training of mentors on arv therapy

Training of Mentors on Anti Retro Viral Therapy

Fatima Memorial Hospital | Introduction 0

Training of Mentors

on Anti Retro Viral

Therapy

Training Report

Dr. Shabnum Sarfraz Global Fund Project Office Fatima Memorial Hospital, Shadman, Lahore, Pakistan



Contents

Introduction ............................................................................................................................................ 3

Objective of Training ........................................................................................................................... 3

Specific objectives ............................................................................................................................... 3

Desired outcome of the training .......................................................................................................... 3

Selection of Audience .............................................................................................................................. 3

Defining content of Training .................................................................................................................... 4

Selection of Trainers ................................................................................................................................ 4

Training Methodology ............................................................................................................................. 6

Agenda of the Workshop ......................................................................................................................... 7

Work Shop Proceeding ............................................................................................................................ 9

Session Outline .................................................................................................................................... 9

Session 1: The Multidisciplinary Adherence Team Referral Networking to enhance ART Adherence by Dr.

Tayyaba Rashid........................................................................................................................................ 9

Session 2: Demystifying HIV & AIDS - A Global Issue by Prof. Dr. Aman Ullah Khan .................................. 9

Session 3: Overview of individual presentation preparation; Assigning of topics by Dr. Shabnum Sarfraz 9

Session 4: What is Adherence? Identifying Barriers and Facilitators to Adherence by Dr. Noreen Hashmi 9

Session 5: Counseling for ARV Adherence and Psychological Management of PLHIV by Dr. Imran Ijaz

Haider ................................................................................................................................................... 10

Session 6: When to start ARV? What is the first line therapy? When to Switch ART Second and Third line

Regimen? by Dr. Ashraf Ali Khan ............................................................................................................ 10

Session 7: Managing the side effects and complications during ARV Therapy Lab Monitoring by Dr.

Ashraf Ali Khan ...................................................................................................................................... 10

Session 8: ART for HIV/Tuberculosis co-infection by Dr. Faisal Sultan ..................................................... 10

Session 9: ART for HIV/HBV co-infection by Dr. Faisal Sultan ................................................................. 10

Session 10: PPTCT- District Model- An overview by Dr. Saira Azhar ....................................................... 11



Session 11: ART for Pregnant Women by Dr. Hammad Nazeer .............................................................. 11

Session 12: Microteach and discussions ................................................................................................ 11

Objective ........................................................................................................................................... 11

Topics of Microteach ......................................................................................................................... 12

Evaluations and Panel of Evaluators ................................................................................................... 12

Top five Mentors ............................................................................................................................... 13

Comments of Participants ..................................................................................................................... 14

Annexure............................................................................................................................................... 15

Annexure 1: List of Participants ......................................................................................................... 15

Annexure 2: Trainer’s Evaluation Form .............................................................................................. 16

Annexure 2: Trainer’s Evaluation Form .............................................................................................. 16

Annexure 3: Pictures.......................................................................................................................... 17



INTRODUCTION

Objective of Training

The Training of Mentors is primarily focused on developing Mentors of Anti Retro Viral Therapy who can

then further train health care providers on ART, acting as individual knowledge centers. The workshop

also attempts at building a network/ liaison of health care providers who are experts in ART.

Specific objectives

This three-day intensive training covers all aspects of ARV Therapy. By the end of this training,

participants will be expected to have knowledge of following topics:

1. When to start ARV

2. What is the first line therapy?

3. When to switch ART-Second and Third line Regimen

4. Managing the side effects and complications during ARV Therapy

5. Laboratory monitoring

6. ART for HIV/tuberculosis co-infection

7. ART for HIV/HBV co-infection

8. ART for Pregnant Women

9. Counseling for ARV Therapy

Desired outcome of the training

At the end of this three-day training, the participants are expected to come out as Mentors of ART,

equipped with the right knowledge, tools and material to take up further trainings of health care

providers. They also have a network of ART expert specialists to fall back upon and refer to, should the

need present itself.

SELECTION OF AUDIENCE


Fatima Memorial Hospital | Defining content of Training 4

A stringent criterion was established, in order to ensure that only capable, qualified and sincere

participants make it to the final workshop. The participants were required to have a background in

medicine and/or allied sciences, a post-graduate degree or diploma and preferably some experience in

HIV/AIDS. Invitations were sent to the Principle’s Offices in Medical colleges all over Pakistan, Heads of

Nursing institutions and health academies, and the CHBC centers. The final participants included Senior

Doctors and Nursing Staff, belonged to the Public and Private Sector Health Institutions (Annexure: 1 List

of Participants).

DEFINING CONTENT OF TRAINING

Since the program was meant to inculcate the latest and most appropriate knowledge on management

of an HIV-positive patient, through the stages of HIV to AIDS, the content was designed to provide a

holistic approach towards the management of PLHIV and hence included the following areas:

i. In-depth knowledge of the HIV regimens

ii. In-depth knowledge about second and third line regimens, times and indications to switch

iii. Management of side effects and complications during ART

iv. ART treatment along with the co-infections

v. Specific treatment of Anti Retroviral Therapy for Pregnant Women

vi. Role of counseling of PLHIVs

vii. Need of Adherence in PLHIVs

SELECTION OF TRAINERS

The intensive 3 days Training of Mentors on Anti Retroviral Therapy required leading experts from the

Infectious Diseases background with hands on experience of managing PLHIVs and may have spoken

about HIV and ARV on various forums. After an extensive research, Fatima Memorial Hospital managed

to arrange the following trainers:

Dr. Faisal Sultan, CEO & Consultant, Shaukat Khanum Memorial Cancer Hospital & Research Center

MBBS, Diplomate American Board of Internal Medicine & Infectious Disease


Fatima Memorial Hospital | Selection of Trainers 5

Dr. Faisal Sultan is currently working as the Chief Executive Officer and Consultant at SKMCH&RC. He

is one of the leading names among Infectious Diseases experts in Pakistan. At the moment, he is

actively involved in managing PLHIVs associated with a CHBC Center in Lahore.

Dr. Syed Hammad Nazeer, Consultant, Shaukat Khanum Memorial Cancer Hospital & Research Center


Dr. Hammad is a Consultant Infectious Diseases at SKMCH&RC with hands on experience of

managing PLHIVs with specific interest in managing Pregnant Women on ART. Before SKMCH&RC,

he had been associated with Fatima Memorial Hospital in a similar capacity.

Dr. Ashraf Ali Khan, Consultant, Shaukat Khanum Memorial Cancer Hospital & Research Center


Dr. Ashraf Ali Khan is working as Consultant at the Internal Medicine Department in SKMCH&RC. He

has extensive experience of both managing in PLHIVs here and back in USA.

Dr. Noreen Rahat Hashmi, Head - Community Medicine Department, Rahbar Medical & Dental College

MD, Diplomate American Board of Internal Medicine, MPH

Dr. Noreen Rahat Hashmi is an expert of Internal Medicine and has dealth extensively with PLHIVs in

the US during her tenure as Internist as John Hopkins. She has recently moved to Pakistan and is

currently serving Rahbar Medical & Dental College as the HOD for Community Medicine

Department.

Prof. Dr. Aman Ullah Khan, Technical Advisor, Nur Center for Research & Policy

B.Sc., MBBS, DPH, MPH & TM, FCPS, PhD, FRSTM&H, FAPHA

Prof. Dr. Aman Ullah Khan has served as the dean of College of Physician and Surgeons of Pakistan

before joining Fatima Memorial Hospital. He has also served as the Professor of Institute of Public

Health Pakistan. He has been involved in miscellaneous research activities on HIV/AIDS in Pakistan

and abroad. He is the author of many publications.

Dr. Tayyaba Rashid, Treatment Coordinator, Punjab AIDS Control Program

MBBS


Fatima Memorial Hospital | Training Methodology 6

Dr. Tayyaba Rashid is the lead facilitator of all the activities of Punjab AIDS Control Program. She is

currently working on the model of multidisciplinary adherence through teams and referral

networking to enhance ART adherence in liaison with all the ART Centers in Punjab.

Dr. Imran Ijaz Haider, Associate Professor, Head of Psychiatry Department, Fatima Memorial Hospital

MBBS, DPM, MRCP

Dr. Imran is the clinical psychiatrist at Fatima Memorial Hospital and one of the key people to set up

an independent psychiatry unit. He is an expert in his area with hands on experience of managing

PLHIVs.

Dr. Saira Azhar, PPTCT Coordinator, Services Hospital Limited

MBBS

Dr. Saira is the PPTCT Coordinator on behalf of Punjab AIDS Control Program. She is responsible for

the effective implementation of PPTCT model throughout the Punjab.

TRAINING METHODOLOGY

The training sessions were interactive and participants were encouraged to reflect on the concepts and

knowledge shared by the veteran trainers. With two and half days packed with these sessions, the latter

half of the third day focused on micro presentations by the participants. The participants were allocated

topics via blind balloting on the first day of the workshop, and briefed on the rules to follow. On the last

day, they had to present their topics to a panel of seasoned professionals and they were judged on the

basis of relevance, organization, preparation, class room presence and effectiveness. The ratings by the

panel of judges were tabulated in real time, with the results being revealed right after the last

participant’s presentation. On the basis of this evaluation the top five Mentors were chosen.


Fatima Memorial Hospital | Agenda of the Workshop 7

AGENDA OF THE WORKSHOP

Day One: Friday October 5 2012

First day focused on ‘Basic Information on Adherence and ARV Therapy’

Session Name Time Facilitator

(Name and Qualification)

Inaugural Ceremony and Group Photograph 9:00 –10:00 am

Session #1: The Multidisciplinary

Adherence Team

Referral Networking to enhance ART

Adherence

10:00 –11:00 am Dr. Tayyaba Rashid

Tea/Coffee Break 11:00 –11:30 am

Session #2: Demystifying HIV & AIDS - A

Global Issue 11:30 –12:45 pm Prof. Dr. Aman Ullah Khan

Jumma Prayers + Lunch 12:45 - 02:30 pm

Session #3: Overview of individual

presentation preparation;

Assigning of topics

02:30 –03:00 pm Dr. Shabnum Sarfraz

Session #4: What is Adherence?

Identifying Barriers and Facilitators to

Adherence

03:00 –04:00 pm Dr. Noreen R. Hashmi

DAY TWO: Saturday October 6 2012

Second day focused on Management of Patients on ARV Therapy

Session #5: Counselling for ARV Adherence

and Psychological Management of PLHIV 09:00-10:00am Dr. Imran Ijaz Haider


Fatima Memorial Hospital | Agenda of the Workshop 8

Session #6: When to start ARV? What is

the first line therapy? When to Switch ART

Second and Third line

Regimen?

10:00-11:25am Dr. Ashraf Ali Khan

Tea Break 11:25-11:45am

Session #7: Managing the side effects and

complications during ARV Therapy Lab

Monitoring

11:45-01:00pm Dr. Ashraf Ali Khan

Lunch Break 01:00-02:00pm

Session #8: ART for HIV/Tuberculosis co-

infection 02:00-03:00pm Dr. Faisal Sultan

Tea Break 03:00-03:10pm

Session #9: ART for HIV/HBV co-infection 03:10-04:00pm Dr. Faisal Sultan

Day 3: Sunday October 7 2012

Third Day Focused on ARV Therapy in Pregnant Women and Children and

Participant Evaluation for mentorship

Session #10: PPTCT- District Model- An

overview 10:00-11:15am Dr. Saira Azhar

Tea Break 11:15 am -11:30 am

Session #11: ART for Pregnant Women 11:30-01:00pm Dr. Syed Hammad Nazeer

Session #12: Microteach and discussions

02:00-03:30pm

Panel of Evaluators

Dr. Haroon Ihsan, Dr. Ali Razaque

and Ms. Maha Rehman

Certificate distribution and Closing Ceremony 03:30-04:00pm


Fatima Memorial Hospital | Work Shop Proceeding 9

WORK SHOP PROCEEDING

Session Outline

SESSION 1: THE MULTIDISCIPLINARY ADHERENCE TEAM REFERRAL NETWORKING

TO ENHANCE ART ADHERENCE BY DR. TAYYABA RASHID

The session primarily highlighted various aspects of ART adherence with respect to team referral

networking. The role of adherence support workers was emphasized upon. Their role in improvement of

patient adherence, knowledge, and understanding; provision of education and counselling in the

patient's own language allows nurses and doctors to focus on other technical and clinical aspects of the

patients’ treatment.

SESSION 2: DEMYSTIFYING HIV & AIDS - A GLOBAL ISSUE BY PROF. DR. AMAN

ULLAH KHAN

The session focused on the global and local spread of the disease todate. The disease stages along with

the modes of transmission were also discussed briefly. The stigmas associated with PLHIVs were also

shared in detail and the ways to remove such taboos were identified.

SESSION 3: OVERVIEW OF INDIVIDUAL PRESENTATION PREPARATION;

ASSIGNING OF TOPICS BY DR. SHABNUM SARFRAZ

This was a short session outlining the guidelines and rules for the micro teach presentations. The topics

for individual presentations were assigned to the participants via blind balloting. It further detailed

about the expectations of the panel of evaluators and the outcome i.e. selection of five participants as

Mentors for further trainings of Health Care Providers.

SESSION 4: WHAT IS ADHERENCE? IDENTIFYING BARRIERS AND FACILITATORS TO

ADHERENCE BY DR. NOREEN HASHMI

The session primarily focused on the importance of level of commitment towards adherence and the

consequences in case of non-compliance. Effective strategies to encourage adherence and ways to

counsel patients about adherence were also discussed in detail. Adherence issue of PLHIVs in Pakistan



were also a part of discussion. The session included a group activity where participants were asked to

present on various dimensions of ARV adherence and counselling.

SESSION 5: COUNSELLING FOR ARV ADHERENCE AND PSYCHOLOGICAL

MANAGEMENT OF PLHIV BY DR. IMRAN IJAZ HAIDER

The psychological management of PLHIVs were brought up for discussion in this session. The trainer

shared the counselling aspects like listening, respect for the client, confidentiality, questioning, self

decisions and help for other services, in relation to PLHIVs. The confidentiality and privacy of a PLHIV

was also discussed at length.

SESSION 6: WHEN TO START ARV? WHAT IS THE FIRST LINE THERAPY? WHEN

TO SWITCH ART SECOND AND THIRD LINE REGIMEN? BY DR. ASHRAF ALI KHAN

The session conferred evidence-based recommendations for ARV Therapy, identification of most

effective first-line, 2nd line and subsequent regimens. The time of initiation of treatment and the

importance of careful decision making for ARV initiation with evidence based timing and regimen

selection were also discussed. The access of ARV Therapy in low-income countries like Pakistan was also

the part of the session.

SESSION 7: MANAGING THE SIDE EFFECTS AND COMPLICATIONS DURING ARV

THERAPY LAB MONITORING BY DR. ASHRAF ALI KHAN

The clinical and laboratory monitoring of drugs, important toxicities, complications and adverse effects

of ARV Therapy was the core of this session. Management of drug toxities were also shared by the

trainer in detail.

SESSION 8: ART FOR HIV/TUBERCULOSIS CO-INFECTION BY DR. FAISAL SULTAN

This session was primarily focused on HIV/TB co-infection as TB is responsible for 13% of deaths in HIV

patients. The progression of HIV infection from latent to active TB was discussed in detail along with the

clinical approach of TB co-infected PLHIV. The application of latest drug regimens for such co-infection

was shared.

SESSION 9: ART FOR HIV/HBV CO-INFECTION BY DR. FAISAL SULTAN



The session aimed for the finding of HIV/HBV co-infection. The aspects of counselling the patient for

avoidance of alcohol, vaccination against hepatitis A (if not immune), advice on methods to prevent HBV

transmission and evaluate severity of HBV infection was the main highlights of this session. The

recommended testing for such co-infected patients was also discussed in detail along with the latest

regimens for treatment.

SESSION 10: PPTCT- DISTRICT MODEL- AN OVERVIEW BY DR. SAIRA AZHAR

This session focused PPTCT - District Model as the common modes of HIV/AIDS spread in females were

the point of discussion. The trainer further elaborated about the functioning and impact of PPTCT –

District Model adapted by Punjab AIDS Control Program in Punjab Province. The achievements to date of

this model were also shared.

SESSION 11: ART FOR PREGNANT WOMEN BY DR. HAMMAD NAZEER

The session emphasised upon the goals of Anti Retroviral Therapy to prolong life and improve quality of

life, to suppress HIV below the limits of detection or as low as possible and to preserve or restore

immune function with a special consideration on pregnant women. The prevention of mother to child

transmission was discussed in detail along with the latest/suggested regimens of drugs for treatment

purposes.

SESSION 12: MICROTEACH AND DISCUSSIONS

This was the culmination of the workshop, where each participant presented on a topic allocated to

him/her on day 1 of the workshop.

Objective

The primary motive of the Microteach was to:

a. Give each participant a taste of being a trainer

b. Increase the interest of the participants in the workshop

c. Understand the grasp of each participant over the area he/she was allocated to present on.

The underlying objective was to see the comfort level of each participant with the position/role of a

facilitator, the potential to take up future workshops in the capacity of a trainer and the

effectiveness of the participant as a presenter.



Topics of Microteach

Name Topic

Dr Haroon Abbas HIV/AIDS- An Introduction

Mr Afsar Ali The Psychological impact of HIV/AIDS on Individual, Society and Family

Dr Misbah ul Arfeen Brief Introduction to ART

Dr Atif Masud When to Start ART

Dr Bushra Sana First Line ART

Dr Fatima Rahman Second and Third Line ART

Dr Inam ul Haq Managing Patients with HIV TB Co Infection

Dr Khalid Mahmud Managing Patients with HIV Hepatitis Co Infection

Ms. Saba Watto Nursing Care for patients on ART

Dr Bushra Phool Pregnancy and ART

Dr Safia Khan Patient Follow-up and Monitoring ART

Dr Ayesha Nauman Basics of Adherence

Dr Shehnila Zafar Drug Adherence and Strategies for Compliance

Dr Fatima Imran ARV Medications in Pakistan

Evaluations and Panel of Evaluators

Presentation Evaluation was done in the latter half of the third day. Following expert judges were part of

the panel of evaluators.

Dr. Ali Razaque (Senior Project Officer, PACP)

Dr. Haroon Ihsan (CEO, NCRP)

Ms. Maha Rehman (Technical Advisor, NCRP)



Top five Mentors

Top five participants were to be chosen as the Mentors for further trainings of Health Care Providers. On

the basis of the criteria mentioned earlier, five of the fourteen were awarded Mentor of the training

certificates.

86 78

72 66 66 64 60 59

54 53 53 51 46 44


Fatima Memorial Hospital | Comments of Participants 14

COMMENTS OF PARTICIPANTS

Following are the comments of the participants on the concluding day, collected anonymously:

This workshop should have been over

two days and should have a more

detailed session about HIV

basics/clinical symptoms and

diagnostics involved. Videos from real

life interaction of HIV patients and

doctors can also be the part of this

training

Good and valuable experience

Excellent way to express a boring

looking topic but I enjoyed a lot

regarding post lunch session ... a

participant’s comment about Dr.

Noreen R. Hashmi session on October

5, 2012

Overall the workshop was

informative and productive


Fatima Memorial Hospital | Annexure 15

ANNEXURE

Annexure 1: List of Participants

Name Designation Department Organization

Dr Atif Masood Senior Registrar Medicine Sir Ganga Ram Hospital

Dr Ayesha Nauman Consultant Gynaecology Fatima Memorial Hospital

Dr Bushra Phool Senior Registrar Gynaecology Fatima Memorial Hospital

Dr Bushra Sana Assistant Professor Medicine Sir Ganga Ram Hospital

Dr Fatima Imran Senior Registrar Paediatrics Fatima Memorial Hospital

Dr Fatima Rahman Post Graduate Trainee Paediatrics Services Hospital Limited

Dr Haroon Abbas PG Trainee Medicine Fatima Memorial Hospital

Dr Inam-ul-Haq In charge Special Clinic Medicine Mayo Hospital Limited

Dr Jamal Nasir Counselor Medicine Treatment Center, Children Complex

Dr Khalid Mahmud Khan Associate Professor Medicine Sir Ganga Ram Hospital

Dr Misbah ul Arfeen Senior Registrar Family Medicine Fatima Memorial Hospital

Dr Safia Khan Senior Registrar Paediatrics Fatima Memorial Hospital

Dr Shehnila Zafar Senior Registrar Gynaecology Fatima Memorial Hospital

Mr Afsar Ali Nursing Instructor Nursing Saeeda Waheed FMH College of Nursing

Ms Saba Watto Nursing Instructor Nursing Saeeda Waheed FMH College of Nursing



Annexure 2: Trainer’s Evaluation Form

TRAINERS EVALUATION FORM

Training Title: Training of Mentors Dates: October 5, 2012

Venue: Conference Room, 4th Floor, FMH College of Medicine & Dentistry, Shadman, Lahore

We are interested in developing and honing the training for future use.

Please take a minute to rate Dr. XYZ as a trainer.

Statement Strongly

Agree Agree Disagree

Strongly

Disagree

The trainer was knowledgeable about the subject

The trainer was well-prepared about the subject

Explanations were clear and concise

The trainer solicited questions and had the answers

The trainer was interested in sharing information and knowledge

The trainer’s presentation style was interesting and effective

The trainer motivated, inspired and instilled confidence

Comments if any:

Training Training of Mentors on Anti Retro Viral Therapy

Venue Fatima Memorial Hospital, Lahore

Date October, 2012



Annexure 3: Trainers’ Evaluation Actual

0

5

10

15

The trainer wasknowledgeable

about thesubject

The trainer waswell-prepared

about thesubject

Explanationswere clear and

concise

The trainersolicited

questions andhad the answers

The trainer wasinterested in

sharinginformation and

knowledge

The trainer’s presentation

style was interesting and

effective

The trainermotivated,

inspired andinstilled

confidence

Dr. Tayyaba Rashid

Strongly Agree

Agree

Disagree

Strongly Disagree

0

5

10

15


about thesubject


about thesubject


concise





knowledge



effective



confidence

Dr. Aman Ullah

Strongly Agree

Agree

Disagree

Strongly Disagree

0

5

10

15


about thesubject


about thesubject


concise





knowledge



effective



confidence

Dr. Noreen R. Hashmi

Strongly Agree

Agree

Disagree

StronglyDisagree



0

5

10

15


about thesubject


about thesubject


concise





knowledge



effective



confidence

Dr. Imran Ijaz Haider

Strongly Agree

Agree

Disagree

Strongly Disagree

0

5

10

15


about thesubject


about thesubject


concise





knowledge



effective



confidence

Dr. Ashraf Ali Khan

Strongly Agree

Agree

Disagree

Strongly Disagree

0

5

10

15

The trainer wasknowledgeable about

the subject

The trainer was well-prepared about the

subject

Explanations were clearand concise

The trainer solicitedquestions and had the

answers

The trainer wasinterested in sharing

information andknowledge

The trainer’s presentation style was

interesting and effective

The trainer motivated,inspired and instilled

confidence

Dr. Faisal Sultan

Strongly Agree

Agree

Disagree

Strongly Disagree



0

5

10

15


about thesubject


about thesubject


concise





knowledge



effective



confidence

Dr. Saira Azhar

Strongly Agree

Agree

Disagree

Strongly Disagree

0

5

10

15


about thesubject


about thesubject


concise





knowledge



effective



confidence

Dr. Syed Hammad Nazeer

Strongly Agree

Agree

Disagree

Strongly Disagree

0

5

10

15

Objective of thistraining programadequately met

Subject matter wasappropriate for

your backgroundand experience

Training will greatlyassist you in your

profession/area ofwork

Training sessionduration was

adequate to coverall relevantmaterials

Participants wereencouraged to

share informationand experiences

Facillitator(s) havegood presentation

skills/styles,knowledge and

grip over thesubject

Training Program/workshop

Strongly Agree

Agree

Disagree

Strongly Disagree

training of mentors on arv therapy

Documents

objective of training

content of training

training methodology

session outline

pakistan training of

arv adherence

line therapy

art adherence