ICTC, PPTCT & ART Centre

visit to ICTC, PPTCT & ART Centre

1. Integrated counselling & Testing Centers ( NATIONAL AIDS CONTROL PROGRAM-Iv )

2. Overview: National AIDS Control Program 1992: National AIDS Control Program Initiated 1997: VCT services started in the country 1999: NACP II Initiated (99-06) 2000/2001: 11 centers of excellence conduct PPTCT 2001: Operational guidelines for PPTCT and VCT (revised in ’04 & ’07) 2002: PPTCT services started throughout the country 2003: GFATM : support to PPTCT 2004: GFATM : support to HIV-TB coordination 2006: NACP-III framework designed, Integration of VCT and PPTCT as ICTC 2007: Provider Initiated testing for ANC mothers, TB patients, STI patients, HRG population. 2014 : NACP-IV launched for 5 years(2012-2017).

3. Packages of services under NACP-IV : Prevention services Care, Support, and treatment services Goals & Objectives  Objective 1 : Reduce new infections by 50% (2007 Baseline of NACP III)  Objective 2 : Comprehensive care, support and treatment to all persons living with HIV/AIDS  

4. Components Component 1: Intensifying and Consolidating Prevention services with a focus on HRG and vulnerable populations Component 2: Expanding IEC services for (a) general population and (b) high risk groups with a focus on behavior change and demand generation  Component 3: Comprehensive Care, Support and Treatment  Component 4: Strengthening institutional capacities  Component 5: Strategic Information Management Systems (SIMS) 

5. Components Component 1: Intensifying and Consolidating Prevention services with a focus on HRG and vulnerable populations This component will support the scaling up of TIs with the aim of reaching out to the hard to reach population groups who do not yet access and use the prevention services of the program, and saturate coverage among the HRGs. In addition, this component will support the bridge population, i.e. migrants and truckers. Component 1 includes the following two subcomponents : 1.1   Scaling up coverage of TIs among HRG           The interventions under this sub-component will include : ( i ) the provision of behavior change interventions to increase safe practices, testing and counseling , and adherence to treatment, and demand for other services ; ( ii) the promotion and provision of condoms to HRG to promote their use in each sexual encounter; ( iii) provision or referral for STI services including counseling at service provision centers to increase compliance of patients with treatment, risk reduction counseling with focus on partner referral and management ; (iv) needle and syringe exchange for IDUs as well as scaling up of Opioid Substitution Therapy (OST) provision. This sub-component also includes the financing of operating costs for about 25 State Training Resource Centers as well as participant training costs over a period of 5 years.

6. 1.2   Scaling up of interventions among other vulnerable populations   The activities under this subcomponent will include: ( i ) risk assessment and size estimation of migrant population groups and truckers at transit points and at workplaces; ( ii) behavior change communications (BCC) for creating awareness about risk and vulnerability, prevention methods, availability and location of services, increase safe behavior and demand for services as well as reduce stigma ; ( iii) promotion and provisioning of condoms through different channels including social marketing; ( iv) development of linkages with local institutions, both public and NGO owned, for testing, counseling and STI treatment services ; ( v) creation of “peer support groups” and “safe spaces” for migrants at destination ; (vi) establishment of need-based and gender-sensitive services for partners of IDUs; and(vii) strengthening networks of vulnerable populations with enhanced linkages to service centers and risk reduction interventions, specifically condom use.

7. Component 2: Expanding IEC services for (a) general population and (b) high risk groups with a focus on behavior change and demand generation   IEC has been an important component of the NACP. With the expansion of services for counseling and testing, ART, STI treatment and condom promotion, the demand generation campaigns will continue to be the focus of the NACP-IV communication strategy. IEC will remain an important component of all prevention efforts and will include: Behavior change communication strategies for HRGs, vulnerable groups and hard to reach populations Increasing awareness among general population, particularly women and youth.

8. Component 3: Comprehensive Care, Support and Treatment   NACP IV will implement comprehensive HIV care for all those who are in need of such services and facilitate additional support systems for women and children affected and infected with HIV / AIDS. It is envisaged that greater adherence and compliance would be possible with wide network of treatment facilities and collaborative support from PLHIV and civil society groups. Additional Centers of Excellence ( CoEs ) and upgraded ART Plus centers will be established to provide high-quality treatment and follow-up services, positive prevention and better linkages with health care providers in the periphery. With increasing maturity of the epidemic, it is very likely that there will be greater demand for 2nd line ART, OI management. NACP IV will address these needs adequately. It is proposed that the comprehensive care, support and treatment of HIV/AIDS will inter alia include: ( i ) anti-retroviral treatment (ART) including second line (ii) management of opportunistic infections and (iii) facilitating social protection through linkages with concerned Departments/Ministries. The program will explore avenues of public-private partnerships. The program will enhance activities to reduce stigma and discrimination at all levels particularly at health care settings. 

9. Component 4: Strengthening institutional capacities                 The objective of NACP IV will be to consolidate the trend of reversal of the epidemic seen at the national level to all the key districts in India. Programme planning and management responsibilities will be strengthened at state and district levels to ensure high quality, timely and effective implementation of field level activities and desired programmatic outcomes. The planning processes and systems will be further strengthened to ensure that the annual action plans are based on evidence, local priorities and in alignment with NACP IV objectives. Sustaining the epidemic response through increased collaboration and convergence, where feasible, with other departments will be given a high priority during NACP IV. This will involve phased integration of the HIV services with the routine public sector health delivery systems, streamlining the supply chain mechanisms and quality control mechanisms and building capacities of governmental and non-governmental institutions and networks.  

10. Component 5: Strategic Information Management Systems (SIMS)                    The roll-out of SIMS is ongoing and will be firmly established at all levels to support evidence based planning, program monitoring and measuring of programmatic impacts. The surveillance system will be further strengthened with focus on tracking the epidemic, incidence analysis, identifying pockets of infection and estimating the burden of infection. Research priorities will also be customized to the emerging needs of the program. NACP IV will also document, manage and disseminate evidence and effective utilization of programmatic and research data. The relevant, measurable and verifiable indicators will be identified and used appropriately .  

11. Targeted Interventions for Prevention, Care and Treatment   For the overall reduction in the epidemic, targeted interventions (TIs) are aimed to effect behaviour change through awareness raising among the high risk groups and clients of sex workers or bridge populations. These interventions are aimed to saturate three high risk groups with information on prevention; address clients of sex workers with safe sex interventions, and build awareness among the spouses of truckers and migrant workers, women aged 15 to 49 and children affected by HIV or vulnerable population groups. Apart from prevention of HIV infection, TIs facilitate prevention and treatment of sexually transmitted diseases as they increase the risk of HIV infection, and are linked to care, support and treatment services for HIV infected.

12. Services for prevention Awareness Raising Management of STI/RTI Condom Promotion Access to Safe blood Integrated Counselling and Testing Centre (ICTC) Post Exposure Prophylaxis (PEP) Prevention of Parent to Child Transmission(PPTCT)

13. What is an Integrated counselling and Testing Centre? An integrated counselling and testing centre is a place where a person is counseled and tested for HIV, on his own free will or as advised by a medical provider. The HIV counselling and testing services, started in the year 1997 . There are now more than 4000 Counselling and Testing Centres, mainly located in government hospitals. Under NACP-III, Voluntary Counselling and Testing Centres (VCTC) and facilities providing Prevention of Parent to Child Transmission of HIV/AIDS (PPTCT) services are remodelled as a hub or ‘Integrated Counselling and Testing Centre’ (ICTC) to provide services to all clients under one roof. An ICTC is a place where a person is counselled and tested for HIV, of his own free will or as advised by a medical provider.

14. The earlier Voluntary counselling and Testing Centers (VCTCs) and facilities providing Prevention of Parent-to-Child Transmission of HIV/AIDS (PPTCT) services are now remodeled as a hub to deliver integrated services to all clients under one roof and renamed as “Integrated counselling and Testing Centers” (ICTCs).

15. Ideally, a health facility should have one integrated counselling and testing centre for all groups of people. However, an ICTC is located in facilities that serve specific categories such as pregnant women. Accordingly, an ICTC is located in the Obstetrics and Gynaecology Department of a medical college or a district hospital or in a maternity home where the majority of clients who access counselling and testing services are pregnant women. The justification for such a centre is the need for providing medical care to prevent HIV transmission from infected pregnant women to their infants. Similarly an ICTC is located in a TB microscopy centre or in a TB sanatorium, where the majority of clients are TB patients. As TB is the most common co-infection in people with HIV, availability of HIV counselling and testing can help patients to diagnose their status for accessing early treatment.  

16. As of today, only 13 percent of HIV positive people in the country are aware of their HIV status. The challenge before NACO is to make all HIV infected people in the country aware of their status so that they adopt a healthy lifestyle; access life-saving care and treatment and help prevent further transmission of HIV. Thus, counselling and testing services are important components of prevention and control of HIV/AIDS in the country.   However, it is not the mandate of an ICTC to counsel and test everyone in the general population. The sub-populations that are more vulnerable or practice high risk behaviour or have higher HIV prevalence levels are the target group for counselling and testing services in the country.

17.   HIV counselling and testing services are a key entry point to prevention of HIV infection and to treatment and care of people who are infected with HIV. When availing counselling and testing services, people can access accurate information about HIV prevention and care and undergo HIV test in a supportive and confidential environment. People who are found HIV negative are supported with information and counselling to reduce risks and remain HIV negative. People who are found HIV positive are provided psycho-social support and linked to treatment and care.  

18. The main functions of an ICTC are: ·         Conducting HIV diagnostic tests. ·         Providing basic information on the modes of HIV transmission, and promoting behavioural change to reduce vulnerability. ·         Link people with other HIV prevention, care and treatment services.

19. Non Coercive, Confidential and Cost effective approach Promotes IEC to motivate behavior change in HIV Positive Individual ICTC an entry point to continuum of care/home based service Integrated counselling and Testing Centre

20. INFRASTUCTURE A counselling room Laboratory Sample collection room CD4 count room

21. WHO IS TO BE TESTED IN AN ICTC? Not Mandatory to counsel and test everyone in the general population. Vulnerable or groups that practice high-risk behavior: Sex workers and their clients Men who have sex with men (MSM) Trans genders Injecting drug users (IDUs) Truckers Migrant workers Spouses and children of men who are prone to risky behavior.

22. Different types of ICTCs?

23. MANPOWER IN AN ICTC The ICTC requires a team of skilled persons consisting of ICTC manager Counselor Laboratory Technician Outreach workers

24. Early detection of HIV. Provision of basic information on modes of transmission and prevention of HIV/AIDS Promoting behavioural change and reducing vulnerability. Link people with other HIV prevention, care and treatment services. ROLE OF AN ICTC

25. GATHER Approach G = Greet the client A = Ask about the problem Active listener Assess degree of risk behavior Show respect and tolerance Enable patient or client to express freely Determine access to support and help in family and community T = Tell the client about specific information that he or she desires H = Help them to make decisions E = Explain any myths or misconceptions(also known as INFORMED DECISION MAKING) R = Return for follow up or Referral

26. KITS USED FOR TESTING SD BIOLINE HIV-1/2 3.0 test -is an immunochromatographic (rapid) test for qualitative detection of antibodies specific to HIV-1 and HIV-2 in plasma/serum/whole blood. -Manufactured by SD BIO STANDARD DIAGNOSTICS PVT. LTD. - sensitivity=100% -specificity=99.8%

27. SD BIOLINE HIV-1/2 3.0 test

28. SD BIOLINE HIV-1/2 3.0 test

29. HIV-1/2 TRISPOT TEST KIT: -it is a rapid Trispot test to detect antibodies to HIV-1 & HIV-2 in human serum/plasma. -Manufactured by BHAT BIO-TECH INDIA(P) LTD. -sensitivity=100% -specificity=99.7%

30. HIV-1/2 TRISPOT TEST KIT

31. HIV-1/2 TRISPOT TEST KIT

32. COMBAIDS HIV-1/2 IMMUNODOT TEST KIT

33. STRATEGY 3 For individual Dx of patients ,ICTC uses STRATEGY 3 which is as follows: All samples are tested with one rapid test.(SD BIOLINE HIV-1/2 3.0 test). If test result is NON-REACTIVE : final report NEGATIVE. If test result is REACTIVE then sample is tested again by different systems (TRI-DOT &BI-DOT tests).

34. Results can be REACTIVE or NON-REACTIVE. If result is REACTIVE with 2 nd & 3 rd antigen test then report is POSITIVE. If result is NON-REACTIVE with either 2nd or 3 rd antigen test ,then report is INTERMEDIATE. If result is NON-REACTIVE with 2 nd & 3 rd antigen test then report is NEGATIVE.

35. Three Tests Done:

36. TESTING ALGORITHM

37. PPTCT

38. The Prevention of Parent to Child Transmission of HIV/AIDS (PPTCT) programme was launched in the country in the year 2002 following a feasibility study in 11 major hospitals in the five high HIV prevalence states. Currently, there are more than 15000 Integrated Counselling and Testing Centres (ICTCs) in the country, most of these in government hospitals, which offer PPTCT services to pregnant women. Of these ICTCs, nearly 550 are located in Obstetrics and Gynaecology Departments and in Maternity Homes where the client load is predominantly comprised of pregnant women.   The NACO Technical Estimate Report (2012) estimated that out of 27 million annual pregnancies in India, 34,675 occur in HIV positive pregnant women. In the absence of any intervention, an estimated cohort of 13,000 infected babies will be born annually. The PPTCT programme aims to prevent the perinatal transmission of HIV from an HIV infected pregnant mother to her newborn baby. The programme entails counselling and testing of pregnant women in the ICTCs.

39. With effect from 1 st January 2014, pregnant women who are found to be HIV positive are initiated on lifelong ART irrespective of CD4 count and WHO clinical Staging; their newborn (HIV exposed) babies are initiated on 6 weeks of Syrup Nevirapine immediately after birth so as to prevent transmission of HIV from mother to child and is extended to 12 weeks of Syrup Nevirapine if the duration of the ART of mother is less than 24 weeks.     The HIV exposed baby is initiated on Cotrimoxazole prophylaxis at 6 weeks and is tested for HIV DNA PCR at 6 weeks by DBS9dry blood spot) collection. If the DBS sample is positive for HIV DNA PCR, then a repeat sample is tested for HIV DNA PCR through Whole Blood collection. The HIV exposed baby is then initiated on lifelong ART at the earliest if confirmed HIV positive through 2 DNA PCR test.   The PPTCT services cover about 37 per cent annual estimated pregnancies in the country. In the year 2013-14, nearly 10 million pregnant women accessed this service. Of these, 12008 pregnant women were HIV positive. In order to provide universal access to these services further scale up is planned up to the level of Community Health Centre and the Primary Health Centre, as well as private sector by forging public-private partnerships. Through these measures Government of India is committed to work towards achievement of global target of “Elimination of new HIV infections among children” by 2015.

40. Treatment HIV infection is not the end of life. People can lead a healthy life for a long time with appropriate medical care. Anti-retroviral therapy (ART)  effectively suppresses replication, if taken at the right time. Successful viral suppression restores the immune system and halts onset and progression of disease as well as reduces chances of getting opportunistic infections – this is how ART is aimed to work. Medication thus enhances both quality of life and longevity.   Adherence to ART is Critical   Adherence to ART regimen is therefore very vital in this treatment. Any irregularity in following the prescribed regimen can lead to resistance to HIV drugs, and therefore can weaken or negate its effect.   ART is Accessible to All   ART is now available free to all those who need it. Public health facilities are mandated to ensure that ART is provided to people living with HIV/AIDS (PLHA). Special emphasis is given to the treatment of sero -positive women and infected children.   

41. When is ART Given?   ART is initiated depending upon the stage of infection. PLHA with less than 200 CD4 (while blood cells/ mm 3 ) require treatment irrespective of the clinical stage. For PLHA with 200-350 CD4, ART is offered to symptomatic patients. Among those with CD4 of more than 350, treatment is deferred for asymptomatic persons.   Criteria for ART * If CD4 is between 200-250, this should be repeated in four weeks and treatment to be considered in asymptomatic patients.   There are 127 ART centres operating in the country as of June 2007. By 2012, 250 ART centres will become functional across the country in order to provide people living with HIV/AIDS better access to treatment.

42. Where are these ART Centres Located?   In order to make treatment more accessible ART centres are located in medical colleges, district hospitals and non-profit charitable institutions providing care, support and treatment services to PLHA. A PLHA network person at each of the ART centre facilitates access to care and treatment services at these centres. ART centres also provide counselling and follow up on treatment adherence and support through community care centres.   Paediatric Care and Support The primary goal of paediatric prevention, care and treatment programme is to prevent HIV infection to newborns through Prevention of Parent to Child Transmission (PPTCT) and provide treatment and care to all children infected by HIV.

43. HSS: HIV Sentinel Surveillance (HSS) in India, since its inception in 1998, has evolved into a credible and robust system for HIV epidemic monitoring and acclaimed as one of the best in the world. Sentinel surveillance provides essential information to understand the trends and dynamics of HIV epidemic among different risk groups in the country. It aids in refinement of strategies and prioritization of focus for prevention, care and treatment interventions under the National AIDS Control Programme (NACP). HIV estimates of prevalence, incidence and mortality developed based on findings from HIV Sentinel Surveillance enable the programme in assessing the impacts at a macro level.   During NACP-IV, HIV Sentinel Surveillance will be conducted once in two years so that adequate time is spent on in-depth analysis and modeling , epidemiological research and use of surveillance data for programmatic purposes. The 13 th round of sentinel surveillance will be conducted during 2012-13.

44. HIV counselling HIV/AIDS counselling /education is a confidential dialogue between a client and a counselor aimed at providing information on HIV/AIDS and bringing about behavior change in the client. It is also aimed at enabling the client to take a decision regarding HIV testing and to understand the implications of the test results.

45. Counselling in HIV/AIDS Concerned with preventing infection and transmission of HIV/AIDS: Determine whether individual is of high risk behaviour Help people to understand their high risk behaviour pattern Define how to change their lifestyle and self image are linked to their behaviour. Help individual to change their behaviour Work with individual to introduce and sustain the modified behaviour.

46. Counselling skills Listen actively Responding to clients feelings Questioning Paraphrasing and interpretation Interpretation

47. PRE- TEST COUNSELLING Provide individual being tested with information on technical aspects of screening and possible personal, medical, social, psychological and least implications of being tested positive or negative. Information should be simple and up to date.

48. Pre test counseling helps a person to understand the possible results of an HIV test. It may be positive, negative or equivocal. The counselor must explain the meaning of each such test result. This should be utilized as an opportunity to assess the likely reaction of the client to a positive or negative test result. An essential element of post test counseling is breaking the news. It requires special skills and right judgment about the client’s state of mind.

49. Types

50. Issues in pre test counselling Personal history and assessment of RISK: Sexual behaviour , multiple partners, prostitutes, unprotected sex, homosexuality, bisexuality Drug users Blood trasnfusion Organ transplant

51. 2) Assessment of factors and knowledge: Why test is being requested? What behaviour/ symptoms are of concern to the client? What the client know about test and its uses? What will the client do if test is positive or negative? Beliefs regarding HIV transmission What role will family play?

52. POST TEST counselling

53. Test Result?

54. WHAT IF NEGATIVE RESULT

55. WHAT IF POSITIVE RESULT

56. WHAT IF EQUIVOCAL RESULT

57. FOLLOW-UP counselling In follow-up counselling there is a re-emphasis on adoption of safe behaviors to prevent transmission of HIV infection to others. Follow-up counselling also includes establishing linkages and referrals to services for care and support including ART, nutrition, home-based care and legal support.

58. WHAT IS COUNSELLING? Counselling has been defined as a process of helping/enabling a person/people solvecertain interpersonal, emotional and decision-making problems. A counsellor’s role is to help clients help themselves. Counselling can be done with an individual, group , with couples or families. Counselling involves Supporting individuals to take charge of their own life by: • Providing information, • Facilitating emotional adjustments, and • Enhancing mental health. and enabling them to: • understand and accept the problem, • develop resources to take adaptable and realistic decisions, and • alter their own behaviour to produce relatively enduring, desirable consequences.

59. Counselling is . • Specific to the needs, issues and circumstances of each individual client • An interactive, mutually respectful collaborative process • Goal-directed • Oriented towards developing autonomy, self-responsibility and confidence in clients • Sensitive to the sociocultural context • Eliciting information, reviewing options and developing action plans • Inculcating coping skills • Facilitating interpersonal interactions • Bringing about attitudinal change Counselling is not • Telling or directing • Giving advice • A casual conversation • An interrogation • A confession • Praying Some common errors in counselling • Judging and evaluating • Moralizing and preaching • Labelling • Unwarranted assurance

60. AIMS AND IMPORTANCE OF HIV/AIDS COUNSELLING HIV/AIDS is a life-threatening, life-long illness. Diagnosis of HIV/AIDS has many implications—psychological, social and physical. Preventive counselling and behaviour change can prevent transmission of HIV and improve the quality of life. HIV/AIDS counselling is a process with four general objectives: 1. Facilitating decision to undergo HIV test 2. Providing psychological, social and emotional support for • People who have contracted the virus and • Others affected by the virus. 3. Preventing transmission of HIV by • Providing information about risk behaviours (such as unsafe sex or needle sharing), • Motivating people to take good care of their health, • Assisting them to develop personal skills necessary for behaviour change, and • Adopting and negotiating safe sexual practices. 4. Ensuring effective use of treatment programmes by • Establishing treatment goals and • Ensuring regular follow-up.

61. Issues to be addressed by HIV/AIDS counselling HIV/AIDS counselling is intended to address the physical, social, psychological and spiritual needs of the client. Besides, the following issues should also be addressed: • Problems related to infection and illness • Death, bereavement • Social discrimination • Sexuality • Lifestyle • Prevention of transmission • Meaning to life It is important to note that, in addition to the issues directly related to HIV/AIDS, clients may be dealing with a range of issues that are pre-morbid or indirectly related to HIV/AIDS, such as alcoholism, drug use, personality problems, unhealthy sexual practices, etc. Specific therapy may be required to assist clients with pre-morbid or co-existing psychiatric illnesses, emotional and behavioural problems, or specific problems such as sexual dysfunction, management of sleep difficulties, panic attacks, etc. HIV/AIDS may also re-activate previously unresolved issues such as those of sexuality, sexual identity (homosexual or bisexual), guilt or shame of being a sex worker, drug addiction or family problems unrelated to HIV.

62. Counseling becomes necessary because people are at a loss and unable to decide what to do with their lives, once they are found to be HIV positive. Those who have practiced high risk behavior are unable to take a decision whether to go for HIV test or not. Another important issue is breaking the news to the family members and sex partners. In such circumstances, counseling helps a person to come to term with the realities of HIV/AIDS and act in a balanced way.

63. Behavior change communication (BCC) is an interactive process of any intervention with individuals, communities and/or societies (as integrated with an overall program) to develop communication strategies to promote positive behaviors which are appropriate to their settings.