Risk factors, Barriers and
Facilitators for Linkage and
Retention in Care in
different settings
Dr. B .B .Rewari
MD,FRCP, FICP,FIACM,FIMSA
WHO National consultant
Care , Support and Treatment
National Programme Officer (ART)
National AIDS Control Organization
India
BBR--India
www.ias2013.org
02/07/13 Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Outline of the presentation
Snap shot of National AIDS control Program
Overview of Care, Support and Treatment programme
Risk factors & barriers for linkages & retention in care
Enhancing Patient retention under National programme
Standard Operating Procedures for patient flow in Care
Support Treatment Services
Use of M& E systems for optimizing patient retention in
HIV Care
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Current HIV Scenario in India
• First few cases of HIV in India detected in Chennai in 1986
• A concentrated low level heterogeneous epidemic , main
route of transmission being sexual
• Prevention is the main focus
• Prevention programme reaching vulnerable population
• No. of new infections dropped by 57% over last one
decade; death rates leveling off;
• ART being provided free to 6.5 lakh PLHIVs;
• India’s programme hailed as a ‘success story’, unique
partnership between Govt. and NGOs and a multi-sectoral
response
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Declining Trends of HIV Epidemic in India
Female: 39% of PLHIV; Children: 7% of PLHIV
www.ias2013.org
Lumpur, Malaysia , 30 June - 3 July 2013
Source: Technical Report India
HIV Estimates Kuala
2012,
NACO & NIMS
District-wise Scenario of HIV/AIDS
Category
www.ias2013.org
Category
NACP-III
A
156
B
39
C
296
D
118
New Districts
30
Total
609
NACP-III Definition
A
> 1% ANC prevalence in any of the sites in
the last 3 years
B
< 1% ANC prevalence in all the sites during
last 3 years with > 5% prevalence in any
HRG site (STD/FSW/MSM/IDU)
C
< 1% ANC prevalence in all sites during last
3 years with < 5% in all STD clinic
attendees or any HRG, with known hot
spots
D
< 1% ANC prevalence in all sites during last
3 years with < 5% in all STD clinic
attendees or any HRG OR no or poor HIV
data Kuala
with no
known
hot ,spots
Lumpur,
Malaysia
30 June - 3 July 2013
5
NACP Strategies
Prevention is the mainstay
High risk
populations
Care, Support and Treatment
Low risk
populations
People living with
HIV/AIDS
•Targeted Interventions for High Risk Groups (FSW,
MSM, IDU, Truckers & Migrants)
• Link Worker Scheme for rural population
•Prevention & Control of Sexually Transmitted Infections
•IEC, Social Mobilization & Mainstreaming
•Condom promotion
•Blood safety
•Counselling & Testing Services (ICTC, PPTCT, HIV/TB)
Strategic Information Management
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•First line & second line
ART
• Care &Support Centres
• HIV-TB
Coordination
•Focus on PPTCT
•Treatment of
Opportunistic Infections
Institutional Strengthening
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Evidence of Programme Impact
57% Reduction in New Infections
(2000-11) with Scale-up of Prevention
Strategies
29% Reduction in AIDS-related Deaths
(2007-11) with Scale-up of Anti-Retroviral
Treatment
Lumpur, Malaysia , 30 June - 3 July 2013
Source: Technical Report Indiawww.ias2013.org
HIV Estimates Kuala
2012,
NACO & NIMS
Care, Support & Treatment Programme in India
• Launched on 1st April 2004 at 8 institutions in 6 high prevalence states
& Delhi
• Presently scaled up to network of 1100 ART centers and Link ART
centers
• All PLHIV including children registered in HIV care are provided free
diagnostic & treatment services
• Nearly 1.5 million PLHIV registered in HIV care
• 0.65 million are currently on ART
• Concept of Link ART centers evolved in 2008 for decentralization of
services so as to facilitate easy access to services
• All ART centers linked to Community Care Centers run by NGOs
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Public Health
Infrastructure
Selected Medical
colleges
Medical college and
District Level
Hospital
Sub-District level
hospitals & CHC
Three-Tier Model of HIV Treatment Service
CoE &
ART Plus
Centres
(43)
ART Centres
(400)
Link ART Centres and LAC Plus Centres
( 850)
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Why Focus on retention?
Consequences of Poor Retention
Society
•
•
•
Increased HIV transmission risk
Higher hospitalization rates & burden on health resources
Increasing prevalence of resistance
•
•
Increased need for second & third line therapies
Productivity of individual for society
Individual
•
•
•
•
•
•
•
Decreased likelihood of timely initiation of ART
Further breakdown of immune system & Faster
disease progression
Increased hospitalization rates
Quality of life and survival rates
Emergence of resistant viral strains
Limited future treatment options
Higher financial burden
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Risk factors and barriers for linkage and
retention
Policy related
factors
Operational
/systemic
factors
Retention
Patient
related
factors
Environmental
& Social
factors
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Risk factors and barriers
for linkage and Retention
Policy related factors
Accessibility to testing & treatment services
Affordability of services
Public health infrastructure & systems
Political & government commitment
Sustainability of services
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Risk factors and barriers
for linkage and Retention (contd.)….
Operational /Systemic issues
Stigma & discrimination in health care facilities
Attitude of staff in health care facilities
Timings of facilities, long waiting at facility ( esp. for HRGs &
children)
Lack of knowledge /skills in Health care Providers
Lack of guidelines & SoPs
Lack of /inadequate M & E systems
Poor Supply chain of commodities
Quality of services
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Risk factors and barriers
for linkage and Retention (contd.)….
Patients specific issues
Economic reasons
Long distance to facilities
Status of health – perception of good health/ ill health/coexisting
diseases or illness
Lack of support from family & community
Other engagement/priorities/being away from home
Lack of information on linkages, follow up & treatment adherence
Complicated drug schedules
Side-effects & toxicities
Misconceptions about treatment
Treatment Fatigue
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Risk factors and barriers
for linkage and Retention (contd.)….
Environmental & Social factors
Natural Calamities - earthquakes, floods
Climatic conditions : rains , extremes of weather
Occupation, harvesting seasons
Migration
Festivities/ family engagements
Cross border issues
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Facilitators for retention in Care In India
Policy Factors
• Free of cost testing & treatment
• HIV testing & treatment services built upon the existing
health systems by strengthening/supporting them
• Strong commitment from Government of India
• Mainstreaming initiatives
• Evidence based scale up
• Drug prices brought down by Indian Generic companiesvery helpful for patients in private set up
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Facilitators for retention in Care (Contd.)…
o Operational/systemic factors
 Standard Operating Procedures for patient follow up

Standardized reporting & recording mechanism
 Operational research studies commissioned to identify the factors
affecting services uptake
 Data collected through M & E, research & field experience is used for:
» updating standard operating procedures for the facilities
» monitoring quality of care including CD4 test for all, early ART initiation, ART
for all those eligible, LFU/Missed rates
» for policy making , planning scale up and launching new initiatives to
address the gaps for better outcomes
– Structured training curriculums for all staff on issues related to HIV,
SoPs & M & E systems
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Facilitators for retention in Care (Contd.)…
• Patient related factors
 PLHIV appointed as Care coordinator at all ART centers to make services
more patient friendly, for peer counseling and to reduce stigma
 Scale up and decentralization of ART services done so as to improve
accessibility to services.
 Established grievance redressal mechanism in each state
 Community engagement--CCC and DLN outreach workers involved in
patient tracking and monthly meeting held between CCC & ART centre for
exchange of lists and information
 Laisoning with other ministries & departments so that PLHIV can take
benefits of existing social protection schemes like free travel, food security,
widow pension etc
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Standard Operating Procedures for patient flow in
Care Support Treatment Services
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Key Features of M&E systems for ART
 Standardised recording and reporting
tools
 Standardised definitions for all
indicators
 PLHA software to capture
indivualised information of each
PLHIV
 Robust M & E system: SIMS
 Team trainings of ART centre staff on
M& E
 Operational Research to support the
programme
www.ias2013.org
TRAINING MODULE
On
MONITORING AND
EVALUATION TOOLS
For
HIV CARE
AND
ANTIRETROVIRAL
TREATMENT
April 2011
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Recording and reporting tools are for…
• Individual treatment records/case management
• Line-list for specific groups for intensified
tracking e.g. pregnant women, HIV
exposed/infected infants, TB-HIV
• Clinic Management formats- ‘daily due lists’, CD
4 due list, appointment dairy, Phone calls on
missing appointment etc
• Monthly report formats for routine programme
monitoring
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Various Stages in Retention of patients in HIV care
Stage 1:
Testing to
Enrollment
From HIV
detection to
enrollment in
HIV care
facility.
Stage 2:
Stage 3:
Stage 4:
Enrollment to Eligibility to ART initiation
Eligibility
Start of ART to Life Long
Care
M&E Systems for CST
From
enrollment in
HIV care to
ART eligibility
testing.
From point of
ART eligibility
to the start of
ART
www.ias2013.org
From ART
initiation to
continued life
long ART
follow up
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Stage 1. Testing to enrolment in HIV care:
Barriers in linkages
Data from ART centres showed that there was a significant loss
from detection at ICTC to registration at ART centres ? Why this
drop out when they have come in interface with a trained
counselor at testing site







Reasons were varied
10000 ICTC vs 200 ART centres
Huge distances, loss of wages
Lack of awareness about ART programme
Asymptomatic
Inadequate post test counseling
Stigma , discrimination, fear of disclosure
What next, How this helped?
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
OR Study on Factors Affecting Enrollment
of PLHA into ART services (2011)
The study was done at 30
ICTC and 10 ART centres.
Cohort of 1057 newly
diagnosed HIV-positive
people followed over 2
months in four states of
country.
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
OR Study on Factors Affecting Enrollment
of PLHA into ART services (2011) (contd.)….
Most commonly cited problems among those registered:
• Transportation and distance to ART centres 11%
• Financial constraints and loss of wages
4.5%
• Difficulty in traveling when sick
5.3%
• Locating the ART centre in the hospital
2.9%
• Fear of disclosure & stigma
9%
Most commonly cited problems among those not registered :
•Perception of relatively good health
•Work and family engagements
• Fear of disclosure & stigma
www.ias2013.org
30%
22%
9%
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Strategies taken up to improve linkages from ICTC
detection to registration in HIV Care
Improving accessibility to ART services
• Scale up & decentralization of ART services
• Pre-ART care introduced at LAC level
Improving systems for monitoring
 Triplicate Referral slips with feedback mechanism have been introduced
 E-mechanisms such as google docs being used for sharing & generating daily
due lists
• Monthly coordination meetings between ART centres & ICTCs at DAPCU level
for data reconciliation
• Tracking system for those not registering by ICTC counselors
• Documentary address proof and phone number of patient and one care giver(
most patients have mobile nos.) for tracking in case of LFU
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Triplicate ICTC-ART Referral Slip
State AIDS Control Society
State AIDS Control Society
State AIDS Control Society
Referral Form
Referral Form
Referral Form
Name & Address of
ICTC:__________________________
Copy-1 (to be retained at the ICTC)
Part-1 to be filled by the ICTC Counselor/Staff
Nurse
Name of Counselor:
Date of
referral
PID No.
Name & Address of
ICTC:_________________________
Copy-2 (to be carried by the client to the ART
centre)
Part-1 to be filled by the ICTC Counselor/Staff
Nurse
Name of Counselor:
Dat
e of
refe
rral
PID No.
Name & Address of
ICTC:_________________________
Copy-3 (to be sent to ART centre through email or post)
Part-1 to be filled by the ICTC Counselor/Staff
Nurse
Name of Counselor:
PID
No.
Dat
e of
refe
rral
Name of the client(optional):
Name of the client(optional):
Name of the client(optional):
Age:
Age:
Age:
Sex:
Ph. No.:
Category of the client (Tick Mark):
ANC/General/Exposed infant
Name and address of the ART centre referred to
Counselor's signature:
Sex:
Ph. No.:
Ph. No.:
Category of the client (Tick Mark):
ANC/General/Exposed infant
Category of the client (Tick Mark):
ANC/General/Exposed infant
Name and address of the ART centre referred
to
Counselor's signature:
Name and address of the ART centre referred to
Counselor's signature:
Part-2 to be filled by the ART centre staff
Sex:
Part-2 to be filled by the ART centre staff
Part-2 to be filled by the ART centre staff
Has the patient reached ART centre: Yes/No
Has the patient reached ART centre: Yes/No
Has the patient reached ART centre: Yes/No
If Yes
Pre ART Regn
No.
If Yes
Pre ART Regn
No.
If Yes
Pre
ART
Regn
No.
CD4
Count
ART Initiated
(Yes/No)
If ART initiated
reason
If ART initiated
reason
ART Counselor Signature
CD
4
Cou
nt
ART Initiated
(Yes/No)
CD
4
Cou
nt
ART Initiated
(Yes/No)
If ART
initiated
reason
ART Counselor Signature
ART Counselor Signature
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
ICTC –Registration in HIV care-Improved with better
M& E systems
2500000
90.0
78.4
80.2
80.0
72.5
2000000
68.2
1907144
1841144
70.0
60.5
1548557
1443611
50.4
1500000
1529000
50.0
1309906
1122351
40.0
1010393
1000000
60.0
893567
30.0
727659
611754
500000
20.0
366641
10.0
0
0.0
2007
2008
2009
ICTC detection
www.ias2013.org
2010
2011
Registraion
2012( March)
%
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Stage 2: Enrollment to Eligibility
Barriers
• Lack of proper counseling at the time of
registration
• Non-availability of facility for CD4 testing at all
sites,
• Patients registering at late hours when OP lab
facilities are closed
• Non –availability of Lab technician
• Supply chain of CD4 kits
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Stage 2: Enrollment to Eligibility
Solutions
 CD linkage and sample transportation mechanism
developed, samples transported by the lab technicians
 Patients who have borderline CD4 counts are monitored
more closely and frequently
 Proper counseling and CD4 due list are the two important
measures to ensure regular follow up and timely initiation
of ART
 A Green Book is issued to patient that gives details about his
CD4 count treatment and follow up visits in local language,
which helps patient in keeping his appointments
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Stage 3: ART Eligibility to ART Intiation
Barriers in retention in stage 3
• Delay in timely CD4 count or clinical assessment (due
to Pre-ART LFU);
• Lack of patient information to patient on ART initiation
• Lack of preparedness/reluctance of the patient for
initiation of ART
• Delay in laboratory investigations
• Co-existing TB infection & others
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Stage 3: ART Eligibility to ART Enrolment
Solutions
 CD4 reports to be given by the counselor with proper
counseling about ART on follow up
• ART initiation preparedness counseling is an important
component of Pre-ART counseling. All aspects of the ART are
discussed and explained to the patient
• Line listing of patients eligible for ART but not Initiated
• Follow up of this list by phone calls and through various
outreach mechanisms.
 Outcome: Nearly 86% of patients initiated on ART within one
quarter
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Stage 3: ART Eligibility to ART Enrolment
Solutions
HIV-TB collaboration:
• All HIV-TB co-infected patients are eligible for ART.
• Referral of PLHIV into RNTCP for TB diagnosis & treatment
led to gaps at this stage. Many patients used to turn up after
ATT completion
• HIV-T B collaborative activities strengthened. Line list of TB
suspects prepared ART centres at ART centres and given to
RNTCP for feedback.
• Patients are being intiatied now early after start of ATT
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
HIV-TB patients: linkage to CPT and ART – Trend
12000
93%
93%
87%
91%
90%
90%
91%
93%
91%
92%
93%
100%
91%
82%
10000
78%
74%
70%
70%
66%
8000
47%
41%
80%
74%
68%
6000
90%
50%
53%
58%
55%
59%
62%
60%
50%
43%
40%
4000
30%
20%
2000
10%
0
0%
4q08
1q09
2q09
3q09
4Q09
1Q10
2Q10
3Q10
Number of HIV+TB patients receiving ART
% of HIV+TB patients receiving ART
www.ias2013.org
4Q10
1Q11
2Q11
3Q11
4Q11
1Q12
Number of HIV+TB patients receiving CPT
% of HIV+TB patients receiving CPT
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Stage 4: ART initiation to Life Long Care
System Reasons why ART Patients Fail to
adhere to treatment
The ART centre
is too far away.
The lines (and the wait) at
the centre are too long.
Medicines cost
too much
Reasons why
ART patients
fail to take
their pills as
directed.
In case of child patients: Not able to
get the tablets of the right size.
www.ias2013.org
Drugs are out of stock at
the centre.
Doctor or counsellor
did not explain how to
take it.
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Personal Reasons why ART Patients Fail to Take Pills as
Directed
My husband and I both have to take
the pills but his ran out so I decided to
share mine.
Medicine makes me
more sick.
I have taken the
medicine for 6
months.
It’s too complicated.
Reasons why ART
patients fail to take
their pills as
directed.
This medicine will make
me impotent.
I don’t have time.
I went on
holiday.
ART drugs produce
heat in the body.
I don’t want to mix it with my
ayurvedic medicine.
Nothing can kill AIDS.
I’m saving the drugs in case I
can not go to the centre on
time.
I forgot.
I drank alcohol
and forgot.
I’m worried my family
will ask too many
questions and find out
my status.
I’m feeling better now.
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
OR to see clients perspectives on LFU
An ASSESSMENT OF ART CENTERS IN INDIA:
CLIENT & PROVIDER PERSPECTIVE was carried out
 Data were gathered in 27 ART centers through:
– Facility Assessment
– Health Providers Interview
– Exit interviews with Clients
A total of 1373 clients and at least 5 health care
providers were interviewed per centre
Journal of Indian Medical Association, vol. 107, pp. 276-280, 2009
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
As reported, 14 percent (164) were not visiting regularly.
Reasons for not coming regularly:
1. Long distance
2. Financial reason
Reasons for not comming ART center regularly
10%
6%
due to long distance
36%
adverse w eather
due to sickness
financial reason
social reason
Other
32%
5%
11%
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Average expenditure incurred for availing ART services (in Rs)
less than 100
7.9
100-200
more than 200
16
No response
57.1
19
Note: Though free treatment is available in the center, expenditure defined
here related to the transportation cost for reaching ART center and returning
back, money spent on tea or food during waiting time etc.
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Planning strategies taken up after research outcomes
to improve retention of patients on ART
Need for Decentralisation of ART services
Concept of Link ART centres was initiated in 2007 to
provide ART Services closer to clients
Any concession in bus or train travel will benefit
Concessions in Railway fare . States have also taken up with
state Transport
Need for capacity building
Centres of Excellence were developed to cater for training
needs
Outcome: On ART LFU rates has been brought down from 12 % to
7%
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Functions of Link ART Centres
Pre-ART management (
only at LAC plus)
Provide ARV drugs to
stable PLHIV on ART
Adherence
counselling &
monitoring of
PLHIV on ART
(side effects/OIs)
Back referral to ART
Centre
LAC/ LAC
plus
Screening of HIV
TB Coinfection
Psycho–social
Support to PLHA
Treatment of minor
OIs
Tracing of LFU/Missed
cases
9
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
LINK ART CENTERS
The study was done in four states:
Gujarat, Maharashtra, Rajasthan &
UP
Results indicated
•Time taken for travel reduced
considerably (Median time taken
:60 minutes)
•The distance traversed also
reduced (Median distance: 25 Km)
•97 % of the patients were
attending LAC regularly every month
•95 % PLHIV reported that waiting
time <30 minutes for availing
counseling & collection of drugs
•Median expenditure on travel Rs 40
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Mechanism to reduce “On ART LFU”
1. All the patients who were supposed to come to the ART centre on
a particular day as per the “daily due list” but have not come, need
to be listed at the end of the day
2. If they do not turn up in the next 48 hours, they need to be called
up through telephone
3. Line list to track “On-ART” patients who have missed their
appointments shall be prepared on a weekly basis and shared with
the ORWs. All those patients who were scheduled to collect ARV
drugs in that particular week but did not show up, shall be entered
in that week’s line list, which shall then be shared with ORW’s of
CCC, DLN, etc
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Tracker Format
10
1. MIS
2. LFU
3. Others
www.ias2013.org
11
12
13
1. Agreed to visit
ART
2. PhysicallyTaken
to ART Center
3. Facilitated
Financial Support
4. Family
involvement
5. Information
about Death
6. Others
14
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Date of visit at ART Center post followup at CCC
9
Discription
8
Outcome of Visit
7
Date of visit by ORW
Reasons for follow up
6
dd/mm/yy
Client ID given at CCC
Due Date of visit at ARTwhen the
patient did not turn up
Age
5
Drug Regime
4
Date of Start of ART
3
Sex
2
: mm/dd/yy
Address
ART Center ID
S.No
1
Name of Client
Date of receipt of form at CCC
Date Of
Returning
the form at
ART:
15
Additional challenges in pre-ART
• A patient registered under "Pre-ART" care is supposed to come
to ART centre, at least once in six months for follow up and CD4
test
• Patient being mostly asymptomatic fail to come on appointed
date(every six months)
• Get into other forms of treatment
• Present again when symptomatic, will have low CD 4 this time
• If he does not come on the scheduled date, he shall be listed
as “Pre-ART” patient with “CD4 due”
• Measures to track these patients shall be initiated immediately
like for those LFU on ART and line lists of such patients shall be
shared with the ORWs of CCC, ICTC, DAPCU during the
meetings
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Community engagement
•
•
•
•
PLHIV appointed as Care coordinator as all ART centers
All ART centers linked to Community Care Centers
ORW at CCC are PLHIV
More than 200 District level networks involved with ART
centers
• PLHIV part of all Technical resource groups and working
groups for planning of NACP
• Use of AIDS forum for understanding problems faced by PLHIV
• State level Grievence Redressal Committees has PLHIV as a
member
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Consideration for Special Groups
• Special timings for FSW at ART centre
• Leave from school to CLHIV to attend ART centre
• Co location of ART and OST centers at Public health
facilities to reduce loss to follow up among IDUs
• Considering split timings/Sunday open for children
• ART also given to parents at pediatric centers where
CLHIV is enrolled
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Other facilitating factors
•
•
•
•
•
•
Co location of VCTC and ART centers
Integration of PPTCT with ICTC
50% travel concession by railways
Free travel by bus in many states
Linkages to AAY, subsidized food schemes
Linkage to other social protection schemes of
government, like widow pension, monetary benefit
for regularity at Art centre's to farmers
• In advanced stages in formulating an insurance
scheme for PLHIV
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
How OR studies Impacted Retention in Care
 NACO OR Study on “Assessment of ART Centers: Providers
and clients perspectives” led to concept of LAC
 NACO OR Study “Factors affecting enrollment of PLHIV in
India” led to expansion of LAC scheme to LAC plus
 “Assessment of CCC” led to revision of CCC concept
 Study on low access to second line led to concept of ART
plus centers
 Field assessment led to two monthly supply of ART to
stable PLHIV instead of one month
We Evolved As We Came Across Challenges and Went Along
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Computerized Management Information System
INPUT FORMAT
PROCESS
OUTPUT
DATA ENTRY OF SCHEDULES AT
STATE AIDS CONTROL SOCIETIES
State report
Data file
At Reporting Unit
TIME FRAME (monthly)
Filled input format from
primary data collection unit
to SACS–1 -7t of the next
month.
CENTRALISED DATA BASE
(REPORTING UNIT
MASTER) MAINTENANCE
CENTRE AT NACO
Selected
reports can
be viewed
on Internet
National
report
SACS to NACO (electronically)
7–15 of the next month
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Smart Card : Proposed Design
Card Features
Name
• 32 Kb Microprocessor
Unique ID
Smart Health Card
• Contact Interface
• SCOSTA Compliant
• PVC/ABS/PET Body
Unique Id No
Name
Address
:
:
:
Card Valid Upto
:
• As per ISO 7816
7684 6035 6359
Vikram Singh
House No 243
Jungpura
New Delhi
27/01/10
Photograph
Signature of Issuing Authority
• Background Printing
• Security Printing
Card Validity
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Signature
Issuing Authority
Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Monitoring and supervision
• Significant increase in number of facilities providing ART and the
decentralization necessitated the need for a strong monitoring &
supervisory structure .
• Realizing the need for Uniformity and Quality of care , NACO
appointed Regional Coordinators (RC) for Care, Support &
Treatment services in different parts of country . They are
mandated to travel for at least 12-15 days a month to the ART
centers and LAC in their region
• The RC’s (and SACS officials) visit allotted ART Centres at least once
in two months and send regular weekly and monthly reports to
NACO. They also mentor the sites on technical issues during the
visit and through e- communication.
• Special focus is given on centers which have high LFU/ death rate
etc or are facing some operational problems.
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Summary
• Retention in care is quite challenging
• Variety of factors affect retention, which may vary from country to
country, region to region within the country
• Health seeking behavior of people is also an important factor
• Counseling and rapport during initial contact is most vital
• Decentralization of services, abolition of user fee, provision of free travel,
reduction in stigma and discrimination are very vital factors
• Certain innovative approaches like triplicate referal slips, daily due list,
CD4 due list, Eligible but not on ART list and use of tracker format by the
community outreach workers have worked well in India
• Johns Hopkins Medicine. "How Doctors And Their Patients Communicate
May Be The Key To Stopping HIV Patient 'No Shows'." Medical News Today.
MediLexicon, Intl.,21Jun.2013.
<http://www.medicalnewstoday.com/releases/262188.phpv
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Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Thank You
www.naco.gov.in
drbbrewari@yahoo.com
www.ias2013.org
Kuala Lumpur, Malaysia , 30 June - 3 July 2013