CHAPTER 2

PLANNING INTEGRATED HIV

SERVICES AT THE HEALTH
CENTRE

2.1

INTRODUCTION

Achieving quality integrated HIV services at your health centre is dependant on good
planning and management. This chapter should help you plan delivery of the essential
HIV services that your health centre needs. In part, this assistance is based on lists of
the basic essential and desirable interventions for HIV prevention, care and treatment
at health centres within a district health network.
These lists require country adaptation that takes into account current national
guidelines, essential drug lists, existing services provided at the health centre, and the
feasibility of adding specific HIV services. Each country should replace this generic
list with a one that identifies both essential and desirable interventions. Some betterresourced health centres may be able to deliver enhanced services. Finally, the chapter
concludes with a section that outlines how you can estimate your HIV service needs
based on the catchment area of your health centre. The material provides formulae
for estimating the required new or expanded services.
HIV services continue to evolve, and new guidelines and interventions are
expected in the future. The lists, tables and formulae below are based on the 2009
evidence summarized in the accompanying Adaptation Guide, and require country
adaptation.
Health centres function within a district network and are the focal point of health
care in the community. On the one hand, they seek support and more specialized
services from the district network. On the other hand, they provide support to
communities, patients, their partners and families. They may do this directly through
outreach or home-based programmes, or indirectly through advocacy, support groups
and education. A number of services, such as door-to-door testing, counselling and

12 l CHAPTER 2 l PLANNING FOR INTEGRATED HIV SERVICES AT THE HEALTH CENTRE

home-based care may be delivered directly at the home. In some settings, hospitals
may also play an important role in community outreach programmes.
The health centres roles in supporting these community services can be found in the
lists that follow. Health centres have the closest connection to existing communitybased structures and organizations involved in HIV prevention, care and treatment,
and both the centres and communities benefit from this. The introduction of chronic
HIV care and ART has further changed the care needs of a patient, making these
linkages and integration even more important. To meet all the needs of patients and
their families as they try to cope with HIV or AIDS and care-related issues, the health
centre needs to function as part of a larger system of support.
2.2

ESSENTIAL AND DESIRABLE INTERVENTIONS

This section outlines the interventions needed for integrated HIV prevention, care,
treatment and support at the health centre, and is based on the WHO priority
interventions for HIV/AIDS prevention, treatment and care in the health sector.
The interventions summarized in Annex 2-1 are compatible with the WHO
recommendation for priority interventions.
More detailed tables on planning and implementation can be found in Annex 2-1.
They have been formatted to help you to assess the services currently being provided
at your health centre. A column in each table uses a key to make reference to relevant
IMAI, IMCI and other training manuals. It also provides cross-references to material
in other chapters of this Manual.
The Annex tables list services applicable to all age groups first, and then spell out special
considerations for children, adolescents and pregnant women. Most interventions are
relevant for both children and adults. However, infants and children also require
special interventions and modifications, or special considerations related to HIV
service delivery. Separate sections of the lists include both routine childhood services
and specific services for HIV-exposed and HIV-infected children.
In resource-constrained settings, common childhood illnesses are significant factors
in the illness and deaths of HIV-exposed and HIV-infected children. A guiding
principle for paediatric HIV services is to ensure that basic HIV-specific services are
fully integrated into existing maternal child health services at health centres. In some
cases, reorganizing the health centres child health services may be needed in order
to ensure that comprehensive care for HIV-exposed, -infected or -affected children
is provided.

OPERATIONS MANUAL FOR STAFF AT PRIMARY HEALTH CARE CENTRES l 13

These lists of essential and desirable interventions are limited to the health sector.
However, it is important to note that an effective response to the HIV epidemic
requires the involvement of multiple sectors as outlined in the section above. The lists
include only the services that can be supported by laboratory tests available to patients
attending the health centre. This includes laboratory tests that are readily available as
send-outs to the district or central laboratory (see the Laboratory chapter).
The components of the WHO priority interventions for HIV/AIDS prevention, care
and treatment for the health sector focus on five strategic directions1:
1. increasing knowledge of HIV serostatus
2. accelerating HIV prevention
3. accelerating the scale-up of HIV treatment and care
4. strategic information
5. health systems strengthening.
This chapter and Annex 2 concentrate on the clinical and behavioural interventions
that can be scaled up at health centre level through focusing on strategic directions
one to three. Direction number four, strategic information is addressed in the
Monitoring chapter. As for strategic direction number five, it flows through the entire
text, since this Manual aims to strengthen health systems by addressing management
and logistics at health centre level within a district health network. Most health
systems strengthening interventions are presented in other chapters of the Manual.
Detailed guidelines and job aids for these interventions are found in country-adapted
WHO Integrated Management of Adolescent and Adult Illness (IMAI), Integrated
Management of Childhood Illness (IMCI) and Integrated Management of Pregnancy
and Childbirth (IMPAC) guidelines or other national clinical guidelines for provision
of acute and chronic HIV care.
2.2.1

INCREASING KNOWLEDGE OF HIV SEROSTATUS

Priority interventions include:

client-initiated testing and counselling (CITC);
provider-initiated testing and counselling (PITC);
family and partner testing and counselling (based on index case);
PITC during early antenatal care, labour, and post-partum period;
infant and child HIV testing and Counselling;
PITC in reproductive health services including family planning;
t

HIV Tes

PITC

See WHO. 2008. Priority interventions HIV/AIDS Prevention, Treatment, and Care in the Health Sector for more detailed information.
http://www.who.int/hiv/pub/guidelines/2008priorityinterventions/en/index.html

14 l CHAPTER 2 l PLANNING FOR INTEGRATED HIV SERVICES AT THE HEALTH CENTRE

PITC when patients show signs/symptoms of illness that may suggest HIV
infection, including TB, STI, other WHO HIV-staging illness, and increasingly
other common minor complaints;
PITC for men seeking circumcision as an HIV prevention intervention;
laboratory services for HIV diagnosis.

2.2.2

ACCELERATING HIV PREVENTION

Accelerated HIV prevention programmes can help with:

Preventing sexual transmission of HIV by
promoting and supporting condom use;
detecting and managing STIs;
safer sex and risk reduction counselling: This includes active support for
partner disclosure and testing, discordant couples risk reduction, counselling
on the possibility of HIV transmission while on ART, assessing substance use,
providing brief alcohol interventions;
male circumcision for HIV prevention;
prevention among PLHIV;
targeted interventions for sex workers and men who have sex with men
(MSM);
non-occupational post-exposure prophylaxis (in cases of condom breakage
and rape);
specific considerations that target young people;
adolescent-friendly services;
assured access to reproductive health services including family planning and
condom provision;
specific consideration for vulnerable populations: displaced, mobile and
migrant populations, prisoners and people in other closed settings;
mental health hospitals/institutions;
interventions for injecting drug users;

Prevention of HIV infection in infants and young children (PMTCT)

primary prevention of HIV transmission among men and
women;
family planning, counselling and contraception;
antiretroviral medicines for preventing HIV infection in
PMTCT
infants;
treatment, care and support for pregnant women living with
HIV;
infant feeding counselling and support.

OPERATIONS MANUAL FOR STAFF AT PRIMARY HEALTH CARE CENTRES l 15

TB control

2.2.3

Preventing HIV and TB transmission in health care settings:

infection control (TB and HIV) in health-care settings
blood safety
safe injections and routine use of standard precautions
occupational post-exposure prophylaxis (PEP) for HIV
safe waste disposal management.

ACCELERATING THE SCALE-UP OF HIV

TREATMENT AND CARE

Primary interventions include:

Antiretroviral therapy for adults, adolescents and children
treatment preparedness and adherence support
patient monitoring.

Prevention and management of opportunistic infections and co-morbidities

included:
managing HIV-related conditions
managing pneumonia
cotrimoxazole prophylaxis
managing diarrhoea
managing malnutrition
preventing and managing malaria
managing viral hepatitis
vaccinations for infants and children, per national programme
preventing and treating mental health disorders
counselling.

Palliative care

Tuberculosis prevention, diagnosis and treatment:

isoniazid preventive therapy (IPT)
intensified TB case finding
early identification and treating HIV-associated tuberculosis.

HIV and TB treatment and care for health workers.

16 l CHAPTER 2 l PLANNING FOR INTEGRATED HIV SERVICES AT THE HEALTH CENTRE

2.3

ESTIMATING HIV SERVICE NEEDS

To estimate the infrastructure and staffing needs that HIV service provision will
generate in your health centres catchment area, you need to include requirements
for HIV testing, care and ART for all patient types. This includes TB patients, both
pregnant and non-pregnant women, children, and other adults. Estimates need to
take into account:
numbers requiring HIV testing and counselling due to scale-up, including
PITC;
increasing numbers of patients in chronic HIV care and ART;
other HIV prevention services that are being scaled up.
The following step-by-step approach will assist you in your planning process.
STEP 1: Find out the population of your catchment area and estimate the proportion
that is under 15 years of age and the proportion that is over 15 years. This information
is often available from district offices, or from the central bureau of statistics, or the
office of population.
STEP 2: Find out the HIV prevalence in your catchment area. If this information is
not readily available, use national or district HIV prevalence data.
STEP 3: Combine information from Steps 1 and 2 to estimate the total number of
PLHIV that your health centre serves, as well as to obtain an estimate of the number
of people who will be enrolled in your HIV programme.
STEP 4: If you have client-initiated services at your health centre, then the next step
is to calculate your counselling and testing requirements. In practise, new sites rarely
see more than 100 clients per month in the first few months, so use this as a guide.
Thereafter, once services are established, the best guide to estimating the patient
number is to refer to the number tested in the previous quarter, taking into account
seasonal variations such as school holidays, rainy seasons, planting and harvest times,
all of which might affect client flow through the centre.

OPERATIONS MANUAL FOR STAFF AT PRIMARY HEALTH CARE CENTRES l 17

STEP 5: PITC will increase the rate of HIV testing. The following
table will help you estimate the number of rapid test kits, human
resources and space requirements for the initial scale-up of PITC. (In
time, you can use the forecasting methods in the Supply Management
chapter). The estimates below are larger than in reality in order to
account for patients who return for repeat testing.

HIV Tes

PITC

Source of information Number of Percentage of group

for estimates
that needs testing
patients

Adults
Antenatal patients

antenatal care (ANC)

register

100%

New TB patients of
unknown status

TB register

100%

STI patients

Acute care register

100%

FP patients of unknown
status

100%

Adult outpatient
department (OPD)
patients (acute care,
people suspected of
having TB, etc.)

80%

Total

Total number of adults needing testing monthly

Estimated number of adults needing testing daily = total number needing testing,
divided by the number of days clinic is open per month
Number of full-time rooms or private spaces and counsellors needed for full scale-up*
* Estimate based on a counsellor able to carry out rapid HIV testing and post-test counselling for 15 patients each day.

After your health centre introduces or strengthens PITC, your estimates for increased
HIV testing will need to take into account:
the number of pregnancies that are currently managed in antenatal care, and
the estimated number you will need to manage when antenatal care coverage is
improved;
the proportion of patients who will consent to be tested in each category;
the current status of your efforts to provide HIV tests for your TB patients. Do
most know their status now, or do you need to recommend testing for all of them?
Once you know the HIV status of most of your TB patients, on a monthly basis
you will only need to give HIV tests to new TB patients, and to people who are
believed to have HIV;
the level of activity your centre has achieved in carrying out partner testing.

18 l CHAPTER 2 l PLANNING FOR INTEGRATED HIV SERVICES AT THE HEALTH CENTRE

The estimates that you arrive at will likely exceed the actual number of patients who
accept HIV testing, especially in the early stages of your scale-up. You should then
consider the resources and likely scale-up rate you can achieve, and use it to come up
with estimates about HIV testing after your services have been established for some
months.
The exact figures may be difficult to forecast. Therefore, it is important that centre
management ensures it has an adequate buffer stock of rapid HIV test kits and a
method for rapid re-supply if stocks become depleted.

STEP 6: Estimate the number of children that need testing.

Children

Paediatrics

Source of information Number of Percentage of group

for estimates
that needs testing
children

HIV-positive women in
ANC clinic

ANC register

100%

Under 5 clinic

Acute care register

100%

Sick children with HIVpositive mothers

100%

Sick children with

mothers with unknown
serostatus

100%

Total

Sick children with HIVnegative mothers

Sick children aged
between ve and 15
years

Estimate of the
prevalence x 2
Total number of children who need testing monthly

* Estimate based on a counsellor able to carry out rapid HIV testing and post-test counselling for 15 patients each day.

OPERATIONS MANUAL FOR STAFF AT PRIMARY HEALTH CARE CENTRES l 19

STEP 7: Estimate the number of patients coming to your centre who will be HIVpositivethis is the number of PLHIV requiring chronic HIV care.
A rudimentary way to calculate the total number of HIV-positive adults in any
population is HIV prevalence multiplied by one-half of the total population (an
estimate of the adult population).
More complex calculations can be carried out by using the prevalence in different
populations, since the prevalence will vary by patient population, e.g. it will be higher
in TB patients. These calculations can be used in the next step to estimate the number
of PLHIV who will be on ART in different populations.
STEP 8: Estimate the number of PLHIV who will be on ART.
This table helps you estimate the need for ART services based on your estimated
HIV-positive patient population once PITC is scaled up. This may then may need to
be modified to reflect your ART allocation.

PLHIV

Estimated
number PLHIV
identied within
next year

Estimated percentage that

requires ART when found to
be HIV-positive

Pregnant women

20-30% will require ART

Remainder (70-80%): PMTCT ARV
prophylaxis

Adults seeking
care for illness

Often 30 to 60% of PLHIV will be

eligible for ART (as HIV testing
expands and patients enter
chronic HIV care earlier, this
percentage should drop)

HIV-infected
children
TB patients

100% (either during or after TB

treatment)

20 l CHAPTER 2 l PLANNING FOR INTEGRATED HIV SERVICES AT THE HEALTH CENTRE

Number of PLHIV
who will need ART
within next year

STEP 9: Estimate the frequency of clinical visits (Note that percentages of patients on
ART need to be adapted to reflect site/country realities).
Number of
visits/month*

Number of
visits/week

Number of visits/day

100 PLHIV in chronic HIV care

If 30% are on ART

53

13

If 50% are on ART

66

17

If 100% are on ART

100

25

250 PLHIV in chronic HIV care

If 30% are on ART

133

33

If 50% are on ART

167

42

If 100% are on ART

250

63

13

500 PLHIV in chronic HIV care

If 30% are on ART

267

68

14

If 50% are on ART

333

83

17

If 100% are on ART

500

125

25

750 PLHIV in chronic HIV care

If 30% are on ART

400

100

20

If 50% are on ART

500

125

25

If 100% are on ART

750

188

38

* The assumption behind these calculations is that patients on ART are seen by a clinician every month (on average)
and pre-ART patients are seen every three months (on average). There will always be patients who are lost to follow-up
(LTFU) and others who miss appointments. However, there will also be additional unscheduled (walk-in) patient
appointments of people suffering from drug toxicity, acute illness, etc.. This calculation assumes that missed and extra
appointments balance each other out. These estimates do not describe visits for counselling, laboratory, pharmacy or
other non-clinical services.

OPERATIONS MANUAL FOR STAFF AT PRIMARY HEALTH CARE CENTRES l 21

STEP 10: Estimate of clinical consultation room capacity.

Number of
visits/month

Number of
visits/week

Number of
visits/day

If the majority of patients are follow-up

cases

600

150

30

If > ve patients/day are new

500

125

25

Throughout, this Manual focuses on both large and small health centres, using
estimates for the management of 100, 250, 500 or 750 PLHIV in chronic HIV care,
with 30% to 50% on ART (these percentages needs country adaptation). Estimates of
infrastructure, staffing and laboratory testing needs are shown for these numbers of
patients, as well as the requirements for testing, other PMTCT interventions, and the
scale-up of other prevention interventions.

22 l CHAPTER 2 l PLANNING FOR INTEGRATED HIV SERVICES AT THE HEALTH CENTRE