1. 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

2. 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%) (1.34%) (1.13%) (0.86%)

3. Goal
Comprehensive
Competent
Compassionate
Care in all
Care Centres

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

5. Key components Systems strengthening Capacity building
Community participation
Community
participation
Linkages

6. 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

7. 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

8. 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!

9. Pharmacy

10. Children Play Area

11. Lab
ART Mangalore
ART Bagalkot

12. 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

13. Assessment of ART Centres in India
27 ART Centres were assessed and a total of 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.  , 2009

14. Link ART Center- Taking ART to grass roots!

15. Innovations

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

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

18. 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

19. 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

20. 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

21. 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.

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

23. 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

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

25. Number of ART Centers Providing CD4 Facility

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

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

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

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

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

36. Overall Breakup of ART Data (till March-2012)

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

40. Status of Link ART Centres in Karnataka

41. 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

42. 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

43. 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.

44. 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!

45. 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

46. 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)

47. Thank You