Table 1 Essential steps in down referral of HIV/ART services from hospital to primary health care clinic level

Joint hospital, primary level care staff and patient representatives to discuss feasibility of down referral

Down referral criteria established

Phased implementation according to capacity

Establish dedicated team who will oversee down referral process

Well trained and adequate number of clinicians

Continued coaching and training during down referral

Task shifting

Receptionists and data managers to accurately register and track patients

Adequate clinic space (i.e. consultation rooms and pharmacy)

Ensure adequate supply of antiretroviral medications

Peer counsellors trained at hospital and PHC level on how to negotiate process of down referral with service users and service providers

Improve efficiency of patient care by establishing fast track and designated phlebotomy dates

Implement appropriate and simplified data collection tools

Standardize identification numbers between tertiary and primary care centres so tracing would be easier

Establish regular contact between tertiary and primary levels to ensure all transferred patients are enrolling at PHC level

Conduct lost to care tracing of patients who are down referred but are subsequently "lost"

Train counsellors at the tertiary and PHC level on how to educate patients on the process of the down referral