Scale-up of OST services under the
National AIDS Control Programme
How is India doing it?
WORKSHOP
“OST in Developing Countries:
A Primer”
Atul Ambekar, Alok Agrawal (India)
Contents
Background: PWID-HIV situation in India
OST service delivery models
Capacity Building, Monitoring and Quality
Assurance of OST
PWID – HIV situation in India
• Estimated PWID
~ 200,000
~ 95% male
~ 8% living
with HIV
• Heterogeneity of
epidemic
– ‘Old’ versus ‘New’
epidemics
– Drugs injected: Heroin /
Brown Sugar;
Buprenorphine,
Pentazocine, Dpropoxyphene
– Wide variations in seropositivity (1% to 50%)
OST in India
• Buprenorphine for treatment of Opioid
dependence
– In existence since 1989
– At a smaller scale
• OST as HIV prevention intervention for PWID
– Since 2007
– Undergoing scale–up
OST scale-up in India - Buprenorphine
Number of OST centres
Number of PWID on OST
15000
16000
14000
140
12000
120
10000
100
8000
80
6000
60
4000
3000
51
40
2000
20
0
0
Year 2007-10
150
160
Year 2014
Year 2007-10
Year 2014
OST scale-up in India - Methadone
• Initiated as a Pilot Project – 2012
– 5 sites, all government hospitals
– About 600 PWID initiated on Methadone
– On the verge of scale-up
2010: The Watershed year
• Introduction of new model of OST service
delivery

OST services
Other Health services
HOSPITAL
NGO
NSEP and other Harm
reduction services
PWID

Outreach worker from
NGO takes PWID to
the OST center in
govt. hospital
HOSPITAL
with OST
NGO
NSEP and other Harm
reduction services
PWID
Mechanisms for building
capacities and ensuring
quality
Capacity Building
1. Induction Training
2. Quality Assurance / Mentoring
3. Accreditation
Evaluation
Mechanisms for building
capacities and ensuring
quality
Capacity Building
1. Induction Training
2. Quality Assurance / Mentoring
3. Accreditation
Evaluation
Induction Training on OST
0 A five day training programme
0 Conducted soon after recruitment of staff
0 Conducted for a mixed group of staff (nodal officers,
doctors, nurses, counselors, data managers,
programme managers and outreach workers)
0 Class-room type training
0 Highly interactive and participatory
0 Exposure visit – an essential component
0 BASED UPON A MANUAL
0 Outcome:
0 Trained staff who begin service delivery after receiving a
certificate
Mechanisms for building
capacities and ensuring
quality
Capacity Building
1. Induction Training
2. Quality Assurance / Mentoring
3. Accreditation
Evaluation
Quality Assurance of OST
0 In the form of ‘visits’ by OST experts / mentors
0 Visits aimed at:
0 Assessment of the quality of services
0 Interaction with and guidance to the staff on ensuring
adequate quality
0 Mentors / experts: Doctors; experience / expertise in
OST; trained on QA guide
0 Outcome: Staff receives hands-on guidance; SACS /
NACO receive a report on performance
Quality Assurance of OST
0 In the form of ‘visits’ by OST experts / mentors
0 Visits aimed at:
0 Assessment of the quality of services
0 Interaction with and guidance to the staff on ensuring
adequate quality
0 Mentors / experts: Doctors; experience / expertise in
OST; trained on QA guide
0 Outcome: Staff receives hands-on guidance; SACS /
NACO receive a report on performance
Atul Ambekar,
Ravindra Rao, Alok
Agrawal, Anju
Dhawan, Rajat Ray,
(2013), Quality
Assurance of OST in
India: A reference
guide for mentors,
NDDTC, AIIMS and
NACO, Government
of India, New Delhi
QA Guide: Contents
0 Introduction / About the Reference Guide
0 Conducting a Quality Assurance Visit
0 Preparing a Quality Assurance Visit Report
0 Tool for OST Quality Assurance Visit
0 OST Quality Assurance Visit Report - Proforma
0 Annexures: List of common problems and their
solutions; Steps for Planning and Managing QA Visits,
Conducting a QA visit
0 Inform the centre staff and concerned SACS prior to visit
0 During visit
0 Observation of the centre, including functioning of the staff and
service delivery processes
0 Review of records
0 Interaction with
0 Staff – OST centre
0 Staff – linked IDU TI
0 Beneficiaries
0 Other stakeholders
0 Use the prescribed format to conduct the visit
0 Use the prescribed format to report the visit
Tool for OST quality assurance visit
Tool for OST quality assurance visit
Section 1: Background information
Section 2: Details of the OST centre
Section 3: Staff-related Details
Section 4: Implementation Of OST
Section 5: Record Keeping-related Details
Section 6: Feedback from Clients and their Families
Section 7: Stock Maintenance & Programme Management
Section 8: Gaps Identified and Addressed
Section 9: Impression on Quality of OST Centre
Impression on Quality of OST centre
0 16 - item scoring scale
0 Each item can be scored 1, 2 or 3
0 Option for giving remarks for each item
0 Quality grading depends upon the total %
score obtained
Impression on Quality of OST centre
Item 1: OST uptake
Item 2: Recruitment and training of staff
Item 3: Knowledge and confidence of staff on OST issues
Item 4: Role clarity
Item 5:Initial assessment of clients before OST initiation
Item 6: Stabilisation dose of buprenorphine
Item 7:Follow-up of OST clients
Item 8:Changes in dose of buprenorphine
Impression on Quality of OST centre
Item 9:Duration of maintenance phase of treatment
Item 10:Follow-up of LFU/irregular clients in the field
Item 11:Dispensing-related protocols
Item 12:Record maintenance
Item 13:Stock management
Item 14:Satisfaction of clients and family members
Item 15:Client retention
Item 16: Treatment adherence and compliance
OST Quality Assurance visit report
0 Observations/findings and specific
recommendations on specific areas of
OST implementation
0 Other specific inputs provided
0 Issues for consideration by
programme authorities
Annexures
0 List of common problems and
possible solutions
0 Planning and managing the OST QA
visits
Mechanisms for building
capacities and ensuring
quality
1. Induction Training
2. Quality Assurance / Mentoring
3. Accreditation
Accreditation
0 All NGO OST centres expected to undergo Accreditation
0 Accreditation for Government centres also on the anvil
0 Conducted by an independent agency: National
Accreditation Board for Hospitals (NABH)
0 Through trained team of two experts (Technical +
Programme)
0 Using a especially prepared tool
0 Report provides
0 Scores
0 Qualitative / descriptive information
Accreditation
0 All NGO OST centres expected to undergo Accreditation
0 Accreditation for Government centres also on the anvil
0 Conducted by an independent agency: National
Accreditation Board for Hospitals (NABH)
0 Through trained team of two experts (Technical +
Programme)
0 Using a especially prepared tool 
0 Report provides
0 Scores
0 Qualitative / descriptive information
The Accreditation Tool
0 In the form of an excel sheet
0 Filled by both the experts through observations and
interaction
The Accreditation Tool
0 In the form of an excel sheet
0 Filled by both the experts through observations and
interaction
0 Sections
0 Infrastructure
0 Staff
0 Service Delivery Process
0 Performance
0 Qualitative information
0 “Essential Items” 
Accreditation: Essential items
Infrastructure
Staff
OST Service
Delivery
Processes
Storage of Medications
Doctor
OST Nurse
Regularity of functioning
Adherence to DOTS
Dosage Change
Dispensing Records
Stock records
Mechanisms to check diversion
Programme
Performance
Service utilization
Resource Materials developed for
Capacity Building and Quality Assurance
1. Training 2. SOPs
Manual
3. Practice
Guidelines
4. QA Guide