The National Initiative to Strengthen and Coordinate HIV-TB response (NISCHIT), supported by the US Centers for Disease Control and Prevention (CDC) through the President's Emergency Plan for AIDS Relief (PEPFAR) aims to strengthen the national response on improving the antiretroviral therapy (ART) services and HIV-TB management for people living with HIV (PLHIV). As a key implementing partner, SHARE INDIA provided technical assistance (TA) to the National AIDS Control Organization (NACO).
Addressing diverse needs of People Living with HIV
Differentiated Service Delivery Models
With adoption of “Test and Treat” policy, more patients were initiated on treatment and hence maintaining quality became essential to ensure retention and better treatment outcomes. To enhance quality of treatment services, SHARE INDIA has supported provision of differentiated care services to people living with HIV (PLHIV). Differentiated service delivery, also known as Differentiated care, is a client-centred approach that simplifies and adapts HIV services to reflect the preferences and expectations of PLHIV while reducing unnecessary burden on the health system.
Project covers 6 select focussed districts of Maharashtra and Andhra Pradesh
Demonstrated differentiated service delivery models
Scale up HIV viral load monitoring
Strengthen HIV-TB prevention and management
Technological solutions for monitoring treatment adherence
Multi-Month Dispensation improving retention in care
Multi Month Dispensation (MMD) is one of the strategies of Differentiated Service Delivery Models (DSDM), where the patient receives antiretroviral medication for three months and will have less clinic visits.
Multi-Month drug dispensation proved to be potentially effective approach in ensuring access to quality care, retention and adherence to treatment. Significant efforts made by the project has yielded positive outcome where about 53,989 eligible PLHIV were initiated on 3 Month Dispensation and among those 93% of them reported on time pill pick up which has demonstrated positive impact on treatment adherence.
SHARE INDIA provided technical assistance to Andhra Pradesh State AIDS Control Society (APSACS) to successfully scale up Multi Month Dispensation across all the 40 ART centers in the State. Standard operating procedures (SoPs), Job aids, M& E tools, regular onsite and virtual monitoring of health centers aided in achievement of these outcomes.
Decentralisation of HIV care and treatment services – ART initiation at testing centres
In order to decentralize and mainstream HIV care and treatment services with the health system, an innovative approach of providing HIV treatment (ART initiation) at peripheral health centers was implemented. Decentralisation of HIV services with the general health system helps to increase access to ART services and decongest the ART centers. It is also envisaged that this model aids in reduction of linkage loss between HIV diagnosis and ART initiations and enhance retention of PLHIV on ART.
The intervention was undertaken at LAC-plus centres located at Area Hospitals of Nuziveedu, Bapatla and Ramachandrapuram located in Krishna, Guntur and East Godavari districts respectively. Feasibility assessment was undertaken in the three sites to ascertain the possibility of ART initiation where availability of resources and specialist medical officers was a criterion. Nominated staff was trained. Recording tools were modified to suit the intervention and updating the patient's details in Inventory Management System (IMS) was initiated at Link ART Centre plus sites.
Decentralising HIV treatment substantially increased access to care and treatment to people living with HIV, where about 40 % of eligible PLHIV were initiated on ART.
Integration of HIV/AIDS services in Tribal Health
Tribal health was one of the areas of concern where the tribal population faces burden of diseases exacerbated by the low access to healthcare especially for HIV/AIDS. Improved access to health services will result in patients undergoing treatment adhering to it, resulting in healthier and longer lives.
Integrating HIV/AIDS-related services into the tribal health plan, provide the opportunity to enhance the quality of care provided to PLHIV in the hard-to-reach tribal areas of East Godavari district and has demonstrated positive outcomes in providing access to ART treatment services and engaging them on care. To integrate HIV/AIDS care, support and treatment services in tribal health facilities, two Link ART centers at Area Hospital, Chintoor and Community Health Center, Kunavaram, tribal areas of East Godavari district.
A special drive was conducted to track PLHIV who had missed doses (MIS)/Lost to Follow up (LFU) and initiate them on ART, and about 102 LFUs were successfully tracked and retained on care. Seven out of 18 PLHIV who are on Pre ART and LFU and 13 On ART and LFUs reported at the LAC centre and got initiated on ART. About 70 % of LFUs and MIS cases were linked to Link ART Centres for re-engagement in care.(more information: Integration of HIV/AIDS care support and treatment services in Tribal Health)
Prisoners have been identified as one of the special groups under NACP, and NACO aims to address all high-risk populations living in prisons and other closed settings in the country.
Enhancing access to ART dispensation within the central prison hospitals ensured access to comprehensive care and treatment to the prison inmates. To provide access to ART treatment and improve adherence to treatment to the prison inmates, Link ART Centre were established within central prison hospital located at Rajahmundry, Visakhapatnam, Kadapa and Nellore districts. Prison Hospitals are adequately staffed, where in medical doctors, staff nurses, laboratory technicians, pharmacists and other paramedical staff, were oriented on HIV care and treatment guidelines.
With this initiative, it is envisaged that there will be considerable reduction of lost to follow Up cases , increase in adherence levels among Prison inmates on ART, as the ART drugs are available within the prison hospital, which will also in-turn reduce the burden on state government.
Scaling up HIV viral load test and uptake of test results
Viral load measurement is a critical tool to assess the impact of HIV treatment efforts, and is endorsed by the World Health Organization (WHO). SHARE INDIA supported 20,955 PLHIV access to viral load test from the three focussed districts of Andhra Pradesh and of them 67% (14,107) are virally suppressed.
To accelerate scale up of HIV-1 viral load test uptake and utilisation of test results, onsite support was provided to ART centres in identification of eligible PLHIV for test, developed and implemented monitoring tools to accelerate referral and linkage.
Initiatives & strategies
To accelerate coverage of VL testing, the following activities were taken up,
Reagent forecasting and scheduling: Based on the viral load tests anticipated in scheduled month, list of reagent forecast was submitted to SACS/NACO.
Prepare due list and align with sample collection date along with CD4 specimen collection: Based upon the eligible list, forecast made for number of patients for each sample collection day.
Fast-track result utilization: Patients with higher viral load were referred to the SACEP within 72 hours. The project team built the capacity of the ART centre staff to adhere to turn around time (TAT).
Patient education material on VL access and result: Knowledge of viral load is essential since attaining and maintaining an undetectable viral load can motivate treatment adherence. Counselling tools targeting the importance of Viral Load, result interpretation and importance of adherence to treatment were developed.
Undetectable = Untransmittable (U=U)
To promote U=U campaign, SHARE INDIA continued to mount its technical assistance on counselling and patient messaging that HIV treatment as prevention strategy, and has developed patient education materials on treatment adherence and reaching suppressed viral load.
Center of Excellence
To provide comprehensive care and treatment services to the PLHIV, Center of Excellence (CoE) was established and operationalised on 1st December 2018, at Siddhartha Medical College, New Government General Hospital, Vijayawada, in the state of Andhra Pradesh.
SHARE INDIA has provided necessary support to train and orient the service providers and members of the State AIDS Expert Clinical Panel (SACEP) to make the newly established CoE fully functional. CoE staff were trained on functioning of CoE and provided hands on support for conducting SACEP.
Strengthened SACEPs among the ten ART plus centres in the state by building capacities of the staff and through distinct mentoring and monitoring . With introduction of e-SACEP mechanism, there was reduction in time to review patients and recommend for switch to appropriate alternate regimen. Patients eligible for second line ART and alternate first line as recommended by SACEP are being initiated on second line ART at respective ART centres.
Over a period of six months a total of 621 patients were reviewed with suspected treatment failure, among those 156 patients were recommended for 2nd line and 33 patients for 3rd line.
Around the world, key populations (KPs) face much higher rates of HIV and AIDS than the general population and are most at risk for contracting HIV. UNAIDS estimates that 40 to 50 percent of all new HIV infections may occur between individuals in key populations and their immediate partner. As per the NACO HIV estimates report 2017, HIV epidemic in Andhra Pradesh continues to be a concentrated epidemic. Access to testing, care and treatment services is low among key population due to fear, stigma and discrimination.
To increase access to treatment, SHARE INDIA partnered with FHI 360 (LINKAGES) to build capacities of Targeted Intervention (TI) organizations working with key population, in the three project focus districts of Andhra Pradesh, on the importance of HIV testing, ART treatment and uptake of viral load. SHARE INDIA also supported FHI 360 and TI's in identifying and ensuring mobilisation of key population to access HIV testing, Treatment and viral load testing services. SHARE INDIA has provided technical assistance to state AIDS control society in viral load monitoring among key population.
In the fiscal year 2017-2018, from three focussed districts of Andhra Pradesh, 738 (81%) out of 914 eligible KPs have undergone viral load test and among them 499 (68%) are virally suppressed.
Worldwide, tuberculosis (TB) is one of the top 10 causes of death, and the leading cause from a single infectious agent (above HIV/AIDS); millions of people continue to fall sick with the disease each year. In 2017, TB caused an estimated 1.3 million deaths (range, 1.2–1.4 million) among HIV-negative people, and there were an additional 300, 000 deaths from TB (range, 266 000–335 000) among HIV-positive people.
India has the second-highest burden of HIV-TB cases in the world, as out of the 2.1 million people living with HIV, 110,000 are co-infected with TB and accounted for 32% of global deaths among HIV – negative people (Global Tuberculosis Report 2015, WHO). Hence screening of PLHIV attending ART centres for TB, has become utmost important. To reduce the HIV-TB burden and the morbidity and mortality associated with dual infections concerted efforts towards prevention, early detection, and prompt management of HIV as well as TB became essential. It is aimed to provide single window services for management of HIV-TB co-infections at ART centres so as to improve access to HIV-TB care and ensure seamless services to PLHIV.
Centers for Disease Control and Prevention (CDC) and SHARE INDIA supported NACO /SACS in developing policies and implementation of single window services for coinfected HIV-TB patients in the select focussed districts of Maharashtra and Andhra Pradesh.
SHARE INDIA along with US Centers for Disease Control and Prevention – Division of Global Health and TB (CDC-DGHT) India, has provided technical support to NACO and Central TB division in the development of the guidelines on Prevention and Management of TB in PLHIV at ART Centres, which was released by NACO in 2016.(http://www.naco.gov.in/ Guidelines on Prevention and Management of TB among PLHIV.pdf)
SHARE INDIA was instrumental to operationalize delivery of single window services to PLHIV which includes referral for diagnosis of TB to DMC/CBNAAT, provision of daily Anti TB Treatment (ATT), and initiation of IPT for TB prevention). It has facilitated improved access to TB screening and diagnostics among people living with HIV , where > 90% of them were systematically screened for TB and those tested and diagnosed with TB 99% were initiated on Anti TB Treatment.
Strengthening capacities of health staff
With an intent to orient and equip ART center staff to implement the guidelines on prevention and management of TB in PLHIV, trained about 956 ART staff including Medical Officers and Staff Nurses from 510 ART centers across the country .
A comprehensive training package covering all the key components of single window services – TB screening, early referral for CBNAAT and daily TB treatment for PLHIV was developed to orient ART center staff. Taking these efforts further, all the ART centre's staff in Andhra Pradesh and Maharashtra have been trained on the revised guidelines.
(find more: Training on daily Anti TB treatment and 3Is, National Report)
SHARE INDIA also supported in capacity building of District AIDS Prevention Control Unit and Revised National Tuberculosis Control Program staff, which led to strengthened coordination and implementation of collaborative TB/HIV activities. It has significantly contributed for improvement in number of PLHIV screened and tested for TB and has ensured 99% initiation of TB treatment among TB co-infected PLHIV and reduced referral loss.
Assessment of Airborne Infection Control measures at 31 ART centres in Pune, Thane and Mumbai was conducted (FY 2017 – 2018).
Retention in HIV care and treatment is defined as continuous engagement of people living with HIV/AIDS (PLHIV) in prevention and care and support services from the time of diagnosis. Despite significant success in HIV Program, many PLHIV will not be retained due to various reasons like death, opted out of treatment and the most important reason is that they do not turn up on their pill pick-up day. Many of the ART centres s has high patient volume with standard limited allocation of human resources and limited time which are critical systemic constraints to implement guidelines and it is challenging for the ART centre staff to identify those PLHIV who requires focused counselling /clinical services and provide them with the same.
For enhanced treatment coverage, improved retention on treatment and viral load suppression, patient centric differentiated package of services based on their needs, clinical status, and duration of ART were provided. These differentiated care packages include rapid ART initiations, Advanced Disease Management (ADM), differentiated service delivery models and differentiated and enhanced adherence counselling services.
These packages were piloted in eight selected high load ART centers. Training of ART centres staff on differentiated interventions, outreach strategies to improve tracking and tracing for short term and long term retention coupled with patient education was provided to the centers for implementation of the package of interventions. Following rollout of package of interventions, SOPs were developed and data managers were oriented on the procedures to ensure error free data entries.
Engaging with Communities
Evidences suggest that engaging communities is essential in advocating for a robust response to the epidemic and delivering services that can reach everyone in need and tackling HIV-related stigma and discrimination. Communities are engaged to identify HIV –positive individuals, link them to HIV treatment and services and ensure that they achieve viral load suppression and long term retention in care.
Collaborations with networks: SHARE INDIA partnered with community networks (district level) to re-engage patients in care. Engaged community as peer navigators to reach those PLHIV who are not accessing treatment, educate and mobilise them to access treatment.
Retention on care: To improve retention on care, involved communities to track lost to follow up cases and engage them in care.
Technology Enabled Adherence Monitoring Tool (TeAM)
Adherence to treatment is a key determinant for people living with HIV/AIDS. To monitor and support treatment adherence of PLHIV with low adherence levels (<95%), a mobile application was developed and piloted Technology enabled Adherence Monitoring tool (TeAM) in four ART centers from the focussed districts in the state. Patients registered on the TeAM were provided with select reminder messages for improved drug adherence.
While it is too early to assess the impact of the pilot initiative, Mobile health interventions have the potential to improve retention in care and clinical outcomes for PLHIV.
SHARE INDIA, in collaboration with India's National Institute of Tuberculosis and Respiratory Disease (NITRD), Project ECHO (Extension for Community Healthcare Outcomes), U.S Centers for Disease Control and Prevention (CDC) and the National AIDS Control Organization (NACO) launched virtual e-NISCHIT (National Initiative to Strengthen Collaboration between HIV-TB through e-Learning) program. This initiative aims to build capacities of healthcare providers from ART centres on HIV-TB co-management, by providing a platform for live interaction with subject experts. This model is based on the hub-and-spoke knowledge-sharing networks, led by expert teams for case based learning and discussions. Within a span of one year from its inception, 40 interactive live sessions were conducted, where experts in HIV-TB arena from Government of India, World Health Organization and premier private healthcare institutions provided their inputs on 30 live cases presented from the field during the sessions. The initiative has successfully reached to approximately 1500 health care providers in 115 ART centres from Northern and Southern states of the country.https://www.youtube.com/channel/UCmlmu_19nqgzaBtKkupHEMg/videos
Data quality assessments
Accurate and consistent data is essential for program management and effective monitoring for improved program outcomes. To ensure correct reporting of data, continuous data quality assessment measures are taken up along with site level distinct mentoring and monitoring support. In line with implementation of new interventions several monitoring tools, Job-aids, dashboards, standard operating procedures were developed by the project team. All these resulted in reduced /error free reporting of data and quality data.
Efforts were made to ensure data entry in Inventory Management System (IMS developed by NACO) and to reduce the gap between IMS and Monthly Progress Report (MPR), which has resulted better performance by the ART centres in NACO quarterly feedback report.
In addition to the regular site level technical assistance and continuous quality improvement measures, SHARE INDIA has provided technical assistance to APSACS for monitoring of process and implementation of newer initiatives like multi month dispensation at the ART centers.
Using ZOOM technology (video conferencing) structured virtual review meetings were held once in every month with all the staff of ART centers in the state of Andhra Pradesh, to inform and improve the service delivery of the centers.
The project staff had provided centre wise written feedback on a monthly basis with identified gaps and probable solutions. Post written feedback, phone follow-up was made to enquire action taken status, based on the feedback.
Regular virtual review meetings with ART centres staff resulted in improved program outcomes viz.,, improved screenings vs initiations on 3MD, decreased errors in recording and reporting and Monthly Progress Report. Virtual review helped the ART centres to initiate the more number of PLHIVs on ART. Apart from reducing travel cost and time of program staff, it also helped in real time monitoring of program implementation. It has served as a platform for cross learnings and experience sharing between ART centres and also for strengthening capacities of health staff. Virtual monitoring proved to be a cost effective monitoring tool that has demonstrated positive outcomes.