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Improving access to care and treatment services for children affected by HIV/AIDS in Andhra Pradesh, India
Ajay Kumar Reddy Technical Manager – Monitoring & Evaluation Balasahayoga
Context
• India– 0.34% prevalence with an
estimated 2.31 Million PLHIV (HSS 2007)
– 3.5% of PLHIV (80,000) constitute the age-group <15 years (HSS 2007)
– 0.49% prevalence among ANC attendees (Annual Report 2009-10, NACO)
– Low knowledge on HIV / AIDS among general population (17% women and 33% men – NFHS-3)
– High prevalence in southern states (Andhra Pradesh, Maharashtra, Tamilnadu and Karnataka) and the North-East
Context
• Andhra Pradesh
– 0.5 Million PLHIV (HSS 2007) constituting 22% of the HIV burden of the Country
– 1.22% prevalence among ANC attendees (pregnant women)
– 17,000 infected children (HSS 2007) and 150,000 affected children (Program Data)
– Low awareness levels on HIV / AIDS among general population (13.7% women and 32% men – NFHS-3)
Issues
• Issues effecting access to care and treatment for HIV affected children– Prevention and Treatment focused on
adults (Ped ART introduced in 2006 and Early Infant Diagnosis in 2010)
– Facilities not treating ‘Family’ as a unit thereby resulting in low identification of infected Children and Partners
– Low knowledge on existing HIV care, treatment and support services
– Absence of Continuum of Care approach and lack of follow-up resulting in high drop-out from care and treatment services
– Delayed testing and identification leading to high mortality rates. (Out of the total children dead, only 37% have been tested whereas 87% were with Mothers HIV Positive)
Distribution of Children Tested for HIV by Age-Group
1%
11%
37%33%
18%
0%
5%
10%
15%
20%
25%
30%
35%
40%
0-2 Years 3-5 Years 6-10 Years 11-14 Years 15-18 Years
Balasahayoga – the program
• Objective: Improve the Quality of Life of Children through access to treatment, care and support services.
• Duration: 5 Year program supported by Children’s Investment Fund Foundation (CIFF) and Elton John AIDS Foundation and implemented by FHI, Clinton Foundation and CARE.
• Coverage: 68,000 children and their families affected by HIV/AIDS in 11 districts of Andhra Pradesh, India
• Interventions in domains of Health, Education, Nutrition, Psycho-social support and Safety Nets
• Works at Community and Facility levels to generate demand for services as well as improve response at facilities.
The Approach
• Family case management (FCMs) approach where FCMs (outreach workers) make home visits, provide care, counsel parents on available services and make accompanied referrals to facility-based services;
• Data sharing with Facilities to identify and minimize Loss-to-follow-up between services
• Develop and Use simple set of tools (algorithms, flip books, etc) for FCMs to screen for eligibility of VCT, ART and other key services
• Work with facilities to improve patient flow, availability of pediatric ART/OI medication, quality of care and child counseling
• Local Coordination Committees to ensure community level and key stakeholder participation and support
• Demonstrate and Advocate with Government to provide access to support services like safety-nets and livelihood promotion activities.
Algorithm used for identifying eligible children for HIV Test
FCM tools – Growth Monitoring, Disclosure, Neverapine Provision, etc
FCM Micro Plan
Name of the FCM:G.K.Satyam Narayana
Date Name of the village
Activities to be Performed
New Househ
oldRegistration
GMART Adhrence
Education
Linkages to
Welfare scheme
s
Referrals (CD4, ART, testing, TB, etc.)
Safety Net
interventions
Support Group
Meetings
Test CD4 ART TB
21 Jun Shareef Nagar
Refer Data from ICTC
43 649 238 43, 746 238 649 649
21 Jun Vasavinagar 123 497
22 Jun Muzafar Nagar 567 476 476 25 Jun
22 Jun Chintalamuni Nagar 297 632 632
23 Jun Nirmal Nagar 1377 397 1377 1377
24 Jun Shareef Nagar 330 1343
24 Jun Shareef Nagar 1339 1451
25 Jun Mahathammanagar 1127 448 937 25 Jun
25 Jun Shareef Nagar 841 778
FCM Performance Summary Sheet (Testing & Treatment)
Children Cascade (0- 14 years) Mar 2010
Registered 282
Children (0 - 14 years) 224
Eligible for testing 167
Tested 95
Tested Positive 17
Registered for ART 13
Ever on ART 5
Currently On ART 5
Caregiver’s Cascade Mar 2010
Registered 257
Eligible for testing 216
Tested 196
Tested Positive 155
Registered for ART 78
Ever on ART 35
Currently On ART 32
Lesson’s Learnt
• The continuum of care approach has resulted in significant improvements in access to services and retention in care – Identification and registration of 46,000 children and 48,000 adults
(infected and affected) from 28,000 Families.– HIV testing rates among eligible children increased from 19% to 58%; – Enrollment in treatment services increased from 42% to 78% for
children and 18% to 66% for adults;– Loss-to-follow up from ART treatment reduced to <2% among children
and <5% among adults;– Improvement in Food Security Levels of Households through access to
Safety Nets and Livelihood Enhancement Initiatives. – Overall retention of children in care is 93%, with 6.3% lost due to
migration and 0.34% due to death.
Testing and Treatment Cascade for Children
Child cascade Balasahyoga: Y3 Number of Children (% increase from previous Year)
45,727
Registered TestedNot tested
9,814 (-3.1%)
14,968 (3.1%)
24,782 (-1.5%)
Eligible for Testing
Registered ART centre
2,432(2.4%)
Not reg. ART
centre
594 (-2.4%)
Positive
3,026 (1.6%)
Received CD4 count
Not received
CD4 count
Eligible for ART
Eligible & not
on ART
LFU on ART
18 (-5.1%)
Ever on ART
859 (-5.8%)
On ART
841 (5.1%)
Y1
Y2Q1Y3
Y3 target
Y5 target
Q2 Y3
16,341
28,200
33,408
54,000
68,000
39,689
85%
59%
51%56%
23%
57%
70%
70%
85%
56%
30%
30%19%19%
-
-
-
-
-
-
-
-
-
-
-
37%
93%
93%
90%
95%
92%
53%
78%
80%
90%
95%
78%
Y3 target
Y5 target
37,800
57,800
-
-
--
3,200
5,000
10,000
13,700
22%56% 77%Q3 Y3 53% 90%40,741
20%60% 80%Y3 54% 98%45,727
-
1042
183
2,235
197
Testing and Treatment Cascade for Caregivers
Caregiver cascade Balasahyoga: Y3Number of Care Givers (% increase from previous year)
Registered
47,744
Tested
35,737 (1.9%)
Not tested
38,568 (-3.2%)2,831 (-1.9%)
Eligible for Testing
Registered ART centre
20,158 (20%)28,780 (1.1%)
8,622(-20%)
Positive Not reg. ART
centre
Received CD4 count
Not received
CD4 count
Eligible, not on ART
Eligible for ART
On ART
8,245 (2.9%)
525(-2.9%)
LFU on ART
8,770 (-1.7%)
Ever on ART
Y1Y2
Q1Y3
Y3 target
Y5 target
Q2Y3
-25,749
29,972
48,000
60,000
36,145
85%84%
85%
84%
88%91%
92%
85%
90%
94%
83%80%
82%
82%
--
-
-
-
-
--
-
-
-
-
47%91%
91%
90%
95%
91%
25%50%
57%
90%
95%
59%
Y3 targetY5 target
40,80054,000
--
--
10,50016,600
29,30041,000
Q3Y3 41,023 79% 94% 80% - - 84%66%
Y3 47,590 81% 93% 80% - - 94%70%
17,116
3,042
862
9,632
Access to PPTCTC services
PPTCT Cascade - Q3 and Q4 Yeasr 3 Cum.
403375 383 366
335
239
8656 34
274243 227
496 476 469441 428
330
11287
302274 259
79
0
100
200
300
400
500
600
Pregnantwomen
Linked toANC
services
Tested forHIV
HIV positive Providedcounseling
Registeredfor Pre-ART
Eligible tobe on ART
Ever on ART Currently onART
Positivedeliveries
InstitutionalDeliveries
MB Pairprovided
Neverapine
Qrt 3
Qrt 4
Next Steps
• Partner with state and national government to adapt this continuum of care approach to other HIV affected areas of India.
• Successfully Pilot the Children Affected By AIDS (CABA) Scheme for scale-up in all the high-prevalence districts in the Country.
• Demonstrate a cost-effective and replicable model for adoption and scale-up by Government to other districts and states.