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.