India HIV/AIDS Resource Centre
National AIDS Control Organisation
Ministry of Health & Family Welfare, Government of India
NACP adopts a comprehensive strategy to strengthen care, support and treatment for People Living with HIV (PLHIV) providing psycho-social support to the infected and affected individuals, especially to marginalized women and children affected by the epidemic, and ensure accessible, affordable and sustainable treatment services. Expanding care, support and treatment (CST) and linking them with prevention helps reduce AIDS related mortality and also positively impacts reduction of poverty, stigma and discrimination. 
 
The Care, Support and Treatment of People Living with HIV (PLHIV) is an important component of National AIDS Control Programme (NACP), and aims to provide comprehensive management to PLHIV with respect to prevention and treatment of Opportunistic Infections, Antiretroviral Therapy (ART), psychosocial support, home based care, positive prevention and impact mitigation. 
 
The free ART services were introduced on 1st April, 2004 in eight government hospitals located in six high prevalence states. Since then, the services have been scaled-up to patients across the country. In order to facilitate the delivery of ART services nearer to the beneficiaries, concept of Link ART Centre (LAC) was conceived and established. All diagnostic as well as therapeutic services related to ART are provided free of cost to PLHIV. Any person who has a confirmed HIV infection is registered in HIV care at the ART centre and is subjected to further evaluation for determining whether she/he requires ART or not by performing CD4 count and other baseline investigations. All those eligible as per national technical guidelines are started on ART.
 
Key Components
 
I. Salient Features:
The strategies for providing care, support and treatment for People Living with HIV (PLHIV) include identification of institutions, strengthening referral linkages for CD4 testing, capacity building of ART centres and procurement of ARV drugs. Quality of ART delivery is enhanced by providing training to all categories of health service providers, linkages to ART centres, adherence to monitoring systems and a mechanism for certification and accreditation of services in both the public and private sectors. The major focus is on ensuring a very high degree of adherence to ART (>95%) so that patients can continue on these services for a longer time. The delivery of care and treatment services for people living with HIV/AIDS is provided through a three-tier structure. The various levels where HIV care and treatment is provided are ART Centre, Link ART Centre and Centres of Excellence. There is a close linkage with Revised National TB Control Programme (RNTCP).
 
II. Tasks, Personnel and Structures:

• Anti-retroviral Therapy (ART) Centres:
Set up based on prevalence of HIV in the district/region, volume of PLHIV detected and capacity of the institution to deliver ART related services, ART centres are established mainly in the Medicine Departments of Medical Colleges and Government District Hospitals. Some ART centres also function in the sub-district and area hospitals. The main objective of Anti-retroviral Therapy (ART) Centre is to provide comprehensive services to eligible persons with HIV/AIDS including ART. NACO supports additional personnel (doctors, counselors, nurses, pharmacists, data managers and care coordinators) at these centres based on patient load. NACO also provides facilities for CD4 testing at these sites and supplies ARV drugs, CD4 kits and drugs required for treatment of Opportunistic Infections.

• Centres of Excellence (COE):
Centres of Excellence established across the country besides performing routine functions of ART centres, also provide second line and alternative first line ART, training, research work and mentoring of ART centres linked to them. Assessment of patients with suspected treatment failure to first line ART for initiation of second line ART is done by an expert panel known as State AIDS Clinical Expert Panel (SACEP) constituted at these COEs.

• ART Plus Centres:
Observing that patients need to travel long distance to access the second line ART treatment which resulted in low uptake of the treatment and also inconvenience and difficulties to patients, it was decided to expand the number of facilities that can provide second line ART. For this, it was planned to upgrade some good functioning ART Centres with geographical considerations and label them as ‘ART Plus Centres’.

• Link ART Centres (LAC):
As ART treatment is lifelong and drugs are provided on a monthly schedule, PLHIV face inconveniences of distance, travel time and costs which constrain access to ART services and adherence to treatment leading to poor drug adherence lost to follow up and missed cases. To make treatment services more accessible and facilitate delivery of ARV drugs, Link ART Centres are established mainly at district/sub-district level hospitals nearer to the patient’s residence to improve accessibility. These LACs are located at the Integrated Counselling and Testing Centres (ICTC) which further helped in linkage between ICTC and ART services.

• LAC Plus Centres:
LACs having more than 70 PLHIV on ART are upgrated as ‘LAC Plus’.

• Pediatric Centres of Excellence (CoE):
Under the National Paediatric HIV/AIDS Initiative certain ART centres have been upgraded to Paediatric Centres of Excellence (PCoE) that provide comprehensive specialized services to children with HIV/AIDS. These centres are also to be the nodal points for research in paediatric care. Their main work is to provide second line ART to children, do research, mentor ART centres as per allocation and treatment of complicated cases.

 

III. Services:

• Anti-retroviral Therapy (ART) Centres:
Set up based on prevalence of HIV in the district/region, volume of PLHIV detected and capacity of the institution to deliver ART related services, ART centres are established mainly in the Medicine Departments of Medical Colleges and Government District Hospitals. Some ART centres also function in the sub-district and area hospitals. The main objective of Anti-retroviral Therapy (ART) Centre is to provide comprehensive services to eligible persons with HIV/AIDS including ART. NACO supports additional personnel (doctors, counselors, nurses, pharmacists, data managers and care coordinators) at these centres based on patient load. NACO also provides facilities for CD4 testing at these sites and supplies ARV drugs, CD4 kits and drugs required for treatment of Opportunistic Infections.

• Antiretroviral Therapy:
Antiretroviral Therapy (ART) suppresses viral replication, slows or halts disease progression, prolongs longevity and greatly improves the quality of life of HIV positive people. ART is given to people at a certain stage of infection. All diagnostic as well as therapeutic services related to ART are provided free of cost to PLHIV through select government hospitals and non-profit charitable hospitals. Services provided by ART Centres include:

  1. Screening PLHIV for eligibility to initiate ART based on clinical staging and CD4 count
  2. Monitoring patients in Pre-ART Care and initiate ART as and when they become eligible
  3. Monitoring patients on ART and manage side effects, if any
  4. Diagnosing and treating Opportunistic Infections timely and also prophylaxis to prevent OI
  5. Providing in-patient care as and when required
  6. Educating PLHIV and their care givers on nutritional requirements, hygiene and measures to prevent  transmission of infection
  7. Providing comprehensive package of services including condoms and prevention education
  8. Facilitating linkages between other service providers
  9. Providing psychological support to PLHIV accessing the ART centre
  10. Providing counselling for adherence to ARV drugs
  11. Advising for risk reduction behaviour including usage of condom

The main functions of LAC are monitoring patients on ART, drug distribution to patients on ART, treatment of minor OIs, identification and management of side-effects.
 

• Care and Support:
Improving the quality of life, social integration and dignity of people living with HIV is an ongoing effort. Care and support services through partnership with non-profit organisations and expanding access to care in an enabling environment, increases the demand for services and motivates those living with HIV to adopt and sustain safe behaviour. Social support, counselling, treatment and patient management including referrals are provided through community care centres. These centres act as a bridge between PLHIV households and ART centres, focusing on management of opportunistic infections as well as adherence counselling for ART.