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Overall Responsibilities

• Build the capacity of case management officers and health facility focal persons to proficiently Identify and enrol eligible clients into the HIV case management model, counselling and psychosocial support, management of virally non-suppressed clients, documentation and updating of patient information in the appropriate registers and HIV care cards and graduating eligible patients from HCM to appropriate DSDM.

• Activities

• Identify site level case management teams

• Orient case management team on case management model, counselling and psychosocial support, DSDM, Management of non-suppressed clients and documentation using the recommended MoH tools/audit trackers.

• Conduct continuous mentorships and coaching on case management including counselling

• Provide counselling and case management tools to track case management services

Support health facilities to implement the YAPS and other similar model to improve HIV prevention and treatment outcomes among Adolescents and Young People (AYP)

Activities

• Identify YAPS for training

• Mentor YAPS on YAPS activity

• Facilitate HFs and YAPS to implement YAPS program

• Hold quarterly district level YAPS activity progress review meetings

• Provide tools for documenting YAPS activities

Provide technical guidance to health facility teams in the utilisation of the HIV case management platform for expanding Index HIV testing, VL testing, AHD screening, TPT initiation as well as increasing uptake of MMD and community DSD models.

Activities

• Orient health facility teams on the efficient use of the HIV case management platform

• Offer ongoing technical support to address any challenges or questions related to the platform's use

• Assisting health facilities to have line lists for clients due for VL, CD4/Serum Crag/TB lam, index testing and optimize VL/CD4/ Index testing procedures to monitor HIV treatment effectiveness

• Monitor and evaluate the progress and outcomes of these activities, and make necessary adjustments based on the results

Support health facilities to conduct and coordinate health education sessions to enhance HIV ART literacy, improve retention in HIV care, adherence to ART and increase awareness about AHD screening and management

Activities

• Collaborate with health facility staff to develop a comprehensive health education schedule and topics tailored to the needs of patients

• Orient Case management team (CMOs, HWs) on effective methods of delivering health education sessions

• Create educational materials to support the health education sessions

• Support health facilities in implementing Advanced HIV disease (AHD) screening, diagnosis, and management guidelines.

• Activities

• Liaise with TB/HIV officers to orient Case management officers and HWs on the AHD screening, diagnosis, and management

• Ensure that the AHD guidelines are readily available and accessible to healthcare providers

• Work with TB/HIV officers to Offer technical support to healthcare staff in the facilities to address AHD work related challenges

• Routinely Monitor and report on site level AHD provision services

Support Case Management officers in facilitating the convening of multi-disciplinary health facility teams to discuss and develop individualized care plans for problem ART clients, and monitor the implementation of these plans

Activities

• Liaise with care and treatment specialists to Functionalise switch committees

• Build capacity of the switch committees to efficiently discuss clients eligible for switching

• Initiate QI projects to monitor progress of switching

• Provide HFs with case conferencing tools to document discussions and decisions made on switching

Support HFs to schedule regular case conferencing meetings

• Support district mentors and coaches in the roll out and continued use of Audit trackers for children and adolescents, the virally non-suppressed, Newly diagnosed HIV positives, Missed appointments, TB cases and HIV positive Pregnant and Breast-Feeding Women (PBFW).

• Activities

• Orient district mentors and coaches on the use of care audit

• Collaborate with district mentors and coaches to plan and rollout the audit trackers

• Assess and regularly monitor the utilization of the audit trackers and provide ongoing technical assistance

Support Health facility teams to implement and document QI projects on HIV case management.

Activities

• Collaborate with HF Case management teams to identify specific areas that need improvement

• Help establish multidisciplinary QI teams within the health facility

• Monitor the progress of the initiated QI projects

• Guide the health facility teams in implementing QI interventions on a broader scale based on the findings

  
  

Support HFs in implementing HIV peer support interventions

Activities

• Plan and budget for peer support group meetings

• Facilitate HFs to conduct caregivers’ and adolescent peer support meetings

• Build the capacity of HFs to conduct outcome driven peer support group meetings