COMMUNITY HIV CARE AND TREATMENT ACTIVITY

MINIMUM QUALITY STANDARD AT SERVICE DELIVERY UNIT LEVEL

Quality assurance is a process of assessing care against standard, that has already been provided and taking action to improve it in the
future. Therefore, in order to ensure quality, it is important to know the (minimum) standard for CHCT activity.
May 2018
Table of Contents
HIV Prevention ............................................................................................................................................................................................................... 3
Targeted HIV Testing Services ........................................................................................................................................................................................ 3
Standard 1: Trained provider (CEF)............................................................................................................................................................................ 3
Standard 2: Physical space that ensure privacy and confidentiality.......................................................................................................................... 3
Standard 3: HTC Safety measures .............................................................................................................................................................................. 3
Standard 4: Compliance with national testing algorithm .......................................................................................................................................... 4
Standard 5: Condom availability ................................................................................................................................................................................ 4
Standard 6: Supply chain reliability ........................................................................................................................................................................... 4
Standard 7: HIV Proficiency testing ........................................................................................................................................................................... 4
Standard 8: HTC referrals and linkages to HIV care and treatment .......................................................................................................................... 4
Standard 9: HTC quality assurance ............................................................................................................................................................................ 5
Standard 10: Counseling ............................................................................................................................................................................................ 5
Care, Treatment and Support Services .......................................................................................................................................................................... 6
Standard 1: Trained individual and group service providers ..................................................................................................................................... 6
Standard 2: Recruitment for group or individual support ......................................................................................................................................... 6
Standard 3: Individualized case management ........................................................................................................................................................... 6
Standard 4.1: Case management approaches: Initial and follow up household visits .............................................................................................. 6
Standard 4.2: Case management approaches: Group case management ................................................................................................................ 7
Standard 5: Adherence support ................................................................................................................................................................................. 8
Standard 6: Self reported viral load monitoring ........................................................................................................................................................ 8
Standard 7: Sigma and discrimination reduction....................................................................................................................................................... 8
Standard 8: STI screening and referral....................................................................................................................................................................... 9
Standard 9: TB screening and referral ....................................................................................................................................................................... 9

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 Standard 10: Family planning education and referral ............................................................................................................................................... 9
Standard 11: Malaria education and referral .......................................................................................................................................................... 10
Standard 12: Food water safety and hygiene education and referral ..................................................................................................................... 10
Standard 13: Adult and pediatric nutrition screening and referral ......................................................................................................................... 10
Standard 14: Positive health, dignity and prevention (PHDP)????.......................................................................................................................... 10
Standard 15: Mental health and substance abuse .................................................................................................................................................. 10
Standard 16: GBV prevention .................................................................................................................................................................................. 11
Standard 17: Economic strengthening ..................................................................................................................................................................... 11
Referral and linkage ..................................................................................................................................................................................................... 11
Minimum standard .................................................................................................................................................................................................. 11
Beneficiary Records ..................................................................................................................................................................................................... 12
Minimum standard .................................................................................................................................................................................................. 12
Data Quality ................................................................................................................................................................................................................. 12
Minimum standard .................................................................................................................................................................................................. 12
Quality management/Quality assurance and improvement ....................................................................................................................................... 13
Minimum standard .................................................................................................................................................................................................. 13
Coordination with public sector................................................................................................................................................................................... 13
Minimum standard .................................................................................................................................................................................................. 13

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HIV Prevention

Targeted HIV Testing Services

Standard 1: Trained provider (CEF)
1.1 The CEF has received knowledge and skills approved by FMOH for providing HTS within the past year (Check certificate for
successful completion)
1.2 The CEF has signed confidentiality agreement with the organization/LIP for maintaining confidentiality and privacy (Check
document)

Standard 2: Physical space that ensure privacy and confidentiality

2.1 There is enough physical space for providing HTS ensuring privacy of the clients i.e. it’s done in a place where others cannot see
or overhear
2.2 Clients are informed about how they can anonymously report violations of their privacy or confidentiality
2.3 There is a mechanism where clients can anonymously report violations of their privacy or confidentiality i.e. there’s at least
suggestion box for clients to report at testing sites other than client’s household

Standard 3.1: HTS Safety measures for testing at static site

3.1.1 The HIV testing point has sharps and waste containers for disposal of lancets, syringes and other sharps
3.1.2 The HIV testing point has clean water, soap and disinfectant or hand sanitizer or hand rub
3.1.3 The HIV testing point has disposable gloves
3.1.4 The service provider/CEFs have received annual infection prevention and personal safety training (IPPS) training

Standard 3.2: HTS Safety measures for household testing

3.2.1 CEFs carry sharps and waste containers with them for disposal of lancets, syringes, and other sharps with them
during HH Visit
3.2.2 CEFs carry disposable gloves with them for HH testing
3.2.3 CEFs have hand rub that they carry with them for HH testing

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Standard 4: Compliance with national testing algorithm
4.1 There is printed testing protocols and cue cards that are in full accordance with the national testing algorithm at the testing
point
4.2 The HTS register collects information of all the three tests kits i.e. names of test kits, lot # and expiration date (check the
register)
4.3 The HTS register has collected all results for all the three tests done and the final result given to the client
4.4 Review of 20 most resent HIV positive test result has at least 90% compliant to the national protocol (Review the 20 most recent
entries within the past 12 months where the final test result was HIV positive in the HTS register. Check if a review of these
reveal 90 % compliance with the national testing algorithm and strategy. )

Standard 5: Condom availability

5.1 There’s non-expired condom available at all times at the testing site
5.2 The condoms are easily accessible (they are available onsite to beneficiaries/clients)
5.3 There is visual information promoting correct condom use including penile model

Standard 6: Test kit supply chain reliability

6.1 All rapid test kits are available all time
6.2 There’s stock for at least a month with a minimum daily testing rate of 8 people per day on working days
6.3 There’s adequate and secure space for storing rapid test kits according to the manufacturer’s specifications
6.4 All rapid test kit’s manufacturers’ standard is maintained while transporting testing kits for household testing

Standard 7: HIV Proficiency testing

7.1 Only test kits validated by the Ethiopian Health and Nutrition Research Institute or provided by government is used
7.2 The point of testing participates in proficiency testing by the regional laboratory at least every six months
7.3 The point of testing achieved a satisfactory score on proficiency test in the past 12 months

Standard 8: HTC referrals and linkages to HIV care and treatment

8.1 There is an active referral system in place to facilitate linkage to HIV care and treatment services for those who test positive
(e.g., use of standard referral forms, transport vouchers, referral directory, peer (CRP) navigator)
8.2 There is documented evidence for confirming successful linkage to HIV care and treatment services (e.g., a returned referral
form, completed phone call, verification by a peer navigator, Commcare)
8.3 The CRPs or CEFs make follow up with HIV-positive clients who fail to enroll in HIV care and treatment services and report back
the outcome

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 8.4 The CEFs conduct regular analysis of beneficiary/client referral and linkage data to assess linkage to care and report to the QI
team every month

Standard 9: HTS quality assurance

9.1 LIPs together with the Woreda/town health office observes and documents each CEFs conducting HIV rapid testing at least twice
a year to monitor proficiency with a standard checklist and provide feedback
9.2 The testing point calculate and review, every month quality assurance variables (These includes positive concordance rate
between test 1 and test 2, number of invalid test results, which is expected to be above 90%) and identify quality issues with the
QI team
9.3 The testing point monthly review whether the testing is done only for target population. Review recent 40 client records and
check whether the clients tested are CHCT Activity targets

Standard 10: Counseling

10.1 CEFs provide pretest information and posttest counseling using PITC cue card to clients irrespective of their HIV test
result
10.2 There’s a space on the HTS register that shows posttest counselling and it’s completed for those tested
10.3 The posttest counselling is provided to all clients (check recent 20 clients with positive test result and check whether
posttest counseling is providing on the register. This has to be 100%)

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Care, Treatment and Support Services

Standard 1: Trained individual and group service providers

1.1 The service providers (CEFs and CRPs) are trained on nationally approved guideline including importance of keeping client privacy and
confidentiality
1.2 The service providers (CEFs and CRPs) have established linkages to designated facility and community services through either use of
standardized tools for referrals or designated points of contact with facilities and community groups that enable referral systems
1.3 The service providers (CEFs and CRPs) receive onsite supportive supervision at least once within a quarter from next higher point and there
documented evidence for this such as feedback

Standard 2: Recruitment for group or individual support

2.1 The client has provided verbal or written consent to be enrolled in services provided by CHCT either in group or individual and there is an
evidence for this
2.2 Clients are informed that their privacy and confidentiality is ensured throughout
2.3 Clients are informed about how they can anonymously report violations of their privacy or confidentiality and there is a mechanism for this
(There’s either suggestion box or number where they can report anonymously)

Standard 3: Individualized case management

3.1 There is completed household assessment form for each individual
3.2 Each client has unique identifier
3.3 Each client has need assessment completed at baseline and then every six months and there is documentation for this (Review 19 records of
beneficiaries whether the need assessment is completed. Expectation is 100%)
3.4 Each beneficiary has individualized case management plan (Review 19 records of beneficiaries whether each individual has individualized
case management plan. Expectation is 100%)

Standard 4.1: Case management approaches: Initial and follow up household visits
4.1.1 Each client is visited once per month and there’s documented evidence for this
4.1.2 There is consent from the household head (Verbal or written)
4.1.3 There is prior communication with the client and time and date has been set before the visit
4.1.4 CRPs/CEFs have assessment, case plan and service delivery forms and cards with unique identifier and referral forms during the visit

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4.1.5 The CRPs/CEFs have the necessary job aids and materials including SBCC materials, weighing scale, MUAC tapes, condom, penile model
during the visit
4.1.6 The visit include distribution of tools and educational materials (e.g. condoms, brochures, handouts)
4.1.7 The visit include referral for additional services (Contraceptives, WASH materials), if required
4.1.8 The visit has skills building component (e.g. condom demonstrations, negotiating safer sex behaviors, negotiating PHDP, improving
communication skills)
4.1.9 Privacy and confidentiality (visual and auditory) is ensured while providing service
4.1.10 Appropriate job aid is utilized while providing service
4.1.11 Next appointment date is set

N.B: Supervisors/CEFs should visit HHs while /CEFs CRPs provide service at HH level for each CRP at least once per month and observe the
process based on the above listed quality standard and provide feedback accordingly

Standard 4.2: Case management approaches: Group case management

4.2.1 Group case management is provided based on scientifically appropriate curriculum (E.g: NEP+ manual)
4.2.2 Group case management facilitators (CEFs/CRPs) are trained on the curriculum or the interventions being delivered within the last year
4.2.3 The group case management session has skills building component (e.g. condom demonstrations, negotiating safer sex behaviors,
negotiating PHDP, improving communication skills)
4.2.4 Sessions include distribution of tools and educational materials (e.g. condoms, brochures, handouts)
4.2.5 Session include referral for additional services (contraceptives, WASH supplies), if required
4.2.6 Sessions include information on where beneficiaries/clients can access other prevention and support services (e.g. HIV testing and
counseling, family planning, STI treatment, TB treatment, malaria prevention and treatment, WASH supplies, substance abuse
treatment, etc.)
4.2.7 CEFs/CRPs performances is assessed through direct supervision for the quality of their work at least once in a quarter and there’s
documentation for this

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4.2.8 There is evidence that facilitators’/CEFs/CRPs performance assessments are used to improve the quality of their group facilitation /group
case management sessions
4.2.9 There’s regular monitoring and documentation of changes in each member’s status over time based on initial/baseline assessment and
this change is used to inform decision on group case management
4.2.10 Each client has need assessment completed at baseline and then six months and there documentation for this (Review 19 records of
beneficiaries whether the need assessment is completed. Expectation is 100%)

Standard 5: Adherence support

5.1 CRPs/CEFs have job aids that address all the core adherence support elements (pre-ART counseling, adherence assessment, and intervention
counseling)
5.2 Review of care and support register or other documentation shows at least 60% of the beneficiary/client received the appropriate core
adherence support elements (pre-ART counseling, adherence assessment, and intervention counseling). [Review 10 beneficiary/client
records (individual or group support records) from within the last three months and see whether this is clearly documented
5.3 There’s documented evidence showing improvement/changes in adherence status over time of clients provided with adherence support

Standard 6: Self-reported viral load monitoring

6.1 CRPs/CEFs have job aids that guide them to monitor self reported viral load
6.2 Each client has self-reported viral load figure registered in the Care and support register every six months (Review 19 records of beneficiaries
in the last six months and check whether self-reported viral load is documented. Expectation is 100%)
6.3 The change in self-reported viral load is used for decision making or further actions for improving viral load suppression and there’s
documented evidence for this

Standard 7: Sigma and discrimination reduction

7.1 There’s a written statement at CEFs/CRPs service provision site promoting beneficiary/client rights and protections from stigma and
discrimination regardless of age, disability, gender identity, HIV status, race or affiliated group, religion, or sex that applies to all staff
7.2 Target population (by age, sex, economic status etc) for stigma and discrimination are identified
7.3 There is specific stigma and discrimination reduction activities supported by job aid to reach target population
7.4 Beneficiaries/clients are made aware of their rights (e.g. Statement posted in plain view, systematic verbal explanation of their rights,
informed consent)
7.5 Service providers (CEFs, CRPs, support staff, volunteers) are trained on this statement annually

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7.6 There’s an anonymous and/or confidential way to report violations of this statement (e.g. Suggestion box in bathrooms, anonymous call)

Standard 8: STI screening and referral

8.1 All PLHIV are screened for STI signs or symptoms every month
8.2 There is clear guideline/job aid for referring beneficiaries/clients who report an STI sign or symptom (e.g., vaginal or urethral discharge,
genital ulcer disease, or [for women] lower abdominal pain) to a health facility for further management
8.3 Review of 19 beneficiary/client records from within the last three months shows that at least 70 percent of registers/records reviewed have
documentation that the beneficiary/client has been screened for STI signs or symptoms
8.4 Review of 10 beneficiary/client records from within the last three months shows that at least 80 percent of registers/records reviewed have
documentation that the beneficiary/client who was referred for STI screening has confirmation of receiving the service

Standard 9: TB screening and referral

9.1 All PLHIV are screened for TB signs or symptoms every month
9.2 There is clear guideline/job aid for referring beneficiaries/clients who report a TB sign or symptom (e.g., cough, weight loss, night sweats) to
a health facility for further management
9.3 Review of 19 beneficiary/client records from within the last three months shows that 100 percent of registers/records reviewed have
documentation that the beneficiary/client has been screened for TB signs or symptoms
9.4 Review of 10 beneficiary/client records from within the last three months shows that at least 80 percent of registers/records reviewed have
documentation that the beneficiary/client who was referred for TB screening has confirmation of receiving the service

Standard 10: Family planning education and referral

10.1 CEFs/CRPs deliver information on family planning, safe pregnancy, and available FP service options at least once in a quarter
10.2 CEFs/CRPs have job aid for providing information on FP
10.3 Supervisors conduct supportive supervision visits on at least a quarterly basis to monitor the quality of FP activities provided by
CRPs/CEFs
10.4 CEFs/CRPs track FP referrals to confirm the beneficiary/client received the service
10.5 Review of 19 beneficiary/client records from within the last six months shows that at least 90 percent of registers/records reviewed have
documentation that the beneficiary/client has been provided with FP information
10.6 Review of 10 beneficiary/client records from within the last six months shows that at least 80 percent of registers/records reviewed have
documentation that the beneficiary/client who was referred for FPs service has confirmation of receiving the service

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Standard 11: Malaria education and referral
11.1 All PLHIV are provided with malaria education using ABDE (Awareness - be aware of risks, Bite prevention, Diagnosis – early diagnosis for
survival, and Effective treatment) at least once in a quarter
11.2 There is job aid for malaria education and referral to a health facility for further management
11.3 There evidence/documentation that PLHIVs has been screed whether they sleep under ITN
11.4 Review of 19 beneficiary/client records from within the last three months shows that at least 90 percent of registers/records reviewed
have documentation that the beneficiary/client sleep under ITNs

Standard 12: Food water safety and hygiene education and referral
12.1 CRPs/CEFs provide education on food hygiene and water safety and personal hygiene at least once every quarter
12.2 CRPs/CEFs have job aid for providing education on food hygiene, water safety and personal hygiene
12.3 Review of 19 beneficiary records from within the last three months shows that the water source for each client has been identified
12.4 Review of 10 beneficiary/client records shows that at least 80% of them consume safe water (either treat at home or get water from
tape water or protected source)

Standard 13: Adult and pediatric nutrition screening and referral

13.1 CEFs/CRPs screen nutrition status of adults by MUAC, visible wasting, weight scale and/or reported unexplained weight loss as a basis for
referral to clinical services at least every six month
13.2 Review of 19 beneficiary/client records from within the last six months shows that at least 80 percent of registers/records reviewed have
documentation that the beneficiary/client has been screened for malnutrition
13.3 Review of 10 beneficiary/client records from within the last six months shows that at least 80 percent of registers/records reviewed have
documentation that the beneficiary/client referred for further nutrition assessment has received services

Standard 14: Positive health, dignity and prevention (PHDP)????

14.1 CEFs/CRPs are trained on PHDP over the past year
14.2 CEFs/CRPs have job aid for promoting PHDP
14.3 PLIVs or their associations have direct involvement in services provided to clients

Standard 15: Mental health and substance abuse

15.1 CEFs/CRPs assess alcohol and other drug use and providing reduction counseling to clients at least once in a quarter

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15.2 Review of 19 beneficiary/client records from within the last three months shows that at least 80 percent of registers/records reviewed
have documentation that the beneficiary/client has been assed for alcohol or drug use
15.3 Review of records of individuals with identified heavy or dependent alcohol consumption/drug use shows that they are referred to
substance abuse treatment programs and/or a professional trained to provide substance abuse counseling and feedback is collected

Standard 16: GBV prevention and response

16.1 CEFs/CRPs have job aid for providing and referring for post-GBV clinical and non-clinical (justice) services
16.2 The job aid include explaining to gender based violence victims about the importance of going to a health facility to access post-
exposure prophylaxis (PEP) within 72 hours of the sexual violence, AND a process for making an immediate referral to a facility
16.3 CEFs/CRPs are involved in active identification of cases of GBV (also known as community-based violence screening) with both the use of
a standard set of questions, AND an established link to a health facility
16.4 Review of 19 beneficiary/client records from within the last three months shows that at least 80 percent of registers/records reviewed
have documentation that the beneficiary/client has been assessed for GBV experience
16.5 Review of records of individuals with identified GBV shows that they are referred to facility and other legal service and feedback is
collected

Standard 17: Economic strengthening

17.1 CEFs/CRPs have a written SOP to implement ES program and vulnerability and economic assessment tool for categorizing ES participants
according to their level of Economic vulnerabilities.
17.2 CEFs/CRPs Conducted vulnerability and economic assessment for ES participants at least every six months and analyze data, publish
results and produced reports (There is documentation for this)
17.3 CEFs/CRPs assess economic status of PLHIV at least every six month and identify economically vulnerable households and refer for
economic strengthening or social protection
17.4 Review of 19 beneficiary/client records from within the last six months shows that at least 80 percent of registers/records reviewed
have documentation that the beneficiary/client has been assessed for economic vulnerability
17.5 Review of records of individuals with identified as economically vulnerable shows that they are referred to and feedback is collected
17.6 CEFs/CRPs monitor success of economic strengthening support at least every six months

Referral and linkage

Minimum standard
18.1 CEFs/CRPs have referral directory
18.2 CEFs/CRPs update referral directory at least annually

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18.3 There is a referral system in place, with standard tools (referral forms or vouchers given to beneficiary/client where forms or vouchers
are collected from referral points to track receipt of services
18.4 There is written or electronic register used to monitor follow-up through phone calls to beneficiaries/clients to track both referrals made
to high-impact services, AND whether the beneficiary/client received those services
18.5 Review of 19 referral records from within the last three months shows that at least 80 percentage has been successfully linked (e.g.
evidence of a signed counter-referral slip from the receiving facility or service)
18.6 Referral and linkage data are reviewed monthly to ensure that the linkages were successful
18.7 Data are used to improve the referral and linkage system and there is documented evidence for this
18.8 Lost to follow up (including those on appointment, missed appointment, lost, dropped ) is monitored every week. Review of LTFW
register shows that the status of at least 90% of LTFU clients is known.

Beneficiary Records
Minimum standard
1.1 Individual beneficiary/client records are maintained with adequate and secure space
1.2 Client records are filed and organized in a way that allows staff to locate client’s file by name or unique identifier
1.3 The filing system allow for identification of clients by service provision category, geographic location, or population (e.g., OVC, PLHIV, WDW)

Data Quality
Minimum standard
1.1 There are written standard procedures available and followed for data quality activities (Recording procedure, reporting procedure and
deadline, indicator definition)
1.2 There is routine data quality assessment/data verification performed over the last quarter (Check if there is any findings and action plans
done for data quality improvement)
1.3 There is utilization of data for decision making (check for graphs, tables, run charts etc)
1.4 Data reporting validation done at least once in the last quarter

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Quality management/Quality assurance and improvement
Minimum standard
1.1 There is QI/A team with members including client representatives/PLWHIV
1.2 The QI/A team have an approved ToR by members of the team
1.3 The QI/A team conducts at least monthly meeting and there is evidence for this (Minutes)
1.4 The QI/A team assess service provision and performance at least every quarter to identify performance bottlenecks (check for assessment
findings)
1.5 The QI/A team has a written action plan with defined roles and responsibilities
1.6 The QI team review HIV positive yield and device method to improve yield (After 40 tests, if there is no HIV positive result, the CEFs should
stop testing and discuss with the QI team on ways to target clients with highest risk)

Coordination with public sector

Minimum standard
1.1 There’s coordination with governmental (Woreda/Town Health Office, Health center, UHEPs, Social workers) or nongovernmental entities to
increase linkages between services and/or ensure sufficient geographic coverage
1.2 There is regular joint supportive supervision at least biannually and documented evidence for this
1.3 There’s at least quarterly review meeting with stakeholders and documented evidence for this
1.4 Functional eMRIS

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