Care, Support and Treatment Services in Karnataka Dr. Suresh Shastri, MD Senior Specialist, Dept of TB Control Government of Karnataka, India Ex-Regional Coordinator Karnataka and Kerala States Karnataka State AIDS Prevention Society Bangalore

Districts with >1% adult HIV prevalence HIV/AIDS Situation in Karnataka Districts with >/= 1% women attending PreNatal Care (aka ANC in India) testing HIV+ - declined from 20 (2003) to 10 (in 2008) 2010: HIV Prevalence 0.69% 2008 (0.89%) Districts with >1% adult HIV prevalence 2004 (1.52%) 2005 (1.34%) 2006 (1.13%) 2007 (0.86%)

Goal Comprehensive Competent Compassionate Care in all Care Centres

Eight core components were identified to scale up CST services: Technical Leadership Human Resource Development Infrastructure Supplies Management Prioritization Maintaining Adherence Monitoring & Evaluation Linkages

Key components Systems strengthening Capacity building Community participation Community participation Linkages

Infrastructure / Waiting space and rooms ART Wadi- Public Private Partnership ART Wadi- Public Private Partnership ART Bagalkot- Govt District Hospital ART St Johns- Non Profit Medical School Infrastructure / Waiting space and rooms

Infrastructure / Waiting space and IEC Recreation for patients-News papers and Magazines in Chikmagalur Counselor Chamber Bagalkot ART Hassan- Govt Dist Hospital ART Tumkur- Govt Dist Hospital Infrastructure / Waiting space and IEC

Even Govt centers can look fabulous! ART Udupi- Govt Dist Hospital ART Mysore- Govt Dist Hospital (Med School) ART Belgaum- Govt Dist Hospital ART Hassan- Govt Dist Hospital Even Govt centers can look fabulous!

Pharmacy

Children Play Area

Lab ART Mangalore ART Bagalkot

Patients’ Waiting Area Display Boards in Patients’ Waiting Area Images Courtesy: ART Centre, Mandya ART Staff Names, Patients' Flow, Current Pre ART & ART Statistics Attached Community Care Centres & Link ART Centres District PLHIV Network Address

Assessment of ART Centres in India 27 ART Centres were assessed and a total of 1373 clients and at least 5 health care providers were interviewed Major findings: 36 % clients travel >/=100 kms Median expenditure per visit was nearly Rs 100 (US $2) 68 percent irregular clients: long distances and financial reasons as key reasons for not attaining services regularly. Journal of Indian Medical Association, vol. 107, pp. 276-280, 2009

Link ART Center- Taking ART to grass roots!

Innovations

Capacity building Use Modules, materials and pools of resource persons for training & mentoring all Care centres in team approach and outreach planning

Bangalore Bagalkot Mysore Program Officers and Care Providers learn through exposure visits & hands-on training at learning sites

Ongoing Capacity building Led by the State Institute of Health and Family Welfare / COE for Adult and Paediatric HIV Care IP and S & D COPE TB-HIV Paediatric HIV Home-based care Clinical Mentoring CME: Website, Fact sheets, etc., Basic minimum package Learning sites SJMC/ KHPT EH / KHPT SJMC/ SVYM/ NIMHANS NACO/ KSAPS KHPT/ SJMC Snehadaan/ SVYM

Client Oriented Provider Efficient Services (COPE) ® - Raising Benchmarks, Improving Quality in ART COPE is required for all the ART Centres - Medical Officer, Bowring ART Centre COPE helps in improved team work and helps us to work satisfactorily - CCC Coordinator, Bagalakote ART Centre Mantra for ART adherence Tumbler with chain attached to the drinking water facility

CBO/NGO extend personalized attention at individual/family level In particular. Livelihood schemes for widows and orphaned children need to be addressed in a more comprehensive manner. PPP for microenterprise Community monitoring of services especially at the PHC level

CST Services: Referrals & Linkages ARTC CD 4 testing Initiation of ART Follow up of patients in Pre-ART & ART ICTC Counselling & Testing LAC & LAC + Pre –ART Registration & Management Monitoring of PLHIV on ART Centre of Excellence / ART Plus Centres RNTCP Care & Support: Community Care Centres & DLN Trainer Notes: The trainer may explain the integration of HIV care in the general health system using the graphic linkages as shown in the slide. The model of HIV treatment services are established in the CoE’s / Medical Colleges where special facilities like the alternate first line and second line drugs are available to needy patients. Every district level hospital is designated to have an ART centre with the exception of low prevalence districts. Link ART centre is located at Community Health centre and is attached to an ART centre and have certain designated functions like drug distribution and treating minor illness. LAC serves as an important linkage between ICTCs, DMCs, CBOs and many NGOs which is located at the level primary health care systems like the PHCs. Community care centres render play important role in the care of PLHIV, which can be both ART and non-ART related. Emphasise that the details of CCC will be covered in a separate session.

Present Scenario 55 ART Centres 60 Link ART + Centres Centers of Excellence: 2 4 ART +Centres 2nd line ART Available

Scale up in Care facilities 2006: 12 ART, 11 CCC, 2 DIC 2008: 28 ART, 22 CCC, 16 DIC 2012: 55 ART, 27 CCC, 30 DIC ART Centre DIC+ CCC

Operationalisation of ART Centers in Karnataka Year wise comparison First ART Centre Started on 1st April 2004 at Bowring and Lady Curzon Hospital , Bangalore

Number of ART Centers Providing CD4 Facility

Number of Link ART and Link ART+ Centers Functioning in Karnataka

Pre ART Registration and Alive on ART (Cumulative From April-04 to March-12)

Alive on ART (Cumulative From Apr-04 to March-12)

Trend line of % Death and % LFU for Karnataka State (till March-12)

Trend line of % Death and % LFU for Karnataka State (till March-12)

Overall Breakup of ART Data (till March-2012)

Number of PLHA’s diagnosed with Opportunistic Infections (from Apr-11 to March-12) Total : 35175

Status of Link ART Centres in Karnataka

District AIDS Prevention and Control Units (DAPCU) to lead… Medical College District Hospital Community Doctors, nurses, ANMs? lay providers (ART aid) Treatment supporters, link workers, anganwadi workers, ASHA, CHWs,, peer support groups, CBOs Doctors/Nurse/ Counsellor Specialised referral CHC, PHC Drugs, diagnostics, commodities, logistic support Supervision by District HIV Management Team Referral, Back-Referral; Clinical mentoring; Outpatient Clinic Emphasis on strong facility- community link DACPU to lead with linking facilities to community initiatives Forward and backward referral Clinical mentoring and supportive supervision

HIV Care Support and Treatment: Integration Free investigations for all PLHIV New scheme announced for travel concession Innovative models of care by partnering with NGOs/CBOs OVC scheme for all infected and affected Children. Special budget for treatment of OIs by honourable CM AAY scheme implementation in all districts Inclusion of PLHIV in Rajiv Gandhi housing scheme as special category

State Specific Innovations-ART LMIS in all centers CUG network for ART SMO/MOs List server for ART mentoring Master counselors for mentoring Pharmacist training Village wise data Dedicated book on Government Schemes by Samastha being used by ART/CCCs.

But, the burden of HIV & TB care is increasing PLHIV on ART at taluka level: Jan 2010 HIV-TB co-infection: 2009 However, the burden of HIV and TB is increasing. Many of the talukas in north Karnataka have more than 250 persons on ART. Similarly 16 districts in Karnataka and all the coastal AP and southern Maharashtra districts have a HIV-TB coinfection rate of more than 10%, which is twice the national average. ~ 50% of talukas (sub-district) > 200 PLHIV on ART > 50% of districts 10%; HIV-TB coinfection double the average for India!

Most Important challenge Treatment Prevention no doubt requires a larger focus particularly in our context but care, support and Treatment is also an important pillar and with new evidence on treatment as prevention, the balance between two is also important Prevention

Key Areas for Future Action: Consolidation & coordination for care continuum Health System Strengthening: Ongoing capacity development Linked CMIS Community Outreach: Children affected/infected by HIV CBO (PLHIV/TI) involvement Committees (VHSC)

Thank You