PHMI Aliance

Human Capacity Development of HIV/AIDS programs

Title of the Project:
Human Capacity Development of HIV/AIDS programs and related activities in India through capacity building, supporting at National and State programs with professional consultants, adopting scientific approaches for program planning, designing and implementation that emphasize on quality and standardization of health care delivery.

Background for project activities:
Shortly after the first cases of HIV infection in India were reported in 1986, the Government of India established the National AIDS cell followed by starting National AIDS Control Programme (NACP) to respond to the HIV epidemic which, over the years, has turned around several strongly held social mores. In 1991, with an increasing spread of HIV, the scope of NACP started to expand focusing on blood safety, prevention among high risk populations, raising awareness in the general population, and improving surveillance. The program grew and a semi-autonomous body called the National AIDS Control Organization (NACO) was established under the Ministry of Health and Family Welfare to implement this program.

The first phase of the NACP was implemented from 1992 to 1999. By the end of this phase several major developments were achieved; awareness increased, screening of donated blood became universal and a decentralized mechanism to facilitate effective state-level responses was established. During the second phase of the NACP, from 1999 to 2006, the expanded program was confronted with an impassioned community of people living with HIV (PLHIV). This phase also saw introduction of Antiretroviral Treatment (ART) services introduced in the country in 2004 and revised protocols for Prevention of Parent to Child Transmission (PPTCT) with multi drug regimen.

a. DAPCU strengthening:
One of the key strategies for the NACP – III in India is decentralization of supportive supervision and monitoring of NACP, creating a mechanism to respond to local specific\ needs of the program at district level. Convergence and mainstreaming of the HIV related services viz., prevention, care, treatment and support are deemed imperative; and required an institutional mechanism / framework within the National HIV program for facilitating convergence. Under NACP III, a major structural reform was initiated by constituting District AIDS Prevention and Control Units with a team of field functionaries in A and B category districts in India. The structure of DAPCU as envisaged at national level is provided as figure 1. Roles and responsibilities of the team were outlined in the Operational guidelines.

Recruitment of DAPCU staff was initiated across the country as per the directives of NACO to SACS. A few states took the initiative to sensitize the DAPCU staff about the HIV AIDS program and to varying extent regarding their roles and responsibilities. At NACO level, it was considered essential to appoint a focal person to monitor and mentor DAPCU functioning. The National Technical Support Unit (NTSU) Team Leader was directed to serve as the focal point for DAPCUs at the National Level. While reviewing the progress of DAPCU staff recruitment, trainings and work assigned to them, the need for a standardized national training and continuous support to make DAPCUs fully functional units was felt.

b. ART Review:
The ART services were introduced during NACP II and services expanded rapidly. The programme has grown to a network of 512 ART centre and 1080 Link ART centre in 2015. More than 8.8 lakhs patients are receiving free ART at these sites, second highest number in the world. Wider access to ART has led to 29% reduction in estimated annual AIDS related deaths between 2007 and 2011. It is estimated that the scale up of free ART since 2004 has averted over 1.5 lakh HIV/AIDS related deaths. It is further estimated that with the current pace of scale up of ART services will further avert approximately 50,000-60,000 deaths annually in the next fi ve years. To understand the quality of service delivery and identify systemic issues related to ART service delivery, NACO has commissioned an assessment of all ART centres in India. This assessment is critical and timely as the country prepares for roll-out NACP IV (2012-2016). During the planning for NACP IV, the CST Working Group made several recommendations, including continued need to monitor and evaluate the ART network, and to ensure quality assurance. In line with the above recommendations, NACO developed, delineating a set of objectives for the ART centres review and a concept note as well as a comprehensive assessment tool for program assessment across the 400 ART centers in the country and requested CDC and SHARE India to support the ART centres review.

c. Strengthening revised PPTCT protocol implementation;
In 2012 NACO issued revised guidelines for a new regimen (Option B) of drugs for PTTCT. Launched on a pilot basis, the new regimen is being tried out in two Southern states (Andhra Pradesh and Karnataka) that have high HIV burden. NACO and Andhra Pradesh State AIDS Control Society, (APSACS) conducted training of trainers for government institutions. However, private medical colleges were not fully engaged. Despite the fact that, the government involved the private medical college hospitals for conducting deliveries for HIV positive pregnant women, providing ARV prophylaxis, counselling and testing services by the Integrated Counselling and Testing Centres. APSACS suggested SHARE INDIA to support in capacity building of the Health Care Workers of the Private Medical colleges in Andhra Pradesh in view of SHARE INDIA’s previous experience and expertise in working with the Private Medical colleges through formation of Andhra Pradesh AIDS Consortium (APAIDSCON). SHARE INDIA formed and groomed the APAIDSCON during a previous CDC funded project during 2005 to 2009.

d. Capacity building of Health Care Workers and Faculty from Private Medical colleges for establishment of Sexually Transmitted Infections (STI) and Reproductive Tract Infections (RTI) treatment services in Andhra Pradesh:
A community-based, prevalence study conducted by the Indian Council of Medical Research reveals that about 6% of the adult Indian population suffers from STIs. An estimated 30 million cases occur in adults, from which 15 million seek treatment from the government sector; and close to 15 million seek care from the private sector. In order to reach more number of needy populations, NACP proposed a strategy to partner with hospitals in private sector and public sector undertakings wherever possible. NACO also introduced Syndormic Case Management (SCM) for STI/RTI treatment with colour coded drug kits.

According to 2010, ICTC monthly reports of 15 private medical colleges in Andhra Pradesh, about 72,312 cases have been tested for HIV at Integrated Counselling and Testing Centres (ICTCs). Of them 1.24 % cases were referred to ICTC for HIV testing from the Dermato –venereology Out Patient Departments (OPD) of private medical colleges; 2.4% suspected STI cases were referred to respective DSRCs located in the public health sector in the districts. Most of the medical colleges are located at 10 to -30kms away from Designated STI/RTI Clinics (DSRCs) and owing to constraints of distance, transportation and cost involved, clients referred to DSRCs find it difficult to reach there.

The Private Medical colleges also offer STI services, usually through the Demato-venereology and Obstetrics and Gynaecology departments. However syndromic case management may not be practiced in these instances. Training of the staff on the use of syndromic case management will not only reduce time spent by patients at the hospital but also reduce costs incurred by him/her. As single dose treatments are available the adherence will also be higher. Availability of infrastructure, human resource (like the nurse, medical officer and medico social worker) and inclination of the management of the private medical college to work with the government provides environment conducive to initiate DSRCs under Public Private Partnership (PPP) model. As part of mainstreaming the HIV services in private sector, APSACS requested SHARE INDIA to support in establishment of Designated STI/RTI clinics (DSRCs) in 20 Private Medical colleges. SHARE INDIA, drawing its experience from working with the private medical colleges trained the faculty from private medical colleges on revised PPTCT guidelines and Syndromic management of STI/RTIs.

e. Capacity building of Trainers from Training centres of Andhra Pradesh on Instructional Design:
NACO recognizes the importance of skilled and competent human resources at all levels of programme implementation, i.e. national, state, district and community levels, public and private health systems, non-governmental organizations and the civil society. It recognizes that the availability of a critical mass of well-trained human resources is the backbone to the elaborate organizational structures, institutional arrangements and strategies proposed under NACP-III.

National as well as State level mechanisms have been laid out to build capacities of a resource pool of trainers who would then be engaged in building capacities of the human resource engaged in different components of the program. These resource pools receive focused capacity building on their respective subject matter and pre designed modules. There is a need to support them in developing an understanding of the processes involved in conceptualizing, planning, designing, conducting and evaluating trainings as well as principles of adult learning.

SHARE INDIA, developed a model of instructional design based on ADDIE, which is a systematic way to plan, prepare and conduct training/learning activities based on the needs of learners. AIDDIE is a popular Instructional Design model with a five stage process viz., i) Analysis/Assessment, ii) Design, iii) Development, iv) Implementation and v) Evaluation. At the request of APSACS, ID training activities were taken up to train a resource pool of trainers from State Reference Laboratories, District Resource Persons of the Link Worker’s Scheme and State Resource Persons of the Training Centres for Targeted Interventions, etc.

f. Support to APSACS to formulate Operations Research Framework :
National AIDS Control Organization’s (NACO) success in tackling the HIV/AIDS epidemic partly lies in how India developed and used its evidence to take critical policy and programmatic decisions. Over the past two decades, the number of data sources have expanded and the geographic units of data generation, analysis and use for planning has shifted from national to the state, district and now sub district level. This has enabled NACO to concentrate on vulnerable geography, populations and fine-tune its response over time. Given the proliferation of data sources and the emerging capacity within India to analyze and use data, NACO has taken up Operations Research (OR) as part of NACP III strategies. For this purpose, NACO has established a Technical Resource Group (TRG) on Research and Development (R&D) and formulated Ethical Guidelines for OR on HIV/AIDS. Regular efforts are made by NACO to build capacity of its staff on OR and it has successfully initiated a number of research activities.

The 2011 estimates for HIV indicate that 2 million people are living with HIV/AIDS in India and Andhra Pradesh (AP) contributes 20% to the total burden (NACO, 2011). To address the growing epidemic, concerted efforts are being made by APSACS using a multi-sectorial and multi-pronged approach. Over the years, APSACS has taken up several initiatives to effectively combat HIV/AIDS by scaling-up services for prevention, care, support, and treatment. Massive campaigns like “AASHA”, “Be Bold”, and “Mee Nestam” were also held. All these efforts resulted in reduction of HIV prevalence from 1.69% in 2004 to 0.77% in 2010.

The decentralized District Annual Action Plan (DAAP) development process in AP has provided immense opportunities for evidence-based program planning and monitoring. During the DAAP development process, data triangulation was carried-out using ANC HSS data, program data generated at HIV/AIDS service delivery sites, Behavior Sentinel Surveillance (BSS) and other data sources to better understand the drivers of the HIV epidemic at the sub-district level. All these efforts have provided scope to consolidate, reformulate and realign the program strategies at the state level. The Mid Term Review Report of NACP III (2009) observes that, there is a lack of emphasis on OR. The report recommends that OR be included in designing, planning, monitoring and evaluation to develop effective and efficient programs. It is envisaged that sustained practice of undertaking OR would help to address program priority areas in time and improve the quality, performance, and efficiency. APSACS realized the need to undertake OR to strengthen evidence base for better decision-making and to improve the gains of NACP.

As part of the OR initiative, APSACS initiated efforts to institutionalize OR in AP and sought support from SHARE INDIA for the purpose. SHARE INDIA, supported APSACS for establishing, an inclusive, participatory, transparent, and consultative body called the “APSACS Operations Research Committee” (APORC). This committee will provide oversight and guidance to OR in the state.

g.  Mainstreaming HIV/AIDS in Tribal Health activities in Andhra Pradesh placing consultant:
The Scheduled Tribes (STs) are official designations given to various groups of historically disadvantaged people in India. STs in Andhra Pradesh constitute 6.75 per cent of India’s tribal population. Although the state’s STs comprise only 6.59 per cent of the state’s population, they account for the largest tribal concentration in Southern India. The Scheduled Areas of Andhra Pradesh, covered by the Tribal Sub-Plan (TSP) approach, are spread over 31,485 sq km in 5936 villages (11,855 habitations) in the districts of Srikakulam, Vizianagaram, Visakhapatnam, East Godavari, West Godavari, Warangal, Khammam, Adilabad and Kurnool. The 35 reported ST communities are mainly concentrated in nine districts declared as Scheduled Areas by special government order in 1950. Sixty per cent of the STs live in forest areas in the Eastern Ghats, on the banks of the river Godavari. Two-thirds of the ST population in the State of Andhra Pradesh live in these areas. This constitutes 11% of the total geographical area of the state.

The National AIDS Control Program (NACP) in its third phase plans to go beyond the high risk behaviour groups covered by Targeted Interventions. This entails extension of interventions to populations that are vulnerable to HIV such as the Tribal people and socially disadvantaged sections of the population in both rural and urban areas. One of the main strategies of the NACP was to mainstream HIV/AIDS activities into various departments of the Government which include, health, education, railways, shipping and transport as well as tribal welfare. APSACS intended to mainstream HIV/AIDS activities in the Tribal Health Plan and requested support from SHARE INDIA for this purpose. SHARE INDIA, provided Technical Assistance to APSACS through placing a consultant in the Tribal Area of Vizianagaram district to mainstream HIV/AIDS activities in the health services of the tribal area.

h. Support to NACO and APSACS for system strengthening through placement of consultants:
India has one of the world's largest and most robust HIV Sentinel Surveillance (HSS) Systems. The HIV Sentinel Surveillance (HSS) system in India involves carrying out cross-sectional facility and Targeted Intervention (TI) based HIV sero-prevalence surveys at regular intervals among selected population groups. These populations are also referred to as "sentinel groups". With HSS, the trends in HIV infection are monitored over the period of time by group and by site. The HSS system is one of the components of the second generation HIV surveillance in India. Over the years, the emphasis of HSS in India was on heterosexual transmission, so, the sentinel sites were mainly at Antenatal Clinics (ANC) and Targeted Intervention sites, to observe the trends and levels of HIV in general population and among people with high risk behaviour. SHARE INDIA supported NACO and APSACS at their request the HSS and monitoring of HIV/AIDS data received from the facilities placing qualified and experience professionals to strengthen the monitoring and surveillance system.

Results:
a. DAPCU strengthening:
To assess the performance levels of DAPCUs, DNRT developed a self-assessment tool was developed based on a set of indicators. This self-administered tool comprises three domains (operational, coordination and monitoring), and eight attributes: Infrastructure & Equipment, Human Resources, Finance, Coordination and Convergence, Referrals and Linkages, Mainstreaming, Monitoring and Supply Chain Management. At SACS and NACO level, the grading/assessment exercise provided an overview of the status of DAPCU's performance. The tool was circulated to all 188 functional DAPCUs in the country, and by December 2014, 183 DAPCUs responded with completed tools. This enabled the DAPCUs to prioritize their efforts in specific areas to improve efficiency in functioning and performance.

Self- assessment data was analysed and DAPCUs were categorized as Good (91 DAPCUs 49.72%), Average (80 DAPCUs, 44.75%) and Poor (10 DAPCUs, 5.52%) based on their score. State wise DAPCU categorization mentioned in below table.

State Poor Average Good Total
<18 18-24 >24
Andhra Pradesh 2 13 8 23
Arunachal Pradesh   1   1
Assam   1   1
Bihar   1 2 3
Delhi   3 1 4
Gujarat   1 9 10
Haryana   1   1
Karnataka   15 11 26
Kerala   1 1 2
Madhya Pradesh   5 1 6
Maharashtra   3 27 30
Manipur 2 5 2 9
Mizoram 3     3
Nagaland 1 6 3 10
Orissa   1 6 7
Punjab 1 1   2
Rajasthan   1 4 5
Tamil Nadu 1 12 14 27
Tripura     1 1
Uttar Pradesh 2 1 2 5
West Bengal 2 5   7
Total 14 77 92 183

Specifically, the data showed that, DAPCUs are performing well in areas like settlement of advances, conducting coordination meetings with all HIV facilities and conducting supportive supervisory visits to NACP facilities to provide onsite support. Below is a graphical representation of DAPCUs from specific states.


While DAPCUs did well in many areas, they need to improve their performance in the domains of coordination: conducting DAPCC meetings, linking PLHIV and HRGs to various social benefit schemes, and improving referral and linkages between ICTC to RNTCP, RNTCP to ICTC, TI to ICTC and STI to ICTC. The task gets complicated with rapid changes within the district hierarchy. New staffs take time to understand the tasks, appreciate the work of DAPCU and support and guide them in completion of the activities.

a.      ART Review:
Almost 48% of the centres were graded as “Good” or “Excellent” and only 14% centre was graded as “Very poor” on average of all the four domains. The overall status of the centres across all 4 domains, based on the scoring and grading is shown in the figure below.

There is a need to reiterate emphasis and develop strategies including SoPs and trainings to strengthen retention in care. Similar emphasis is required to strengthen mechanisms for outreach. To ensure regular availability of other OI and ARV drugs, SACS should get the drugs incorporated in the State List of Essential Drug list (SLEM), as has been done by some centres in which have included the OI drugs in their hospital list. Though more than 80 % of the HIV –TB coinfected PLHIV were receiving ART, there is further scope for improvement in terms of coordination, information sharing and facilitating single window services to reduce loss during cross –referrals between both programs.

c.      Strengthening revised PPTCT protocol implementation;
The two-day training, imparted technical information on the new regimen, feeding practices for new-borns, and helped the participants in developing a time-bound action plan to translate the knowledge gained into support for the national program. Each college prepared a context and time specific plan. The plans are jointly monitored by APSACS, CDC and its partners. Following the plan, about half of the colleges conducted continuing medical education during June to September 2013 and reached 3,821 health professionals in their institutions.(college faculty- 626; post-graduate students and interns-963; graduate students-623 and nursing staff and nursing students-1609). Review of the management information system data reported by the medical colleges indicates good impact of the training provided by SHARE INDIA and partners. The Private Medical Colleges were not using the new regimen introduced by the Government and using Nevirapine as single dose regimen. However, after the training program, during April to September 2013 a total of 13,958 pregnant women was counselled and tested for HIV and 35 women were seropositive for HIV. Of this, two pregnant women underwent medical termination of pregnancy and 32 (91%) were registered with ART center. The participating private colleges conducted deliveries for 28 women, 27 women (one woman died) were introduced to the new regimen of drugs. The state government has invited the private medical college faculty to serve on the District AIDS Prevention and Control Coordination Committee at district level to promote their engagement with the PPTCT program and encourage them to work in close coordination with the public health system at the district level. The training on new PPTCT guidelines has led to a change in practise of the faculty from abstaining to use old PPTCT regimen (Option A) and shift to the new regimen Option B. The other change in practise is that there is increase inter-departmental coordination which is evident by almost 100% of follow-up from ANC HIV diagnosis (Microbiology), ARV/ART (ART centre), institutional delivery (OBG), follow-up (Community Medicine and PPTCT outreach) and Early Infant Diagnosis (ICTC) by the private medical colleges in AP


d.  Capacity building of Health Care Workers and Faculty from Private Medical colleges for establishment of Sexually Transmitted Infections (STI) and Reproductive Tract Infections (RTI) treatment services in Andhra Pradesh:
SHARE INDIA through support of CDC and APSACS had training 169 Medical doctors and faculty, 40 Nurses in 24 Private Medical Colleges as master trainers during October2013 to September 2014. These master trainers in turn trained 3239 staff and students of their colleges in 14 Medical Colleges as part of continuing medical education. Nurses in the DSRC are provided on job training towards counselling, health education and documentation. These activities were closely monitored and supported by APSACS.

After the training, 11 private medical colleges have established DSRCs in their respective departments and started reporting to APSACS on national information management system. This is the only data available across the country from private sector. Between November 2013 and September 2014, a total of 879 clients have visited 11 DSRCs. Of these clients, 874 (99%) are diagnosed with STI/RTI complaints of which 738 (84%) clients got tested at ICTCs. 17 clients (2.3%) are diagnosed with HIV. The remaining 14 medical colleges are in the process of establishing DSRCs, as they are facing a challenge to get supplies of SCM drugs from government. Investing in private Public partnerships with sustained TA plan produced effective results for improved access.

e. Capacity building of Trainers from Training centres of Andhra Pradesh on Instructional Design:
The 21 trainers from SRLs comprised of 10 Technical Officers from SRLs, 9 Medical Officers (MOs), a Lab Technician and a Technical Officer from a National Reference Laboratory were trained on Instructional Design. The participants were selected from all over Andhra Pradesh including districts like Guntur, Vijaywada, Anantapur, Tirupathi, Warangal etc.

Conclusion:
The TA indicate that, despite challenges faced in the course of implementation which include high staff turnover, delays in recruitment of staff, lack of long-term capacity building plan, inadequate supplies of commodities and finances to the field, lack of active engagement of NACO and State level officers to address field level issues and challenges, human capacity building is a long drawn and effective mechanism to support and strengthen the health system to accelerate provision of services to the target audience for prevention, care, treatment and retention.

DAPCUs proved to perform their tasks provided they are given on- going support and periodical onsite supervision to address field level challenges. The efforts of DAPCU are reflective in the decreasing prevalence of epidemic in the high burden states over a period of time. DAPCUs play an important role providing decentralized programmatic oversight to NACP with more than 80% of disease burden in DAPCU districts, having 70% of NACP facilities having 69% of NACP staff in these districts.

The review of the ART Centres reiterated the need for continuous support to the ART centres to maintain quality of services and data. Based on the action plans prepared, the centres are now required to share “Action taken” reports on a periodic basis.

Through PEPFAR US CDC support, SHARE INDIA has been successful in demonstrating the engagement of private medical colleges in assisting the government in rolling out new PPTCT regimen and following the national protocols for Syndromic Case Management of STIs/RTIs in Andhra Pradesh, Lessons from this project could be replicated in other states in India for harnessing better reach of ANC HIV positive women and in strengthening PPTCT and establishment of STI/RTI service in private sector through PPP in India.