DAPCU Kurnool (Andhra Pradesh) Response to the Theme : Strategies for reducing ART-LFU at district

DAPCU, Kurnool is one of the A category districts in Andhra Pradesh.  We have been implementing and practicing the following process to link PLHAs to ART center as well as reducing the LFUs in our district with the support of the entire district team.

• DAPCU Kurnool facilitates and conducts meetings with ART Centre and Care and Support Centre (CSC) on fixed dates every month to focus on LFU and MIS cases with the involvement of Network, NGOs and LWS staff.
• We have been conducting LFU Special Drive every year to re-start the LFU, MIS cases, collecting evidence based information on death cases and linking PLHAs with care and support services.
• Mobile Messages (pre-alert) are sent for ART due date, focused on ANC cases with the support of PPP
• Seven Link ART centers have been established at route corner areas in the district.
• Providing free bus pass to PLHIVs and 50% concession to the Attender twice a month with the support of APSRTC. Conducted sensitization for APSRTC bus conductors and depot staff on HIV/AIDS and free bus passes to PLHIVs and avoiding stigma and discrimination.
• DAPCU Kurnool is facilitating access to social security benefit schemes for PLHIVs through DAPCU Led Single Window Model with the support of line departments as well as District Collector.

Sensitization meeting facilitated by DAPCU Kurnool for ART centre and ICTC Counsellors and Mahila Mandali representatives. Participants were sensitized on tracking and reducing LFU cases and importance of taking ART medications without missing any doses.

DAPCU Imphal East (Manipur) Response to the Theme : Strategies for reducing ART-LFU at district

DAPCU Imphal East is playing a vital role in tracking LFU clients in coordination with ART Centre, District Level Network (DLN), Care and Support Centre (CSC) and related NGOs in the district.

The following strategies have been executed by DAPCU Imphal East in reducing LFU:-

1. Monthly review meetings are conducted with NACP facilities with a special agenda to discuss and resolve the issue of LFU.
2. Two staff from CSC have been deployed to ICTC, JNMS (main ICTC where a number of HIV positive cases have been detected) to link clients with the ART Centre.
3. DAPCU maintains the report of LFU cases in coordination with ART centre, CSC and DLN. Coordinated efforts are being made to track all lost clients.
4. Service providers are advised to counsel care givers to ensure adherence to treatment by the clients on ART.

DAPCU Khordha (Orissa) Response to the Theme : DAPCUs role in strengthening referral between ICTC - ART

Linkages and referrals to the positive people are one of the major responsibility of the counselor at ICTCs. However, it is not ended with linkages only but to make proper follow up hence forth and to ensure partner notification for further test. In most of the DAPCU Districts it is being followed up and monitored to ensure 100% ART linkages. It may not be easy for the ICTCs which are far from the ART centre.

Although we have achieved good results in ART linkages, still the scenario was not so convenient in earlier days. There are some of the issues which are still could not be addressed. However, the percentage (%) of ART linkages under DAPCU Khordha was 94% during the period of 2012 and there was no such effort was made to ensure 100% ART linkages and also there is no system initiated to linkages the pending cases. And later these issues have been observed seriously and various efforts were made to ensure 100% ART linkages in the District. Now we have achieved 97% in ART linkages.

Efforts made:

It is viewed that number of testing were increased and number of positives too. So, it was challenge for us to link them with ART Centre. So, following efforts were made to reduce the linkage gaps between ICTC and ART.

1. Discussions and review in the monthly TB- HIV cum coordination meeting with data, showing number of positive detection in the ICTC in the month and ART enrollment. Along with highlighting the no of cases (from the ICTC) are not yet enrolled at ART Center.
2. Sharing of detected positive cases (source SIMS) of all ICTCs for the current month with the ART centre providing data in line listing format containing address, age, occupation, mode of transmission, ICTC where positive detected, date of detection etc to get filled Pre –ART number, Base line CD4, and ON ART Number if he/she eligible for ART.
3. Cross verification of these data with the concerned ICTCs through meetings and through telephonic discussion and feed backs.
4. All Counselors are suggested to ensure that the referred client has visited/reached to the ART center or not, through telephonic discussion / in a written format
5. ART linkages is also been discussed in the monthly ART coordination meeting where DPM is attending in a regular basis.
6. The drop out cases that are not visited to ART centre after detected positive, are the major challenge for us. Although we have no separate mechanism, but the concerned counselor is advised to visit her / his house with CSC / Link Worker/ ORW ( if it falls LWS/TI  area)  to convince them in each Saturday during the outreach activity.
7. Simultaneously the line list of the PLHA who is denying for ART registration after given consent at ICTC are to be shared with the CSC for tracking and in this effort, the concerned counselors are also going with the CSC.
8. Some long pending cases are also shared with CSC for tracking and the action taken report of those cases are submitted to DNO, DAPCU.
9. The cases who are belong to other district are ensured that they are linked with their nearest ART centre if he/she is not enrolled at our ART center. This is facilitated through telephonic discussion with the concerned DAPCU/ ART. (recently 3 cases are linked through this process)
10. Responsible also given concern TI NGO & LWS (for those cases referred by LWS/ TI and detected positive in ICTCs) to follow and ensure to ART registration.

10. DIS and other DAPCU staffs are joint visit with CSC and Concerned counselor to the PLHA who are not agreed to visit ART center.
11. CDMO & ADMO (PH) apprised concern counselors who are achieved 100% ART linkages in monthly meeting. So, that all counselors are taking initiate for achieved 100% ART linkages.

Constrains:

Difficulties to enrolled denying those cases who were agreed initially. Whereas the list of those cases could not be removed from the list.

100% enrollment is not happening due to death after detection and even for denying and absconded cases. 

Not achieving 100% in case of repeat cases.

DAPCU Thoubal (Manipur) Response to the Theme : DAPCUs role in strengthening referral between ICTC - ART

What strategies are currently being adopted to ensure linkages between ICTC and ART centre in your District?
DAPCU is making an effort to integrate the CST services within the health system. Accessing of free Health Check-up , free treatment  under government, giving of Transportation charges to all PLHIV who are  taking  drugs from ART centre under the NACO guideline, intercommunication or sharing of information in between the ART and ICTCs. ART Visit by ICTC Counselor, utilization of Outreach worker of TI –NGOs to link all the Positive Clients to ART, co-ordination with RNTCP Staffs and DOTs providers, ASHA are the main current strategies which are adopted by DAPCU Thoubal.
The delivery of Care and treatment services to the people living with HIV/AIDS   need three –tier service structure, a part from the maintenance of reconciliation sheet of ICTC- ART linkages data because these three-tier systems will help a lot to strengthen the ICTC and ART linkages. So, we need various level of service accessibility.
They are: -

1. Centre of Excellence and link ART.

2. ART Centre.

3.  Decentralized Link- ART centre& link ART plus centre.

 ART centres are also linked with community support centre run by NGOS for a comprehensive packages of services. Detection of HIV positive is the normal duty of the ICTC and accessing of treatment and care activity is for ART centre, both are the two sides of a coin. There  are many challenges for PLHIV and care givers  for taking of Drugs  and for giving drugs, in terms of transportation, cost to access ART and  Stock availability, late entry of PLHIV into ART  and also the poor ownership of ART centres by Health system etc. so, the understanding these problem of Staffs and PLHIV help to strengthen the  linkages of ICTCs /ART. Proper pre –ART counseling , regular follow –up  of every 6 months, strengthening coordination and flow of information between the various services  starting from  Pre-ART enrollment to  continuum care will also  support to strengthen the linkages of ICTC/ART centres.

What steps can DAPCU take to link all the patients who are detected positives for HIV at the ICTCs to ART?

DAPCU is the monitoring and supervision unit. DAPCU has taken some steps to link all the positive clients to the ART centre:

They are: -

1. Maintenance of proper reconciliation sheet.
2. Regular field visit.
3. Organized monthly ICTC/ART Review meeting and sharing of all the information between the ICTC/ ART center.
4. To Link to the Line department for the entitlement of Social benefits scheme & nutritional support to PLHIV.
5. Reduction of Stigma and Discrimination at the health facilities and community link to the Line department for the entitlement of Social benefit scheme & nutritional support to PLHIVs are also the main activities of DAPCU.
6.  Organizing District coordination meeting of CSC/ART and TI-NGO etc.

DAPCU Central Delhi Response to the Theme : DAPCUs role in strengthening referral between ICTC - ART

Following are the strategies currently being adopted to ensure linkages between ICTCs and ARTC in our district:

1. Proper documentation of address & contact details of all clients visited at ICTC.
2. Gapless Line Listing of all HIV Positive Clients.
3. Outreach by ICTC Counselors to motivate the HIV Positive clients who are reluctant to register themselves at ART.
4. Also, outreach by DSRC & TI-NGO staff of their respective clients (detected HIV Positive at ICTC) to ensure their ART Registration.
5. Strengthening linkages between ICTC & ARTC through regular meetings.
6. Support ICTC staff for ART Registration of HIV Positive Clients if they face any difficulty at ARTC.
7. An intensified LFU Tracking Exercise was coordinated, monitored & facilitated by DAPCU-Central Delhi in Central, West & New Delhi Districts (in 2013-14) through following activities:
   1. Facility & Area wise scrutiny of all LFU data provided by Delhi SACS & 9 ARTCs of Delhi.
   2. Scrutinized details of LFUs were disseminated to the concern ICTC, PPTCTC, DSRC & TI-NGO staff for tracking of the same.
   3. LFU tracking were done by the concern facility staff and reported the same to the DAPCU.
   4. 1355 LFU cases were tracked out of total 1612 LFU cases provided during the Intensified LFU Tracking Exercise.

Following steps can be taken by DAPCU to link all the patients with ART who were detected HIV at the ICTCs:

1. DAPCU can emphasis ICTC/ PPTCTC staff to note the proper addresses & details of ID Cards (particularly Aadhar Card details) of all the clients visited at the Center.
2. More stress can be given on Out Reach activities by ICTC/ PPTCTC staff.
3. Intensified LFU Tracking Exercise as cited above can be undertaken annually to minimize the gaps at ICTC-ARTC Level.
4. DAPCU can coordinate with, and take support from other DAPCUs of the State for effective follow-up of clients missed/ LFU for ART.
5. The help of CSC/ Help Desks can be taken, in case of the clients who do not have any Id-Card. Address of the client can be verified by the CSC/ Help Desk after proper visit at and client can be registered at ART on the behalf of the reported address verification of the Client by CSC/ Help Desk.
6. The HIV Positive Clients can be motivated to register themselves at ART by aware them the benefits (including benefits of Financial Assistance Scheme of Delhi Govt.) which they can avail after ART Registration.

DAPCU Mehsana (Gujrat) Response to the Theme : Views on DAPCU's role in Non-DAPCU Districts

How can the DAPCUs extend their support to non-DAPCU districts to manage/ coordinate the NACP activities?

In Gujarat there are 10 high Prevalence (i.e. ‘A’ & ‘B’ category) Districts out of 33 Districts. In all the high prevalence districts DAPCUs were established in 2008-09.

• Supervision & monitoring is the essential part for achieving the goals & objectives of NACP-IV.
• The DAPCUs are playing a critical role to achieve the objectives of NACP-IV in the DAPCU districts. However, there is also a need to ensure similar coordination in Non DAPCU districts.
• Currently Gujarat state has evolved unique models to concentrate in Non DAPCU districts by the existing DAPCU team.
• GSACS has allotted one or two non DAPCU districts to each DAPCU. Respective DAPCU team is managing and coordinating HIV activities in Non DAPCU districts. Generally, the DAPCUs allotted neighboring Non DAPCU districts for easy access and efficient coordination.
• GSACS has allotted Sabarkantha as one of Non DAPCU district for extending technical and coordination support.
• DAPCU team has evolved a plan of action for providing specific time and support to the Sabarkantha district. In Sabarkantha district (Non DAPCU) managed and coordinated NACP activities, with the support of existing DAPCU staff.
• Support has also been provided to NACP facilities in the non- DAPCU districts, Poor performing centers in Non-DAPCU district are visited on periodic basis.

Based on our experience DAPCU district can Support the non-DAPCU districts to manage/ coordinate HIV activities on the following aspects:

1. Participation and Conducting Monthly Review Meeting in non-DAPCU districts every month with the NACP facilities (including HIV-TB coordination meeting). 

• DS DAPCU Mehsana is participating and conducting Monthly review meeting for reviewing the performance by referral and linkages between ICTC /PPTCT/DSRC, TI, CSC & ART centers of Non-DAPCU district.
• DS DAPCU Mehsana Coordinates with the concerned Nodal officer (DTO) of NACP activities and all NACP facilities staff in the District.
• The DS also extend support in planning review meetings, evolving agenda by topics for discussion, Etc.

The Minutes of the meeting are being prepared by District level ICTC Counsellor and finalized by DS. The minutes of meetings are shared with the participants / facilities and initiating for follow up action. Basically, the DAPCU extend their support in introducing systems similar to DAPCU districts for achieving the desired objectives as per NACP IV.

2. Support is given through monitoring and Supportive Supervisory Field Visits.

DAPCU district DS will supervise the work of ICTC & Coordination visit to ARTC, DSRC, Blood Bank, CSC & TI NGO. During the monitoring and supervision visit to ICTC, the DS DAPCU will cross check the SIMS Report, registers/referral & linkage/ data validation etc & giving suggestions to the ICTC Counsellor & LT to improve the quality.

3. Ensuring strengthening the referral and linkage between the NACP facilitates ICTC – RNTCP and among HIV/AIDS facilities.

DAPCU Mehsana is emphasizing on strengthening the referral and linkages between the facilitates i.e. ICTC-RNTCP and between HIV/AIDS facilities by validating the data and maintaining line listing data.

• Minimize gap between referral and linkage loss through establishing coordination between the facilities. This can be done through field visits at regular intervals.
• DS DAPCU will visit the facilities for ensuring data validation, cross verification of data from source registers, ensuring correct and timely reporting. Also ensure 100% reporting through SIMS.

4. Supply Chain Management.

• DAPCU DS also manage the stock of ICTC Kits by coordinating with all ICTCs in Sabarkantha District.

5. Replication of good practices of DAPCU.

Experiences will include:

• Opportunity to replicate the best practices in Non DAPCU districts.
• Opportunity to learn newer initiatives to overcome the existing gaps in the DAPCU districts.
• The team felt it is an opportunity to guide and learn than consider it to be an additional responsibility.
• The team at Non DAPCU districts feel happy to receive additional support/hand holding.

6. Financial Management.

• DAPCU will need to co-ordinate with facilities in the Non-DAPCU districts for submission of SOE & UCs in time.

DAPCU Angul (Orissa) Response to the Theme : Views on DAPCU's role in Non-DAPCU Districts

In Odisha there are 7 high Prevalence (i.e. ‘A’ & ‘B’ category) districts in which DAPCU was established in 2008-09, (out of 30 districts.)

• Supervision & monitoring is the essential part for achieving the goals & objectives of NACP-IV. But in Non-DAPCU Districts  , it is very difficult to coordinate the HIV activities
• OSACS allotted one Non-DAPCU District each to the DAPCU districts to manage / coordinate HIV activities in Non-DAPCU District. Dhenkanal district was allotted to DAPCU, Angul.
•   It is possible to manage & coordinate NACP activities in Non DAPCU District with the support of DAPCU staff

DAPCU district can Support the non-DAPCU districts to manage/ coordinate HIV activities on the following aspects.

S.No.	Component	Role of DAPCU	Remarks
1	Monthly HIV – TB meeting	DAPCU district can help to facilitate conduct monthly HIV – TB meeting in the non DAPCU district.	§     With the effort of DAPCU, Angul the Monthly HIV – TB meeting of Dhenkanal District is being organized every month. DAPCU Angul coordinates with the district health administration and concerned district DACO/DTO and all NACP facilities staff. Discussing on monthly reports, issues faced. Accordingly, decisions are taken by the higher officials. §  DPM DAPCU is facilitating the preparation of meeting minutes.
2	Supervision	DAPCU district staff may Supervise the work of ICTC/ DSRC/ Blood Bank & TI work	§  During the monitoring and supervision visit to ICTC/ DSRC/ Blood Bank & TI, the DAPCU Staff will cross check the registers/ referral & linkage/ data validation etc & giving suggestions to the staff to improve the quality. After DAPCU Angul supervision the ICTC Dhenkanal Staff are maintaining the details of outreach workers / PLHIV Line list/ HIV-TB Line list data. §     After filed visits referral and linkages strengthened in the district.
3	Supply Chain Management	DAPCU Staff Should facilitate in Supply Chain Management to the Non-DAPCU Districts	§  DAPCU Angul Providing ART Medicine / STI Kits to the Dhenkanal (Non DAPCU District) on a regular basis. §      DAPCU also manage the stock out of ICTC Consumables by coordinating among all ICTCs of Dhenkanal District.
4	Capacity Building of TI Staff	DAPCU Should facilitate the Capacity Building of TI Staff.	DPM DAPCU providing hand holding training to TI Projects of Dhenkanal (Non DAPCU District) with PO, TSU.
5	Social Benefit Scheme	Necessary Steps should be taken by DAPCU District to providing the Social Benefit Schemes to PLHIVs/ MARs/ CABAs	§  DAPCU Angul shares all the documents to Dhenkanal District HIV/AIDS Facilities Staff for implementation of Bus Pass to PLHIV. §   DAPCU Angul facilitated the Linkage of orphan CHLIV of Dhenkanal District with Swadhar home (Orphan Home) by coordinating with concerned ICTC, District Child Protection Office & District Health Administration of Dhenkanal District.
6	Red Ribbon Club	DAPCU Should co-ordinate the RRC (Red Ribbon Club) for sensitization Programme / training/ IEC Campaign etc.	DAPCU Angul Organised Sensitization workshop for the Peer Educators/ Programme Officers of RRCs of Dhenkanal Non DAPCU District).  Total 89 participants attended the Programme.
7	Financial Management	DAPCU Should co-ordinate for submission of SOE & UCs in time.	§     DAPCU Staff of Angul District co-ordinate with the HIV/AIDS facilities and District Health Administration for submission of SOE/UC to OSACS in time. §  Supervision/coordination/Liasioning with different facilities/departments of non-DAPCU District done from DAPCU Travel Expenses.

ADMO(PH) , Dhenkanal/DTO,  Dhenkanal & DPM DAPCU, Angul Conducting the HIV-TB Monthly meeting of Dhenkanal District (Non-DAPCU District)