I Course Title: Comprehensive Care Management for Pediatric and Adolescent living with HIV/AIDS”

II  Duration: 20-31 March (10 days)

III Closing date for application: 23 January 2017 IV Rationale

From the onset of the HIV/AIDS epidemic children around the world have been directly and indirectly affected by the disease. The WHO (2011) has warned that hundreds of thousands of children across the world become infected with HIV every year. In 2010, an estimated 2.7 million people around the world were newly infected with HIV, of which as estimated 390,000 were children. In Thailand, children under 15 years have been increasingly affected by this potentially fatal sickness. Considering only this age group, from September 1984 to February 28, 2011 there were 18,057 cases of accumulative AIDS reported in Thailand (Bureau of Epidemiology, 2011). The exact number of children infected with HIV is assumed to be much higher than the reported cases. In the adolescent period, the report shows that there are an estimated 2.1 million adolescents were living with HIV globally in 2012. Between 2005 and 2012, HIV-related deaths among adolescents increased by 50%.

 Once children are infected with HIV, they experience with tremendous life threatening and suffering conditions caused by the disease itself as well as their growth and development. HIV infected children are more likely to progress to full-blown AIDS quicker than adult. On the other hands, adolescent HIV-related deaths is due primarily to poor prioritization of adolescents in national HIV plans, inadequate provision of accessible and acceptable HIV testing and counseling (HTC) and treatment services, and lack of support for adolescents to remain in care and adhere to antiretroviral therapy (ART). They are also highly vulnerable to opportunistic infections and often respond poorly to immunization and treatment for other common childhood illnesses. As a result, many of them have a greater chance of

life-threatening illness and death, unless they can successfully be provided with comprehensive management on treatment and care.

 Currently, the development of the special treatment and care for children and adolescent who are living with HIV/AIDS is globally challenging. In Thailand, about half of HIV-infected children receiving antiretroviral therapy (ART) in pediatric HIV clinics were 13 years old or older. The HIV-infected adolescent population comprises a mixed group of 1) perinatally infected adolescents who are now surviving into adulthood, and 2) behaviorally infected adolescents, most of whom were infected sexually. In recent years, many perinatally HIV-infected adolescents have begun to reach adulthood, giving rise to several challenges and concerns among pediatric and adult specialists. Firstly, as HIV-infected adolescents grow into adulthood, it becomes necessary for them to transfer to adult care settings, take responsibility for their own health, and develop life goals. To provide efficiency and quality of care to lessen the suffering of these pediatric, adolescent and their families, it is required that physicians, nurses, and other health care providers working with this population need to receive a specific training.

 For this reason, the International Training Center on AIDS, TB and STIs (ITC), Bureau of AIDS, TB and STIs, Department of Disease Control, Ministry of Public Health, Thailand, has developed the international training course curriculum entitled “The International Training

 Course on Comprehensive Care Management for Pediatric and Adolescent living with HIV/AIDS” in order to serve for those demands. Many experts from international agencies, academic institute, regional and provincial hospital and Department of Disease Control transferred their experiences to assist ITC to develop this curriculum. The curriculum is developed based on the needs of countries facing problems with HIV pediatric and adolescent care by using model development and implementing at Siriraj hospital, Chiangrai Prachanukroh hospital (Chiang Rai), Srinakarind hospital (Khon Kaen) and Prajomklao Petchburi hospital (Petchburi) which is a recommended good practices of Pediatric and Adolescent Living with HIV/AIDS Care model in Thailand. Using this comprehensive HIV pediatric and adolescent care model has improved the adherence and quality of life of children and adolescent receiving ARV. Also, the curriculum will provide a good understanding on the management for adolescent living with HIV in terms of key interventions to address HIV problems among youth, and major component of youth friendly services, ARV care and treatment for children and adolescent including its common problems, intervention of treatment adherence, psychosocial aspects, HIV pediatric

disclosure, technique in communication and counseling and assessment the behavioral problems in adolescence living with HIV.

Thailand has been considered as a global learning hub on HIV/AIDS for years. As ITC is a training center which is a unit of Bureau of AIDS, TB and STIs under the Department of Disease Control, it works closely with both local and international experts on HIV, TB and STIs. The ITC regularly organizes 5 – 6 international training courses every year. So, the ITC is well equipped to organize this training course smoothly. Since ITC has a professional academic partnership such Faculty of Medicine Siriraj Hospital, Mahidol University where is the oldest and largest medical school in Thailand, this course will fulfill with high-quality and effectiveness.

 The course has been designed to strengthen capacity of health professionals to effectively address the needs of children and young people living with HIV, as well as, it aims to enhance public health management and provide Thailand’s best practices in Global Health paradigm.

 V Course Objectives

 -       To provide knowledge and guidance on comprehensive care management for pediatric and adolescent living with HIV/AIDS.

 -       To share the experiences and practices on comprehensive care management for children and adolescents living with HIV/AIDS among participants.

 -       To assist the participants in the development of action plan for comprehensive services for pediatric and adolescent living with HIV/AIDS in their settings by utilizing knowledge, lessons learned, and experiences from the training and study visit.

-       To assist the participants to create multidisciplinary pediatric and adolescent living with HIV/AIDS care team in their settings.

 VI Expected outcome

Participants can set up multidisciplinary pediatric and adolescent living with HIV/AIDS care team and/or develop a network for comprehensive pediatric and adolescent living with HIV/AIDS care. The knowledge/skills gained from the course could be applied to the work responsibility.

VII Course contents

The training course is presented in 6 modules as follow:

Module  1:  Overview  of  pediatric  and  adolescent  living  with  HIV/AIDS  situation  and

comprehensive care management This module covers the topics as follow: 4 

1.   Global and Thailand pediatric and adolescent living with HIV/AIDS situation and epidemiology 

1.1 Global pediatric and adolescent living with HIV/AIDS and PMTCT epidemiology and situation 

1.2 PMTCT epidemiology and situation in Thailand 

1.3 Pediatric and adolescent living with HIV/AIDS epidemiology and situation 

in Thailand 

2.  Thailand health care and national policy on pediatric and adolescent living with HIV/AIDS care

2.1 Thailand health care system 

2.2 National policy and benefit package of PMTCT and pediatric and adolescent living with HIV care under Universal Health Coverage (UHC) in Thailand

3.  Comprehensive pediatric and adolescent living with HIV/AIDS care model 

3.1 Medical care and clinical Management to HIV-infected children 

3.1.1 Provision of PMTCT services

                                    3.1.2 Diagnosis of pediatric HIV infection 

3.1.3 Treatment and care for HIV-exposed infants 

3.1.4 Treatment and care for HIV-infected children and adolescent living 

with HIV/AIDS 

3.1.5 Clinical HIV status monitoring 

3.1.6 Provision of antiretroviral therapy, promotion of ARV adherence, and management of ARV toxicity and treatment failure

3.1.7 Opportunistic infection prophylaxis and treatment 

3.2 Pediatric and adolescent living with HIV/AIDS care and support 3.2.1 Growth and development monitoring 

3.2.2 Nutritional support 

3.2.3 Immunization 

3.2.4 Counseling and testing (Risk reduction, Harm reduction) 

3.2.5 Psychosocial support

3.2.6 Outreach/education 

3.2.7 Clinical quality improvement 

3.3 Referral services to or from 

3.3.1 PMTCT service 

3.3.2 TB clinic 

3.3.3 STIs clinic

                                    3.3.4 Specialized clinics 

3.3.5 Adolescents to adult HIV clinic 

3.3.6 VCT clinic 

3.3.7 Home-based care 

3.3.8 Community-based care 

3.3.9 Supportive services 

3.4 Public health system monitoring 

Module 2: Treatment and standard of pediatric and adolescent living with HIV/AIDS care 

This module is organized into 2 sub-modules as follow:

Sub - module 2.1: ARV management This sub-module covers the topics as follow: 

1.  Clinical manifestation/ Laboratory diagnosis in infant /children/adolescent 

2.   ARV Initiation – what ARV/ when to start ( updated US CDC, WHO, PENTA, Thai 

guidelines)

             3.  Monitoring – 

3.1 Clinical, immunological and virological 

3.2 Drug interactions 

3.3 Adherence, immunization, growth/development 

4. Treatment failure cases – how to manage

Sub - module 2.2: Opportunistic infection (OI) management This sub-module covers the topics as follow: 

1. Introduction 

1.1 Definition of opportunistic infection 

1.2 Common opportunistic infections among children including bacterial, mycobacterial, fungal and viral infections.

2.  Clinical manifestations, diagnostic tests, treatment and prevention 2.1 Bacterial infections: pathogens and diseases

2.2 Mycobacterial infections 

2.3 Viral infections 

2.4 Fungal infections 

3.  Prevention of opportunistic infections 

3.1 Primary prophylaxis: to prevent first episode of OIs 

3.2 Secondary prophylaxis: to prevent recurrence of OIs 

4.  Immune reconstitution inflammatory syndrome (IRIS) 4.1 Type of IRIS 4.2 Risk factors for IRIS

4.3 Clinical manifestations 

4.4 Treatment and prevention 

Module 3: Psychosocial care and support This module covers the topics as follow: 

1. The importance of psychosocial support for children and adolescent living with 

HIV/AIDS 

2.   Psychosocial support intervention responding to the major HIV/AIDS effects to children and adolescent 2.1 Disclosure and HIV/AIDS counseling and education

2.2 Promoting adherence to ARV 

2.3 Promoting positive prevention 

3.   Thai lesson learned on holistic approach, integrated psychosocial support with treatment and care, the reflection from children/adolescent living with HIV

4.  Group discussion 

Module 4: Performance measurement and quality improvement of pediatric HIV/AIDS care 

This module covers the topics as follow: 

1.  Importance of measurement and data utilization for quality improvement 

2.  Concept of performance measurement and quality improvement 

2.1 Performance measurement 

2.1.1 Pediatric HIV care indicator development 

2.1.2 Data collection and analysis 

2.2 Quality improvement 

2.2.1 Problem identification and cause analysis 

2.2.2 Continuous quality improvement using PDSA cycle 

3. Example of pediatric HIV/AIDS care quality improvement in Thailand

Module 5: Site visit pediatric HIV/AIDS care at Chiangrai province 

1.  Regional level (Chiangrai Prachanukroh hospital) 

2.  Community level (Phan hospital in Chiangrai province)

This module is organized into 4 sub-modules:

Sub - module 5.1: Introduction and pre-training assessment. In this site visit sub-module, participants will learn/experience in the following topics: 

1.  Introduce team members of the training sites and the study team 

2.  Pre-clinic observation training needs assessment

Sub - module 5.2: Overview of pediatric HIV treatment and care services in the study hospital In this site visit sub-module, participants will learn/experience in the following topics: 

1.  Review component of holistic HIV treatment and care for children. 

2.  Review service flow in the clinic 2.1 Pre-clinic case conference 

2.2 Pre-clinic preparation: document, lab results/request, ARV preparation 

2.3 Team meeting/conference 

2.4 Clinic day activities . 

3.  Review roles of multidisciplinary care team 3.1 Doctor

3.2 Nurse 

3.3 Pharmacist 

3.4 PLHA 

3.5 Others 

4.  Review performance measurement and quality improvement (Pediatric HIVQUAL model) activities in the HIV clinic 

4.1 Provide performance measurement data (PedHIVQUAL data) 

4.2 Describe quality improvement activities (QI project) based gaps in the services identified by PM data 

5.  Example of Holistic HIV treatment and care for children (displayed by DVD)

Sub - module 5.3: Observe pre-clinic case conference, service provision in the HIV clinic, study forms, tools, media used in the service In this site visit sub-module, participants will learn/experience in the following topics:

1.  Pre-clinic conference 

2.  Roles and responsibilities of multidisciplinary team 2.1 Doctor

2.2 Nurse 

2.3 Pharmacist 

2.4 PLHA volunteer

3.  Service provision

Sub - module 5.4: Summary lessons learned from clinic observation In this site visit sub-module, participants will learn/experience in the following topics:

1.   Review current pediatric HIV care services: flow, existing personnel, tools and materials

               2.    Formulate plan - Identify what resources needs to be added, additional personnel to be recruited to form pediatric HIV care team, any service flow needs to be adjusted

3.  Assign responsible persons and timeline to follow the plan

Module 6: “Case Finding Program and Friendly HIV Services” This module covers the topics as follow:

1.  Influence factors and key interventions to address HIV problems among youth

2.   Key components of youth friendly services. It is comprised of 3 sessions as following; Youth Friendly Service, High Tea with Youth and Family, and Site Visit. Meeting for discuss or interview with the adolescents with HIV and relevant workers are provided. Site visit: The trainees are encouraged to learn and share experiences in the following topics; youth friendly health services, promotion strategies for youth service and online services. The module also provides study visit at clinic and sexual health museum.

Module 7: “Pediatric HIV Disclosure” The main points of this module are basic knowledge and how to create pediatric HIV disclosure which suit both cognitive function and perceptive ability of children as well as country culture and individual family contexts. This module also included pediatric HIV disclosure demonstration, and practice session.

Module 8: “Counseling and Dealing with Behavioral Problems in Adolescent Living with HIV” The main contents in this module are effective communication techniques with adolescent

assessing and dealing with behavioral problems in HIV-infected adolescent. Small groups practice in individual counseling with case scenario are provided.

Module 9: “Comprehensive Transition from Adolescent to Adult, Positive Prevention, Health Promotion” The module aims to encourage the trainees about how to conduct interactive group education among HIV-infected adolescent including the transition youth to adult HIV care services. ‘Happy Teen 1 Model and Happy Teen 2 Model’ are demonstrated by various learning techniques for example lecture, demonstration, group activities, game etc. Tools and materials are shared in a market place.

Module 10: Workshop on country comprehensive pediatric and adolescent living with HIV/AIDS care program development In this workshop, participants will have experience on country group work and develop action plan on the topic:

1.  Adaptation of lessons learned from Thailand to their countries

2.  Group work (Gap analysis, Action Plan)

Advance assignments: Participants are required to prepare their country profile on pediatric and adolescent living with HIV/AIDS care program consisting of

-      Demographic data

-      Situation of HIV/AIDS including HIV prevalence among pregnant women and children under 18 years old

-      Epidemiology/ Policy/ HIV/AIDS

-      Maternal and child health services system

-      HIV counseling and testing services

-      Care service for HIV infected mother and children

-      Pediatric HIV/AIDS care program implementation including M&E/Public Health Services System

             -      Community participation in health care systems especially pediatric and adolescent living with HIV/AIDS care program

Training methods conveys in this course are based on interactive lectures, discussion, case based discussion, experience sharing, brain storming, role play, group work, after action review (AAR), demonstration, and site visit.

VIII Number of Participants: 20 persons

IX Qualifications

Candidates must possess qualifications as specified in “Guideline for Thailand’s Annual International Training Course Programme” No. 2 “Qualifications” as well as following qualifications.

        -       Be a doctor, nurse, counselor, pharmacist or h ealth personnel who are responsible in pediatric and/or adolescent living with HIV/AIDS care program and prefer multidisciplinary care team from one hospital or a country

-       Age between 27 to 50 years old.

-       Be in good physical and mental health in order to undergo and be able to attend the entire course.

-       Expected to continue working in the pediatric and/or adolescent living with HIV/AIDS care program/ services after finishing this course.

X  Venue Bangkok

XI Evaluation

Participants are required to attend all activities organized during the course as attendance in all sessions is obligatory. TICA reserves the rights to revoke its fellowship offer or take appropriate action deemed appropriate in case a participant is in attendance of less than 90 percent of the training hours.

By the end of each session, participants will be required to evaluate training course in terms of the essential content coverage and usefulness, lecturer’s explanation and presentation, training materials, methods of learning, appropriateness of time allocated and the knowledge gained, etc.

XII Training Institution:

 International Training Center on AIDS, TB and STIs (ITC), Department of Disease Control, Ministry of Public Health, Thailand