement and the immediate priority of government was to make this effective treatment widely available to all eligible persons, to the extent that no plans were made for provision of non-medical Care and Support for the PLHIV. With increased access to Antiretroviral drugs (ARVs) and with more people surviving, other implications of living with HIV/AIDS are more pressing and the need to provide Care and Support services other than ART has become more evident. In 2005, The Federal Government of Nigeria commenced work on the National Work Place Policy on HIV/AIDS, in recognition of the fact that care for the PLHIV does not stop with ART. The work place policy effectively brought the discriminatory practice of mandatory pre-employment testing for HIV/AIDS to an end. By 2006, HIV/AIDS Care and Support became better established with the expansion in the scope of services offered by health facilities and an increase in community-based services. 01 National Guidelines on HIV/AIDS Care and Support 2014 The National Guidelines for HIV/AIDS Palliative Care was developed in 2006 with the sole purpose of providing direction for HIV/AIDS Care and Support interventions. There has been a remarkable growth in the implementation of Care and Support services since then with a marked increase in preventive treatment of opportunistic infections using Cotrimoxazole prophylactic treatment (CPT) and other medication. Presently CPT is a key component of the Care and Support interventions and it has contributed significantly in reducing morbidity and mortality of PLHIV. Other Care and Support interventions that have received a significant boost include nutritional intervention with food-based supplements, prevention of Opportunistic Infections through provision of safe water and distribution of long lasting insecticide treated nets (LLITN) for prevention of diarrheal diseases and malaria respectively. Community based Care and Support services made considerable progress in this period with more NGOs coming on board with services ranging from redress for rights violations, nutrition support, support for income generating activities, care for vulnerable children and support for caregivers. A major success story is the growth of PLHIV support associations, which followed the establishment of the Network of People Living with HIV/AIDS in Nigeria (NEPWHAN) and its state chapters. There are numerous PLHIV associations (coordinated by NEPWHAN), some of which have evolved into Community Based Organizations (CBOs), which provide tangible Care and Support services However, major difficulties still exist in the implementation of Care and Support services; there are significant gaps in coordination of Community Based Organizations, poor government ownership and sustainability of programs. Delays exist with early enrollment of PLHIV (immediately after diagnosis) into Care and Support programs. In addition, referral, linkage and network systems that will ensure a robust continuum of care require strengthening to function effectively. Furthermore, there is still the need for a well-defined national standard package for Care and Support services and training curriculum for HIV/AIDS Care and Support. The implementation plans and tools for quality assessment are also not standardized. This National HIV/AIDS Care and Support guideline provides guidance for the design, implementation, monitoring and evaluation of Care and Support services. 02 National Guidelines on HIV/AIDS Care and Support 2014 CHAPTER 2: CONCEPTUAL FRAMEWORK FOR HIV/AIDS CARE AND SUPPORT 2.1 Introduction are and Support is the third, but neglected pillar of Universal Access; it is central to achieving universal access and the Millennium development goals (MDGs). Retention in care, support and treatment is a challenge that would require efforts that ensure interaction between the health system, the community system and social protection programs. The Care and Support services provided to each PLHIV and their community should be need based and vary according to the different settings and levels of HIV/AIDS prevalence. Comprehensive HIV/AIDS Care and Support services will best delivered in an enabling environment that caters for the Medical, Psychological and Socioeconomic needs of the PLHIV. C 2.2 Definition 'HIV/AIDS Care and Support is the holistic and comprehensive client-focused, community centered care provided by a multidisciplinary team at all stages of the HIV/AIDS infection.' The primary objective of Care and Support is to reduce the burden of the disease on the PLHIV, improve quality of life of the individual, support affected families and communities by anticipating and addressing the medical, psychological and socioeconomic challenges of HIV/AIDS. 2.3 Guiding principles of HIV/AIDS Care and Support These include the following: v HIV/AIDS infection is now a chronic condition that requires a multi-disciplinary approach and multisectoral collaboration in its management v Care and Support of the PLHIV should be holistic within the continuum of care v Meaningful involvement of PLHIV and PABA in the design, implementation and evaluation of Care and Support services v Effective referral, linkage and network support systems v Coordinating mechanisms for Care and Support should include and position the communities delivering and accessing, Care and Support services in leadership roles to ensure ownership and sustainability 2.4 Components of HIV/AIDS Care and Support programming and relevant interventions. The basic needs of PLHIV reflect the multidimensional nature of the impact of HIV/AIDS on an individual and these needs fall within three main domains: medical, psychological and socioeconomic. These components consist of the following interventions: Medical care for PLHIV · HIV/AIDS testing and counseling · Preventive therapy · Prevention of opportunistic Infections (OIs) including Tuberculosis, fungal infections; use of Cotrimoxazole · Prevention of Mother To Child Transmission of HIV/AIDS (PMTCT) · Prevention of selected vaccine preventable diseases including hepatitis B, pneumococcal influenza, and yellow fever 03 National Guidelines on HIV/AIDS Care and Support 2014 · Universal safety precautions · Post-exposure prophylaxis (and pre-exposure prophylaxis) · Management of HIV/AIDS related illnesses (including Opportunistic Infections, Sexually Transmitted Illnesses (STIs), cancer related illnesses and Tuberculosis control) · Antiretroviral Therapy · Family Planning · Nutritional support · Health education/promotion including healthy living; water sanitation and hygiene; prevention of malaria, among others · Support systems such as laboratory investigations and drug management systems Psychological support · Counseling · Initial and follow up counseling for emotional and spiritual needs, disclosure and partner motivation · Community support services including support groups, peer groups, community or volunteer outreaches and spiritual support · Support for caregivers Socioeconomic support · Material support to meet nutrition, housing and daily living needs · Microcredit schemes · Health insurance schemes · Food support · Planning and support for orphans and vulnerable children · Participation of PLHIV and their families in ? Planning and delivery of comprehensive Care and Support services ? Reinforcing adherence, prevention and care ? Promoting health seeking behavior · Human rights and legal needs ? Addressing stigma and discrimination at health facilities, care centers, communities and workplaces ? Addressing issues of confidentiality and individual rights to disclosure ? Promoting equal access to care ? Succession planning 2.5 Eligibility for HIV/AIDS Care and Support All persons living with HIV/AIDS including women and children are eligible for Care and Support services throughout the entire duration of HIV/AIDS disease from the time of diagnosis irrespective of the clinical stage of the infection. The type of Care and Support services they receive will depend on the clinical, emotional, social and economic impact of the disease on the individual. Families of persons living with HIV/AIDS are also eligible for Care and Support services, to cope with the stress that results from close association with persons living with HIV/AIDS such as stigma and discrimination, loss of income, impoverishment and the emotional burden of caring for the PLHIV. Caregivers are equally eligible for Care and Support services to deal with stress, doubts, safety concerns, fears, and burnout associated with HIV/AIDS infection. Finally, members of communities are also eligible for Care and Support services that deal with fears, myths and misconceptions that fuel stigma and discrimination. 04 National Guidelines on HIV/AIDS Care and Support 2014 2.6 Providers of Care and Support services Care and Support for PLHIV is the responsibility of every individual. Everyone who encounters a PLHIV should treat him with empathy and dignity. The society should reject all acts of discrimination and stigma against PLHIV; these individuals should be supported to live a normal life. Government and agencies of government have a major role in creating an enabling environment for provision of meaningful Care and Support services to PLHIV. Specific organs of government that have these responsibilities include: - the Federal and State Ministries of Health, National Agency for the Control of HIV/AIDS (NACA), relevant line ministries such as Labour, Education, Women Affairs and Social Development, Agriculture, Justice. Other agencies include Small and Medium Enterprises Development Agency of Nigeria (SMEDAN), Industrial Training Fund (ITF) and others similar to the defunct National Directorate of Employment (NDE). Health facilities and health workers have a primary role of caring for the PLHIV who require Care and Support to overcome health issues associated with HIV/AIDS infection. All categories of Health care workers play important role in caring for the PLHIV. Non health workers also play a critical role in caring for the PLHIV and are found in different sectors of the society; they include PLHIV, family and community members, persons and groups involved in the protection of rights of PLHIV and law enforcement agencies. Family members and PLHIV play essential roles in providing community and home based care, which includes management of minor ailments, treatment and psychological support, financial support and support to access available Care and Support services. In broad terms, providers of Care and Support services are categorized into individuals, Community Support Organizations (CSOs), Non-governmental organizations and Governmental organizations. The role that each of them plays will be determined by the specific needs of the PLHIV. 2.7 HIV/AIDS Care and Support settings The main settings for HIV/AIDS Care and Support services are: · Health facilities · Homes · Communities (CBOs, Support Groups, Faith Based Organizations (FBOs), NGOs, etc.) · Work place 05 National Guidelines on HIV/AIDS Care and Support 2014 CHAPTER 3: DELIVERY OF HIV/AIDS CARE AND SUPPORT SERVICES H ealth and social services should be accessible for everyone living with and/or affected by HIV/AIDS. Care and Support interventions required by PLHIV and PABA vary from one individual to the other and are determined by the specific needs of the individual at any point in time. PLHIV/PABA should receive access to available Care and Support services through fostering linkages and strengthening referral systems between service providers. 3.1 CONTINUUM OF CARE The needs of PLHIV extend from the time of diagnosis to terminal stages of the HIV infection. ACTIVE REFERRAL NETWORK Social and legal support services District hospitals, HIV clinics, specialists an specialized care facilities Health centers, dispensaries traditional care Poor support and voluntary services Individuals seeking or needing care Homes, community services, hospices HIV voluntary counseling and testing (VCT) ACTIVE REFERRAL NETWORK Care seeking/providing Active Retinal Source: Treatment Division, Family Health International Figure 1: Continuum of HIV/AIDS Care & Support 3.2 COMPREHENSIVE PACKAGE OF CARE AND SUPPORT INTERVENTIONS The comprehensive package of Care and Support interventions are the range of services that should be available to PLHIV and persons affected by HIV/AIDS. These can be medical or supportive. Medical services are those services that have a direct bearing on the health of the individual while supportive services assist the individual to cope with the burden of the disease 3.2.1 Medical services Medical care for PLHIV refers to those services that have a direct bearing on the health of the individual and inclusive of laboratory and clinical management of HIV/AIDS and its medical complications. These services include but are not limited to: HIV counseling and testing (HCT), laboratory services, management of Tuberculosis, opportunistic infections and other medical complications of HIV/AIDS, pain and symptoms management, Antiretroviral Therapy, Post Exposure Prophylaxis (PEP) and Pre- Exposure Prophylaxis (PrEP), prophylaxis for Opportunistic Infections and Tuberculosis (TB), Prevention of Mother to Child Transmission (PMTCT) as applicable. 3.2.2 Supportive services Supportive care consists of a broad range of services and aims to improve quality of life of these individuals by empowering them to cope with the social and economic burden of HIV/AIDS. It addresses issues of inequality, social isolation, poverty, stigma and discrimination and seeks to mitigate the emotional stress that is associated with HIV/AIDS. 06 National Guidelines on HIV/AIDS Care and Support 2014 3.2.2.1 Socio-economic services PLHIV and PABA should have access to interventions that empower them to cope with the social and economic challenges of HIV/AIDS. These interventions include · Schemes for mitigation of stigma, discrimination and social exclusion · Skill acquisition, income generation and empowerment · Access to basic education and literacy programmes · Social welfare schemes that improve access to nutritional support, housing and medical services · Access to affordable health insurance · PLHIV support groups and associations · Access to legal protection 3.2.2.2 Psychological services These services consist of a broad range of interventions that cater primarily to the emotional, psychological and spiritual wellbeing of PLHIV and PABA. They include HIV/AIDS counseling services inclusive of couple counseling and adherence counseling, Mental Health services and Spiritual counseling. 3.3 CARE AND SUPPORT IN THE HEALTH FACILITY. Health facility based Care and Support services refer to services that offered in the health facility usually by trained health care professionals. These are services that; maintain physical and psychological health, monitor progression of illness, delay onset of HIV/AIDS–related infections and initiate linkages with community-based resources. They include: · HCT services for HIV/AIDS screening and diagnosis · Periodic clinical & laboratory monitoring of CD4/lymphocyte counts, Viral load and resistance monitoring. · Laboratory services for the diagnosis of Opportunistic Infections and Tuberculosis. · Psychological/mental health services with emphasis on counseling services · Health education for Positive Health Dignity and Prevention (PHDP), personal and food hygiene, use of ITNs, early recognition and reporting of illness, improved health seeking behavior and provision of safe water treatment · Treatment of intercurrent infections and conditions that may be unrelated to HIV/AIDS disease · Appropriate treatment of opportunistic infections, malignancies and other illnesses · Prophylaxis (CPT, IPT, PMTCT, PEP and PrEP) · Assessment for ART eligibility, treatment education and adherence support. · ART initiation and monitoring, · Pain management · Provision of family planning services · Nutritional assessment, counseling and support · Effective linkages and networking with community resources and referral for: homebased/community care, 3.4 COMMUNITY BASED CARE AND SUPPORT OF PLHIV The community can play an important role in the Care and Support of PLHIV. This role will depend on the specific needs of the individual. Community based Care and Support is usually complimentary to care obtained in the health facility. Caregivers play a pivotal role in caring for the PLHIV in the community and these could be family members, friends or volunteers at the community level. Community based Care and Support services should include: · Basic nursing care at home, with training for caregivers · Health and treatment education 07 National Guidelines on HIV/AIDS Care and Support 2014 · Adherence support and monitoring · Nutritional assessment counseling and support · Counseling and community mental health services · Access to PLHIV support groups for peer support · Linkage to other community-based services including legal protection, skills acquisition schemes, income generation and social welfare · Access to basic amenities including potable water, shelter · PHDP 3.5 THE MINIMUM PACKAGE OF CARE AND SUPPORT INTERVENTIONS FOR PLHIV The minimum package of Care and Support interventions describes the basic unit of interventions every PLHIV should receive at either the facility or community level. At the facility, the minimum package for PLHIV at each encounter should include: · Counseling for PLHIV and when possible attach them to a treatment supporter · Assessment of eligibility for ART · Cotrimoxazole Preventive Therapy for all eligible persons · Screening for Tuberculosis · Linkage with a community PLHIV support group and other community-based services · Provision of a basic self-care preventive kit on enrolment (The kit should usually include a lidded bucket, water purifier and a long-lasting insecticide-treated net.) · Provision of PHDP services (STI and risk assessment, condom education and supply, sexual and reproductive health and family planning referral, adherence counseling, alcohol and substance abuse assessment) For the PLHIV presenting initially to a community-based organization the minimum package of care should include: · HIV/AIDS counseling and when possible testing · Provision of supportive service obtainable in that organization · Referral to a health facility for comprehensive medical assessment and management 3.6 MINIMUM PACKAGE OF CARE AND SUPPORT FOR PABA 'A Person Affected by HIV/AIDS&AIDS (PABA) may be a person living with, caring for, and/or a dependent of a PLHIV.' All PABA should receive: · Appropriate counseling at each encounter at the facility or the community · Referral to appropriate Community Based Organization for socioeconomic support 3.7 SUPPORT GROUP SYSTEMS Definition of a Support Group: 'A support group is a group of people who come together to share experiences about their common issues, provide peer support for one another as well as engage their communities to foster convenient environment for their welfare'. Support groups are based in the health facility or the community. Types of support group include amongst others: · General Support Groups (Everybody) · Mother -to -Mother support groups · Singles support groups · Adolescent support groups · Women support group 08 National Guidelines on HIV/AIDS Care and Support 2014 · Kids clubs · Discordant couples Activities: 1. Treatment adherence support among members and tracking of defaulters and bringing them back to care. 2. Mentorship of new PLHIV 3. Community involvement and advocacy towards stigma reduction, prevention, Care and Support. 4. Monthly meeting for members. 5. Economic empowerment among members (e.g. Skills SLA) 6. Health talk and life-skill. 7. Peer education. 8. Provision of voluntary services at the facility and community levels 09 National Guidelines on HIV/AIDS Care and Support 2014 CHAPTER 4: POSITIVE HEALTH DIGNITY AND PREVENTION (PHDP) 4.1 Introduction ositive health dignity and prevention (PHDP) emphasizes the importance of placing persons living with HIV/AIDS (PLHIV) at the center of managing their health and well-being. HIV/AIDS services need to include PLHIV in the conception, design and implementation of the services meant for them. PHDP highlights PLHIV as key players in the solution to the long-standing challenge of HIV/AIDS transmission prevention. PHDP advocates that all stakeholders in HIV/AIDS prevention should work towards meeting the broad health needs of PLHIV – by supporting their physical, mental, emotional and sexual health – and upholding their dignity. When this is done within a human rights framework, the resultant enabling environment will decrease the chances of new HIV/AIDS infections. PLHIV therefore become “active participants” and not “passive targets” in the response to HIV/AIDS in all contexts. P 4.2 Definition 'Positive Health Dignity and Prevention (PHDP) is defined as a set of actions that help people living with HIV/AIDS to live longer and healthier lives.' Core Values and Principles Positive Health, Dignity and Prevention is defined by people living with HIV/AIDS and guided by the following values and principles: v People living with HIV/AIDS should be leaders in the design, programming, implementation, research, monitoring and evaluation of all programmes and policies affecting them v A human rights approach is the foundation of Positive Health, Dignity and Prevention v Preventing HIV/AIDS transmission is a shared responsibility of all individuals irrespective of HIV/AIDS status v Sexual and reproductive health and rights should be recognized and exercised by everyone regardless of HIV/AIDS status Table 1:Key elements of PHDP · Health promotion and access · Treatment access · Sexual and reproductive health and rights · Prevention of transmission of HIV/AIDS and other sexually transmitted infections (STIs) · Protection of human rights, including stigma and discrimination reduction · Gender equality · Mental Health support · Social and economic support; and · Empowerment of people living with HIV/AIDS · Measuring impact 4.3 COMPONENTS OF THE KEY ELEMENTS OF POSITIVE HEALTH, DIGNITY, AND PREVENTION The concept of PHDP recognizes that various elements of the approach are relevant to interventions at the community level and the facility level. 10 National Guidelines on HIV/AIDS Care and Support 2014 Facility and Community PHDP Skills Building for Income Generating Activities Mental Health Care Legal Support Spiritual Support Referral Services Facility PHDP Community PHDP Provider Initiated Prevention Messages for PLHIV Reinforcing Provider Initiated Prevention Messages for PLHIV Direct Services Safe Water, Food, and Nutritional Counseling Condoms and Family Planning Commodities IES on STI prevention, family planning, health promotion, HIV transmission prevention Continued Post-Test Counseling Alcohol Reduction and other Substance Abuse Support Psychosocial Support, Palliative Care Treatment Adherence Counseling Table 2 : Facility and Community PHDP 4.3.1 Health promotion and access · HIV/AIDS Counseling and Testing (HCT) · Provider-initiated counseling and testing and community counseling and testing under conditions of informed consent and confidentiality · Antiretroviral therapy (ART), including clinical monitoring, adherence support, access, availability and quality assurance · Health education for living well · Treatment literacy · Psychosocial wellbeing, including building self-esteem and confidence · Mental health · Preventing disease progression and further infections/prophylaxis for Tuberculosis (TB) and opportunistic infections (OIs) 4.3.2 Sexual and reproductive health and rights · Sexual and reproductive health care services · Maternal health · Family planning · Prevention and treatment of sexually transmitted infections (STIs), including hepatitis B &C · Sex and sexuality education and services 4.3.3 Prevention of transmission · Transmission literacy · Harm reduction (drugs and alcohol) 11 National Guidelines on HIV/AIDS Care and Support 2014 · Prevention of parent to child transmission · Palliative care 4.3.4 Human rights, including stigma and discrimination reduction Ensuring confidentiality of status Safe and voluntary disclosure (“to create an environment of open communication and equality in relationships”) Autonomy of the individual (“i.e. choice as to when, and if, to initiate ART”) Legal literacy, advocacy and activism Enabling environment, including protective laws Shared responsibility 4.3.5 Gender equality Gender-based violence prevention and management Women's rights Economic empowerment 4.3.6 Social and economic support Social and economic support, including for caregivers Food and water security Health and social protection for children and adolescents living with HIV/AIDS Education and awareness 4.3.7 Empowerment Meaningful involvement of people living with HIV/AIDS, including positive leadership Participation and advocacy Social mobilization and community engagement Linking to other social justice and development movements 4.4 MEASURING IMPACT Continued and/or increased funding for Positive Health, Dignity and Prevention programs Building evidence and sharing lessons learned Indicators for monitoring and evaluation 4.5 MINIMUM PHDP SERVICES FOR PLHIV PHDP messages and services should be routinely offered to all PLHIV attending Care and Support services in both clinic and community settings. Messages and services should include as a minimum: · Promote and preventive recommendations (status disclosure, partner testing, safe sex with condom promotion/distribution and alcohol/substance use reduction) · Adherence assessment, counseling and treatment support · Family planning and safe pregnancy counseling · STI assessment, diagnosis and treatment · Referral to community-based programs for relevant non-clinical services 12 National Guidelines on HIV/AIDS Care and Support 2014 CHAPTER 5: HIV/AIDS CARE AND SUPPORT SERVICES FOR SPECIAL POPULATIONS 5.1 DEFINITION OF SPECIAL POPULATIONS ll People Living with HIV/AIDS should have access to HIV/AIDS Care and Support services suitable to their needs and circumstances, and these services should be affordable and accessible. There are however, certain populations that require special attention to ensure equity in access to services. A PLHIV who fall under the category of special populations include women, especially pregnant women, children, the elderly, physically challenged persons, people in conflict situations, internally displaced persons (refugees & migrants) and military personnel on special missions. Other special populations include Intravenous Drug Users (IDU's), Key Affected Populations (KAP) and blood transfusion dependent persons such as people suffering with sickle cell anemia, refractory anemia or bone marrow depression, etc. Children are a special group because they are often dependent on adult caregivers and guardians for their wellbeing and in most cases are unable to make critical decisions that affect their lives. In many cases, the welfare of the child is inextricably intertwined with that of the parents, adult caregivers and guardians and as such provision of Care and Support should as much as possible be inclusive of care of the family. Vulnerable children (VC) require special care and every effort should be made to ensure that they are placed in stable homes with caring and responsible adults who provide basic protection and guidance. The preferred approach to the Care and Support of children is a family centered approach. 5.2 CARE AND SUPPORT SERVICES OF THE HIV POSITIVE CHILD The Care and Support of the HIV positive child is complicated by the complex nature of the effects of HIV/AIDS on the child. The design and implementation of Care and Support interventions for children living with HIV/AIDS should recognize these peculiarities. With regard to children, the following are important considerations: § Clinical course of HIV/AIDS is usually more rapid in children, with the majority of them dying in the first two years without definitive treatment with ART. § Conclusive diagnosis of HIV is complex in children under the age of 18 months. § Infant nutrition poses a great challenge in the early months of the child's life especially with the risk of mother to child transmission of HIV via breast milk. § Children are almost entirely dependent on adults for survival. § The whole family is affected because the diagnosis of HIV/AIDS in a child often leads to discovery of the HIV status of other members of the family, with attendant psychosocial problems. § Communicating with children requires special techniques to determine their feelings and needs. A comprehensive plan for the Care and Support of HIV positive children should be family centered and delivered by a competent multidisciplinary team of experts with good understanding of the complexities of managing children. 5.3 COMPREHENSIVE PACKAGE OF CARE FOR HIV POSITIVE CHILDREN Care and Support of the child with HIV/AIDS should consist of a comprehensive package of care (in line with the National Pediatric treatment guidelines) that aims at providing complete protection from the effects of HIV/AIDS and ensures the following: NationalGuidelines Guidelineson onHIV/AIDS Hiv/Aids Care Careand andSupport Support2014 2014 09 National 13 · All HIV exposed infants should have access to appropriate prophylaxis and technologies for early diagnosis of HIV/AIDS. · All HIV positive children under 24 months should be placed on antiretroviral therapy. · Provisions should be made to take care of other medical needs such as immunizations, treatment of Opportunistic Infections of all HIV positive children. · All children should receive counseling appropriate to their age. · HIV positive children and caregivers should have access to nutritional support. · HIV positive children of school age should not be denied access to education because of being HIV positive. · Families and caregivers of the HIV positive child should empowered to cater for the welfare of the child. · All HIV positive children should be protected from stigma and all other discriminatory practices because of their HIV status. · Community systems should be strengthened to provide protection and material support for children living with HIV/AIDS. 5.4 CARE AND SUPPORT SERVICES FOR VULNERABLE CHILDREN (VC) 'The child rendered vulnerable by HIV/AIDS can be described as one who, because of death or disability of one or both parent resulting from HIV/AIDS, is prone to abuse or deprivation of basic needs, care and protection, and thus disadvantaged relative to peers. ' Care and Support of the Vulnerable Child (VC) should focus primarily on strengthening the capacity of families to protect and care for them by: · Implementing measures that prolong the lives of surviving parents or caregivers and ensure that they have unhindered or even preferential access to essential medical care · Providing comprehensive HIV/AIDS related health care services for all members of the family who require care · Ensuring that adults who care for the VC whether they are parents or guardians have access to opportunities for economic empowerment such as income generation activities (IGA) and vocational training · Implementing measures that allow universal access to education support for VC as an additional way of reducing the economic burden for indigent caregivers and guardians · Ensuring that all families with VC have access to regular and qualified psychosocial support to reduce the emotional pressures and stress associated with HIV/AIDS · Implementing measures for sustainable food and nutrition support for all members of the family-adults and children alike · Establishment of mechanisms that provide VC sustainable shelter in the context of the family 14 National Guidelines on HIV/AIDS Care and Support 2014 · Providing or ensuring access to legal rights aid and assistance for families and caregivers of the VC for protection against discriminating practices 5.5 CARE AND SUPPORT SERVICES FOR WOMEN LIVING WITH AND AFFECTED BY HIV/AIDS In most African societies, women are the homemakers and they play a central role in stabilizing families and maintaining its health. There is evident need to keep women healthy and safe for the sake of their health and the stability of the family. All women with HIV/AIDS should have free access to health facility based services for the management of HIV/AIDS. They should receive basic and ongoing HIV/AIDS counseling support that includes disclosure counseling, adherence counseling, routine preventive treatment of opportunistic infections including Tuberculosis diagnosis and treatment, and a comprehensive package of ART for all eligible women. As well as ensuring that they receive ART for their own health, programmes that offer HCT to pregnant women should be strengthened to improve access to routine HIV/AIDS counseling and testing for all pregnant women. All women who test positive should be linked to a Prevention of Mother to Child Transmission (PMTCT) programme. In addition to improving access to responsible spiritual care and effective psychotherapy, all women who are infected and affected by HIV/AIDS, should have access to effective and appropriate community based support services to reduce the burden of HIV/AIDS and improve standards of living. Women in households with HIV positive individuals should receive training on basic home-based care of HIV positive persons to enhance their roles as caregivers. They should also receive vocational training and improved access to other income generating activities for economic empowerment of the individual and their household. Women living with or affected by HIV/AIDS should have access to legal aid and protection from domestic violence and abuse. Systems ought to be strengthened to deliver community education aimed at changing gender norms that disenfranchise women and girls and discourage access to community health and vocational services. 5.6 CARE AND SUPPORT SERVICES FOR PLHIV IN TIMES OF CIVIL STRIFE AND CONFLICT Conflict and civil strife refer to wars, civil disobedience and in recent times intensified terrorist activities during which time there are disruptions in law and order and administration of key organs of government and civil society. PLHIV who are trapped in conflict zones are particularly vulnerable because they are cut off from HIV/AIDS Care and Support services. Care and Support of PLHIV during periods of strife and conflict requires special interventions that guarantee that ongoing Care and Support services continue uninterrupted. Arrangements should be made using emergency relief organizations to supply medicines and commodities to PLHIV in refugee and internally displaced persons camps. PLHIV support organizations should be encouraged to develop emergency plans for ensuring continuity of treatment for its members during periods of strife and civil disorder. PLHIV in displaced persons camps should receive appropriate education and counseling on positive living and adherence counseling. Mobile clinics should be established as a component of relief materials to take medicines to persons trapped in conflict zones and they should offer medicines for HIV/AIDS treatment and care. 15 National Guidelines on HIV/AIDS Care and Support 2014 5.7 CARE AND SUPPORT SERVICES FOR OTHER SPECIAL POPULATIONS These include Intravenous Drug Users (IDUs), and blood transfusion dependent persons and prisoners. IDUs and other special persons in this category should have access to HCT. Counseling should also include risk reduction and adherence to ART. They should also have access to support groups. Other medical care and ARVs should be provided. Blood transfusion dependent persons are continually at risk of re-infection. Therefore, every effort should be made to ensure that blood and blood products used for transfusion are properly screened and certified safe. 16 National Guidelines on HIV/AIDS Care and Support 2014 CHAPTER 6: POLICY AND PROGRAMMING ISSUES IN HIV/AIDS CARE AND SUPPORT SERVICES T he implementation of HIV/AIDS Care and Support programs will require effective policy, collaboration and coordinated inputs of a large number of stakeholders including governments at all levels, international and local NGOs, association of PLHIV, Community Based Organizations (CBOs), Civil Society Organizations (CSOs) and families. While there will be multiple stakeholders involved in provision of HIV/AIDS Care and Support programs, there are agencies that should provide leadership for the coordination of the implementation of Care and Support interventions. There should be clear and unambiguous policy and guidelines for the offer of HIV/AIDS Care and Support services and government has the responsibility for not only providing this but ensuring compliance. 6.1 GOVERNANCE In the context of HIV/AIDS Care and Support, governance involves the control and regulation of interventions for the Care and Support of persons living with HIV/AIDS in a manner that ensures access to safe, dignified and quality Care and Support services. Governance for HIV/AIDS Care and Support operates at different levels, and is not restricted to government. It operates at the level of government and its agencies, local and international HIV/AIDS Implementing organizations, private sector, health facilities, PLHIV Networks and all other bodies and persons involved in Care and Support of PLHIV. 6.1.1 Policy, Guidelines and Regulations The Federal Government should ensure that there are clear policies and guidelines for the provision of HIV/AIDS Care and Support. Government and its partners should ensure widespread dissemination and compliance with the guidelines. Government should establish systems for effective public private sector partnership for Care and Support services. All organizations engaged in the provision of HIV/AIDS Care and Support services should ensure that services offered are in line with the provisions of the national guidelines for HIV/AIDS Care and Support. Faith Based Organizations (FBOs), CBOs and PLHIV support groups should engage community groups and unorthodox medicine practitioners as well as faith healers to limit the proliferation of false claims, inappropriate practices and harmful practices Civil society organizations and the legislative arms of government should work together to enact binding anti-stigma laws and these should be enforceable by relevant agencies. The Ministry of Labour and Productivity should actively monitor and enforce the implementation of the work place policy in both the public and private sectors 6.1.2 LEADERSHIP, COORDINATION AND COLLABORATION Government should exercise overall leadership and oversight for the implementation of HIV/AIDS Care and Support services in Nigeria. 17 National Guidelines on HIV/AIDS Care and Support 2014 Government at all levels should establish and implement mechanisms for effective coordination of Care and Support services. All HIV/AIDS Implementing Agencies especially those engaged in providing funding for international and local NGOs in the country have the responsibility to coordinate the activities of NGOs funded by them in line with national guidelines. Faith Based Organizations (FBOs) and CBOs are encouraged to strengthen and work with other existing community structures to ensure effective coordination and implementation of HIV/AIDS care & support services. HIV/AIDS treatment centers and health facilities should strengthen effective linkages with community based HIV/AIDS Care and Support services. 6.1.3 COMMUNITY PARTICIPATION AND OWNERSHIP The community is the closest milieu to the client and for services to have an impact on both PLHIV and PABA, the community has to participate and own the programme. There is also need to engage community stakeholders in the design, implementation, monitoring and evaluation of HIV/AIDS programmes 6.1.4 FINANCING CARE AND SUPPORT SERVICES Government at all levels and international partner organizations should increase financial commitment to the provision of HIV/AIDS Care and Support services. Public Private Partnership (PPP) and donor collaboration should be encouraged to enhance resource mobilization for HIV/AIDS Care and Support services. Government, private organizations and donor agencies should strengthen capacity of PLHIV support groups to leverage financial resources for the delivery of HIV/AIDS Care and Support service. Government should strengthen community and facility level social welfare schemes to respond to the Care and Support needs of indigent PLHIV and PABAs. PLHIV support groups should engage in constructive advocacy for increased government funding for HIV/AIDS Care and Support services. 6.2 HUMAN CAPACITY DEVELOPMENT There is evidence of poor collection and analysis of data as well as implementation due to inadequate capacity in the public sector and CBOs. There is also inadequate capacity of support groups to play their role in the national response. A recent review highlighted the need for capacity building and 1 community systems strengthening . Government should provide necessary support to develop and strengthen human capacity including training, mentoring, supervision and provision of equipment for the delivery of comprehensive HIV/AIDS Care and Support services. The development and review of a national curriculum for training of care providers in HIV/AIDS Care and Support should be the responsibility of Government and it should facilitate the incorporation of HIV/AIDS education in the curricula of schools from primary to tertiary levels. All NGOs, CBOs and Faith Based Organizations (FBOs) should ensure regular training for HIV/AIDS Care and Support personnel in their service according to the national guidelines. PLHIV Support Groups should provide literacy seminars on treatment Care and Support for its members. 1 NACA, Mid Term Review of the Nigerian HIV/AIDS response, 2013. 18 National Guidelines on HIV/AIDS Care and Support 2014 6.3 ADMINISTRATION OF HIV/AIDS CARE AND SUPPORT PROGRAMMES The needs of the PLHIV are myriad and they cut across different disciplines making it difficult for any single service provider to address all of them. Consequently, all organizations involved in the Care and Support of PLHIV will be required to work in collaboration with each other in a coordinated manner to ensure that most of the needs of PLHIV are met. The needs of the PLHIV are covered under the following main headings: medical, psychological, and socio-economic. For each category of needs, the organizations that are best positioned to address them, should take the lead in providing such services. Government agencies responsible for supervising and coordinating the provision of HIV/AIDS Care and Support services should ensure the availability of and adherence to appropriate guidelines. 6.3.1 Medical services The FMOH and NACA in collaboration with all counterpart agencies in the other tiers of government should work with HIV/AID Implementing Partners and stakeholders to accomplish the following: · Develop and enforce compliance with national guidelines for HIV/AIDS Care and Support in Nigeria. · Review and ensure compliance with other guidelines for implementation of other interventions such as ART, PMTCT, CPT, IPT for Tuberculosis, IPT for Malaria in Pregnancy, HCT etc. · Procure commodities and essential drugs including ARVs, drugs for Opportunistic Infections, HIV test kits and reagents. · Establish a functional logistics management system that ensures regular and uninterrupted supply of HIV medicines and other commodities. · Strengthen human and infrastructural capacity of health facilities to provide comprehensive medical services for all PLHIV. · Improve access of PLHIV and PABA to community health insurance schemes · Establish programmes for education and orientation of family members and caregiver on the basic management of HIV/AIDS related OIs. 6.3.2 Psychological Services Government at all levels, implementers of HIV/AIDS care, and support programmes should establish strong systems for promoting the mental and psychological health of PLHIV. Stakeholders including government, civil society organizations, community-based organizations and PLHIV support groups have the duty to develop and implement anti stigma and discrimination plans. Implementers of HIV/AIDS Care and Support programmes have the responsibility to work with religious groups to develop safe and realistic spiritual practices relating to issues around cure of HIV/AIDS and adherence to medical treatment. HIV/AIDS Care and Support programmes should commit to establishing strong and viable mental health programmes that include a robust and comprehensive HIV/AIDS counseling programme and unlimited access to mental health services. 6.3.3 Socio-economic empowerment Government and major HIV/AIDS implementing agencies should adopt a deliberate policy of encouraging the formation of PLHIV support groups and networks. 19 National Guidelines on HIV/AIDS Care and Support 2014 PLHIV and their families that have material needs should have access to economic empowerment schemes that improve their capacity to cater to their financial needs. Governments should strengthen its social welfare schemes and extend services of these schemes to indigent PLHIV. Households of PLHIV should be strengthened to provide basic essential services to family members especially children. Government backed poverty reduction schemes such as National Directorate of Employment (NDE), Subsidy Re-Investment and Empowerment Programme (SURE-P) and National Poverty Eradication Program (NAPEP) should implement support policies that are favorable to PLHIV and their families. Civil society organizations and multi-national organizations should invest in schemes that provide economic empowerment for HIV/AIDS affected households such as income generating activities, cooperative low interest loans to family members and vocational skills acquisition for PLHIV. 6.4 MONITORING AND EVALUATION (M&E) Monitoring and Evaluation is an essential component of HIV/AIDS and AIDS Care and Support. The purpose of M&E is to keep activities on track and ensure that they are in line with overall programme goals. Government should lead and supervise the establishment of functional systems for M&E of HIV/AIDS Care and Support services. Government and stakeholders should ensure that appropriate structures, including staff training, are in place for effective M&E systems. Government and stakeholders should establish functional mechanisms for analysis and utilization of M&E data. 6.5 LOGISTICS MANAGEMENT Government should strengthen logistic and commodity management systems that ensure that commodities for HIV/AIDS Care and Support services are well managed and readily accessible to the end users. Government and stakeholders should strengthen an integrated Logistics Management Information Systems (LMIS) for effective management of commodities for HIV/AIDS Care and Support services and to ensure accountability. 6.6 ADVOCACY, SENSITIZATION AND MASS MOBILIZATION Focused advocacy is essential for successful implementation of HIV/AIDS Care and Support services. Necessary steps should be taken to ensure that at every level of government there is adequate public commitment to the provision of Care and Support for PLHIV. Government and relevant stakeholders should develop a national advocacy package for HIV/AIDS Care and Support services. A package that addresses issues such as provision of legal backing for policies for HIV/AIDS Care and Support, increased public involvement in the Care and Support of PLHIV, implementation of work place policies, community involvement in HIV/AIDS Care and Support services and increased financial commitment to HIV/AIDS Care and Support. Government and stakeholders at all levels should plan and implement sensitization and mass mobilization campaigns on HIV/AIDS Care and Support. The objective of this campaign is to increase community awareness of the benefits of Care and Support for the PLHIV. 20 National Guidelines on HIV/AIDS Care and Support 2014 CHAPTER 7: Nutrition For People Living With HIV 7.1 The Link between Nutrition and HIV/AIDS Adequacy of nutritional status enhances the immune system. The figure below illustrates that a wellnourished person has a stronger immune system for fighting infections and coping with HIV/AIDS&AIDS. Good Nutrition (Good food intake, maintenance of weight and muscle tissue, good microutdent status) Strengthening of the Immune System’s (ability to fight HIV and other infections) Management of HIVrelated Complications (e.g mal absorption, diarrhea, lack of appetite, weight loss) Increased Resistance to Infections (e.g. diarrhea, tuberculosis, respiratory infections) Figure 2 : Relationship between nutrition and HIV/AIDS 2 7.2 Nutrition Challenges of PLHIV in Nigeria Malnutrition is a serious problem that aggravates the spread of HIV/AIDS. HIV/AIDS prevalence in Nigeria is stabilizing but malnutrition is still a problem. The NDHS 2013 shows that 37% of children 3 aged less than five years were stunted, 29% were underweight and 18% were wasted . It is clear that malnutrition negatively affects an optimal immune function, thus increasing the susceptibility of victims to high morbidity and mortality. Adults living with HIV/AIDS&AIDS may suffer from loss of appetite, difficulty in eating due to oral infections. It is important therefore, that the provision of quality Care and Support for People Living with HIV/AIDS (PLHIV) should include nutritional counseling Care and Support. The goals of the nutritional counseling Care and Support for PLHIV should include: · Improvement of nutritional status · Ensuring adequate nutrient intake · Preventing food and water-borne diseases · Enhancing quality of life and prolong survival 2 Adapted from Ellen G. PIWOZ and ELIZABETH A. PREBLE, HIV&AIDS and Nutrition; A Review of the literature and Recommendations for Nutritional Care and Support in sub-Saharan Africa. Washington D.C.: Academy for Educational Development (AED), 2000. 3 National Population Commission. Nigerian Demography and Health Survey, 2013 21 National Guidelines on HIV/AIDS Care and Support 2014 This section of the HIV/AIDS Care and Support guideline focuses on Nutrition & specifically addresses the following objectives: v To provide consistent and evidence-based recommendations for nutritional response to HIV/AIDS v To assist in improving the nutritional status of PLHIV v To provide users (service providers, PLHIV, caregivers) evidence-based information on quality nutritional Care and Support v To assist in the improvement of the quality of life of PLHIV through maintaining a healthy lifestyle 7. 3 Recommended Nutrient Requirements Using Local Food Sources: Energy giving foods: yam, cassava, plantain, rice, bread, maize, potatoes (Irish and sweet) and cocoyam Sugars and Sugary Foods: sugar cane, honey, sweets, jams, marmalade, sugar cakes (Alewa) and cookies Fats and Oils: palm oil, groundnut oil, cottonseed oil, soybean oil, shea butter and margarine. Dietary Fiber: garden eggs, maize, fruits, vegetables, cassava, yam, sweet potatoes, and cocoyam Body Building Foods (Protein Rich Foods): Beans, groundnuts, pigeon peas, soya bean, Bambara nuts, meat, eggs, fish and milk (including yoghurt, wara (local cheese) Protective Foods: jews mallow (ewedu), spinach, water-leaf, bitter-leaf, zogale (moringa), ugu, oha, sorrel, cassava leaf, worowo, amunututu, sokoyokoto, ujuju, elemionu, kerenkere, afang, okazi, gbologi, ayakwa, okro, carrot, green peppers, onions. Avocado pears, local pears (Ube), bananas, guavas, mangoes, oranges, pawpaw, pineapple 7.4 Nutritional Care and Support for adults living with HIV/AIDS Key points to note: To keep healthy, Adults with HIV/AIDS&AIDS: · Need to do light exercises · Should use anti-retroviral (ARVs) if prescribed · Early identification and treatment of symptoms is essential. · Periodically check their nutritional status (weight, BMI), hemoglobin level determined and recorded PLHIV found to have weight loss of more than 10% in the last three months, should have their diet intake and history of illness assessed. PLHIV should increase the amount and the frequency of eating nutritious meals rich in energy, protein and essential micronutrients. 7.5 Nutritional Care for HIV positive pregnant women/adolescents · Family members should support pregnant adolescents and women living with HIV/AIDS to access appropriate health and nutrition services · They should be given priority at meals to eat enough of the right foods · They should not restrict food intake during the last months because of fear of having a big baby or obstructed labor · Those who expend energy on household or agricultural work should also increase their energy intake or reduce workload and have adequate rest. 7.5.1 Safe Food Handling Practices · Wash and keep food preparation surfaces, utensils, and dishes clean · Wash all fruits and vegetables, avoid eating raw food, cook foods thoroughly especially meats and chicken. · Avoid storing cooked food without a fridge; serve all food immediately after preparation · Drink clean and safe water, · Do not use bottles with teats to feed children, use cup and spoon instead 22 National Guidelines on HIV/AIDS Care and Support 2014 7.6 INFANT FEEDING OPTIONS FOR HIV POSITIVE WOMEN & ADOLESCENTS According to the national PMTCT guideline and the Nigerian Infant and Young Child Feeding (IYCF) policy, all HIV positive pregnant women should be on ART throughout their pregnancy and up to one week after cessation of breastfeeding. HIV positive breastfeeding mother should not breastfeed their baby for more than 12 months. 7.6.1 Exclusive Breastfeeding Mothers need to know that breast-feeding, · Gives infants all the nutrients they need, Protects infants and children from diseases other than HIV/AIDS and breast milk is easily digestible. · Lowers the risk of transmitting HIV/AIDS · Increases risk of HIV/AIDS transmission if the mother has a breast infection (e.g. mastitis or cracked and bleeding nipples) Breastfeeding mothers should: · Be given information to make BF as safe as possible, receive nutrition counseling, be taught good positioning and attachment · Put the baby to the breast immediately (within half an hour) after birth · Breastfeed exclusively until 6 months of age · Avoid mixed feeding · Introduce complementary foods at the age of 6 months · Be taught that infant mouth problems such as mouth ulcers and candidiasis (oral thrush) increase the risk of HIV/AIDS transmission. 7.7 NUTRITIONAL CARE FOR PLHIV TAKING MEDICATION OR HERBAL/LOCAL REMEDIES Various medications may produce side effects such as taste changes, loss of appetite, vomiting, nausea, and diarrhea, which can negatively affect food intake, nutrient absorption and metabolism leading to weight loss. It is important, therefore, for service providers to be aware of food/drug and nutrient/drug interactions in order to minimize negative side effects. 7.8 NUTRITIONAL ASSESSMENT COUNSELLING AND SUPPORT (NACS) Nutritional Assessment, Counseling and Support (NACS) is an essential strategy and component of Care and Support for PLHIV. NACS should be conducted at every setting where Care and Support is provided to PLHIV in the Community or Facility. In the community, this assessment and necessary interventions should be carried out during home visits, support group meetings and other community outreach activities. The Facility assessment should be carried out on the clients at each clinic visit at PHC, secondary and tertiary centers. Specialist advice for complicated cases may be sought from dieticians and nutritionists at secondary or tertiary health facilities or at state ministries or local government departments. Note: Inpatient treatment may be appropriate for patients with severe malnutrition. 23 National Guidelines on HIV/AIDS Care and Support 2014 7.8.1 Components of NACS 7.8.1.1 Assessment The counselor should work with the client (PLHIV) to assess the following. Nutritional status · Weight, height; and then calculate BMI for adults and mid upper arm circumference (MUAC) for children and pregnant women o Use of the height/weight chart for adults or WHO Road to Health chart for children o Compare findings with previous records · General wellbeing and functioning · Appetite · Any nutritional or health problems Dietary Practice · 24- hour Dietary recall of food intake and related problems · Occurrence of drug/food related interactions · Clinical (in relevant settings): Clinical assessment for signs of malnutrition 7.8.1.2 Counselling The key Issues for Nutritional Counselling of PLHIV should be based on the principles of PHDP. They should be provided with information on: · Good dietary practices including information about food groups, balanced diets, local dietary options etc. · Positive Health Dignity and Prevention (PHDP) practices including: o Water and Sanitation Hygiene (WASH) o Food hygiene o Safe storage, preparation and preservation of animal products, fruits and vegetables o Smoking and alcohol use o Opportunistic infections o Family planning and child spacing o Lifestyle modification including exercise, o Support group membership o Positive mental attitude · Awareness and prevention of food/drug interactions and how to prevent or minimize side effects of medications and herbal remedies. o Note instructions on drug/BMS packaging. o Consult relevant health professionals when queries arise. · Attend conferences, seminars meetings and workshops where issues on HIV/AIDS& AIDS are been discussed · PLHIV need IEC materials that address dietary issues For complicated or specialized dietary issues requiring medical nutrition therapy, Please consult the dietician. 7.9 OUTCOMES OF ASSESSMENT 7.9.1 Anthropometric Categories of anthropometric assessment · Undernourished/underweight · Normal · Overweight 24 National Guidelines on HIV/AIDS Care and Support 2014 Assessment outcome BMI <18.5 (Underweight) 18.5 24.9 (Normal) 11.5-12cm (Normal) 25 – 29.9 >30 (Overweight) (Obese) >40 (Morbidly obese) MUAC <11.5cm >13cm (Under (Underweight) (Overweight) 5) MUAC <23cm (Pregnant (Underweight) Women) Table 3: Outcome of Anthropometric Assessment 7.9.2 Nutritional Literacy Poor Nutritional Literacy is defined as the inability to understand the importance of good nutrition in maintaining health. 7.9.3 Referral criteria PLHIV assessed and identified to be clinically undernourished will meet the following criteria: · Adult BMI< 18.5 · Children under 5 (MUAC) < 11.5cm · Pregnant women (MUAC) <23cm 7.10 NUTRITIONAL SUPPORT FOR PLHIV Support includes but not limited to the following: · Goal setting/Planning · Food demonstration using locally available food options · Innovative agricultural practices like kitchen gardens, food banks etc. · Food rehabilitation using Ready-To-Use therapeutic foods for severe malnutrition, food supplies from CBO's etc. · Follow up. · Referral and linkage (in cases of malnutrition, food insecurity: - food not readily available for the family e.g. less than on regular meal per day.) 25 National Guidelines on HIV/AIDS Care and Support 2014 CHAPTER 8: MONITORING AND EVALUATION OF CARE AND SUPPORT SERVICES 8.1 Introduction onitoring and Evaluation (M&E) is an essential component of HIV/AIDS Care and Support activities. The overall purpose of monitoring and evaluation is to measure programme results at all levels and guide toward achieving the goals and strategic objectives. Information obtained through M&E can be used to demonstrate to programme managers and policy makers that programme efforts had measurable effects and inform future programming/planning. M Monitoring is a routine process used to verify step-by-step progress of the programme at various levels to see whether activities are being implemented as planned, ensuring accountability, and identifying successes and challenges related to the intervention activities. It also provides resources for evidencebased planning through timely feedback to relevant authorities. Monitoring is best carried out using well-defined indicators meant to measure the input, process, and outputs of the intervention. Evaluation is carried out periodically to determine and document the extent to which results are attributable to the intervention, measured through the outcome and impact indicators. It is concerned with identifying reasons for success and failure of a programme. It addresses future options, challenges, strategies and priorities for the continuous process of development. Monitoring and Evaluation involves the collection, collation, analyzing, report writing and feedback on various thematic activities. The feedback provides information for informed policy development, guidelines and implementation of the programme. 8.2 Responsibility for Monitoring and Evaluation Activities The Federal Ministry of Health (FMOH) will maintain the central management information system database and provide technical assistance to the states, health facilities and CBOs for continuous monitoring of the HIV/AIDS Care and Support programme. NACA has the responsibility of coordinating the adaptation, development and review of the guidelines, indicators and data capturing tools (DCT) that guide the collection of HIV/AIDS Care and Support data at various levels. HIV/AIDS Care and Support data reporting will follow the national data flow and reporting timelines as stipulated in the National Health Information System Policy. Process evaluations will be conducted periodically to assess the quality of HIV/AIDS Care and Support implementation at all levels. The overarching purpose of process evaluation is to guide programmatic implementation and aid in appropriate redirection of human resources and commodities to meet the national targets. Evaluation of the level of implementation and quality of services will focus on the ability of all facilities and CBOs to meet the minimum service delivery and reporting requirements. Targeted evaluations and other operational research (OR) including complex analysis of the routine Care and Support data will be used to periodically evaluate the effectiveness of services and intervention outcomes and impact in Nigeria. Some of the areas of interest include but not limited to: · HIV/AIDS retention of care, · HIV/AIDS related stigma and discrimination. These evaluation activities will be conducted by the FMOH in collaboration with other stakeholders and implementing partners. 26 National Guidelines on HIV/AIDS Care and Support 2014 8.3 Data Quality The Federal Ministry of Health will ensure all implementing sites are provided with the National Monitoring and Evaluation tools: · Registers (see Annexes) · Summary forms (see Annexes) · Standard Operating Procedure (SOP) · Guidelines and Training Manuals For proper completion of the registers and forms at the sites, the Federal Ministry of Health and other stakeholders shall provide trainings at all levels (National, State, LGA, health facility and CBO) on appropriate data collection and reporting system which feed into the National Health Information System. Quality assurance, quality control and quality improvement mechanisms will be disseminated to health facilities and CBOs. The heads of the health facilities and CBOs will be responsible for: · Ensuring an internal routine check of the registers being completed by the site team · Providing regular supportive supervision and mentoring to the site team completing the registers and monthly summary forms. Using a standardized data quality checklist, a systematic plan for periodic external data quality assurance (DQA) check will be conducted by the Federal/State/Local Government Ministry of Health and other stakeholders. This will ensure data availability, consistency and validity. The on-site activities during DQA should: · Check for the availability of the registers and monthly summary forms · Review of site registers and summary forms for completeness and accuracy · Check for the availability and use of guidelines and SOP · Check patient and data flow The FMOH or SMOH in collaboration with relevant stakeholders should conduct monitoring and supervisory visits quarterly and DQA at least twice every year using a standardized checklist. At each of the visits, onsite mentoring and supportive guidance should be provided. At the end of the M & E visits, feedback should be provided to the entire site team. 8.4 DATA COLLECTION AND REPORTING TOOLS In order to adequately capture the indicators mentioned above, and monitor the Care and Support programme, the following DCTs were developed for recording and reporting Care and Support services. · National Care and Support Enrollment Form · National Care and Support Community Screening Checklist · National Care and Support Service Form · National Care and Support Service Register · National Care and Support Summary Form 8.5 SUPPORTIVE SUPERVISION There will be regular local, state and national M & E supportive supervision for all Care and Support services in Nigeria. This ensures that data collected on HIV/AIDS Care and Support programmes in Nigeria are valid, consistent, accurate, timely and reliable for informed programme decision-making. A system to periodically monitor the quality of Care and Support services and data will be developed by all local programs and monitored by external resource persons (designated as Site Support 27 National Guidelines on HIV/AIDS Care and Support 2014 Supervisors) at the LGAs, State, and National level. A National Care Quality process will be developed to address quality issues. During each on-site supportive supervision visit, the standardized Care and Support checklist will be applied to review the services and data collection process. This in-depth review will ensure identification of inconsistencies in data collection; collation and transmission to the next level of data flow and serve as an opportunity for on-site capacity building process for the service providers. To ensure the effectiveness of this supportive supervision, relevant cadre of health care providers and M & E specialists should be identified and then trained, on how to provide supportive supervision, to Care and Support sites within their locality. At the state and LGA levels, the State AIDS Program Coordinator and LGA Department of Health HIV/AIDS Focal Person should be identified. 8.6 DATA REPORTING AND INFORMATION FLOW Health facilities and CBOs are to summarize all information in the Care and Support registers into the summary forms at the end of every month. The summary forms will be checked and signed by the supervisor before they are submitted to the M & E unit of the LGA health office. The Local Government M & E officer, and the LGA data management team will then enter the data from all the facilities within the LGA into the national database (DHIS) The SMOH will review the data from the LGAs; provide feedback to the LGAs before the database closes. FMOH will analyze all data from the States, write report and provide feedback to all levels. FMOH should share the reports with Implementing partners and other stakeholders at national levels including National Agency for Control of AIDS (NACA). Implementing Partners supporting Care and Support services at various levels are to key into this information flow and strengthen the LGAs and State monitoring mechanism. 28 National Guidelines on HIV/AIDS Care and Support 2014 29 National Guidelines on HIV/AIDS Care and Support 2014 Indicator Level Outcome Sex (male/female) Age (0-5, 5-15; 15+) Pregnant women Proportion of undernourished PLHIV attitudes towards people living with HIV/AIDS Sex (male/female) Age (15-19; 20-25; 25-49) Pre-ART/ ART Sex (male/female) Age (<15; 15+) Proportion of adults and children with HIV/AIDS known to be in care 12 months after enrollment into HIV/AIDS care Proportion of women and men aged 15–49 who report discriminatory Disaggregation Indicator Proportion of women and men aged 15–49 who report discriminatory attitudes towards people living with HIV/AIDS Denominator: number of adults and children who enrolled in HIV/AIDS care who were expected to achieve 12-month outcomes within the reporting period. 3-5 years Annual Annual Proportion of adults and children with HIV/AIDS known to be in care 12 months after enrollment into HIV/AIDScare Numerator: Number of adults and children with HIV/AIDS, still alive and in care 12 months after enrollment into HIV/AIDS care Frequency Definition Appendix 1: Indicator Tables i Population based survey (NDHS) Routine Facility &Community data National Registers (needs to be included in the Monthly Summary form. Data Source 30 National Guidelines on HIV/AIDS Care and Support 2014 Indicator Level Outcome Sex (male/female) Age (<18; 18+) Number of PLHIV provided with a minimum of one clinical service Setting: (Community /Facility) Sex: (male/female) Age: (<18; 18+) Setting (Community /Facility) PLHIV/PABA Sex (male/female) Age (<18; 18+) Number of eligible adults and children (PLHIV& PABA) provided with a minimum of one care service Number of PLHIV provided with minimum package of Positive Health Dignity & Prevention (PHDP) interventions Disaggregation Indicator Numerator: Number of People Living with HIV/AIDS (PLHIV) reached with a minimum Package of Positive Health, Dignity and Prevention (PHDP) Interventions Number of PLHIV reached with a minimum package of prevention interventions and services that include evidence based behavioral and biomedical interventions designed to protect the health of the infected person and reduce the spread of HIV/AIDS to their sex partners and children (PHDP) as defined in the National Care & Support Guideline Numerator: Number of adults and children provided with a minimum of one care service The number of all individuals receiving care services through from facilities and/or Community Based Organizations. An individual should receive at least one care service to be counted. Care service could be clinical, preventive or supportive Definition Appendix 1: Indicator Tables ii Monthly Monthly Monthly Frequency Routine Facility &Community data Routine Facility &Community data Routine Facility &Community data Data Source 31 National Guidelines on HIV/AIDS Care and Support 2014 Indicator Level Setting (Community /Facility) Sex (male/female) Age (<18; 18+) Number of eligible adults and children (PLHIV&PABA) receiving food and/or other nutrition services Setting (Community /Facility) Sex (male/female) Age (<18; 18+) Proportion of clinically undernourished PLHIV identified Setting (Community /Facility) Sex (male/female) Age (<18; 18+) Setting (Community /Facility) Sex (male/female) Age (<18; 18+) Number of People L i v i n g w i t h HIV/AIDS receiving Adherence Support Proportion of clinically undernourished PLHIV who received therapeutic and/ or supplementary food Disaggregation Indicator Numerator: Number of clients who received food and/or nutrition services during the reporting period The number of clients who received supplemental food (for nutritionally vulnerable clients), therapeutic and supplementary food for OVC whose HIV/AIDS status is negative or unknown, food security support and/or nutrition services during the reporting period. Denominator: The number of PLHIV that received anthropometric assessment during the same reporting period Numerator: The number of all PLHIV, including adults, children, and pregnant women and lactating mothers, that were undernourished at any point during the reporting period, The proportion of PLHIV in care and treatment who were identified as clinically undernourished at any point during the reporting period Numerator: Number of People Living with HIV/AIDS receiving Adherence Support Number of People Living with HIV/AIDS receiving Adherence Support Definition Appendix 1: Indicator Tables iii Monthly Monthly Monthly Monthly Frequency Routine Facility &Community data Routine Facility &Community data Routine Facility &Community data Routine Facility &Community data Data Source 32 National Guidelines on HIV/AIDS Care and Support 2014 Setting (Community /Facility) Sex (male/female) Age (<18; 18 Proportion of PLHIV GBV suspects identified Setting (Community /Facility) Sex (male/female) Age (<18; 18 Setting (Community /Facility) Sex (male/female) Age (<18; 18+) Number of PLHIV screened for gender based violence (GBV) Proportion of PLHIV GBV suspects referred for GBV related services Disaggregation Indicator Denominator: Number of PLHIV GBV suspects identified Numerator: Number of PLHIV GBV suspects referred for GBV related services Proportion of PLHIV with a reported episode of gender related violence and or abuse referred for GBV services Denominator: Number of PLHIV screened for gender based violence Numerator: Number of PLHIV GBV suspects identified Proportion of PLHIV assessed for gender violence and or abuse with a reported episode of gender related violence and or abuse Numerator: Number of PLHIV screened for gender based violence The number of PLHIV or assessed for of gender related violence and or abuse Definition Monthly Monthly Monthly Frequency Routine Facility &Community data Routine Facility &Community data Routine Facility &Community data Data Source Note: For Care and Support indicators relating to Vulnerable Children (VCs) please refer to the National VC Guidelines Indicator Level Appendix 1: Indicator Tables iv
