Initiative

WHO Cares for HIV/AIDS

With its unique integrated management approach, WHO is reaching out to the rural HIV population. Nancy Singh highlights this unique strategy

You must have noticed the superstars of Hollywood and Bollywood sashaying across Indian streets to spread awareness about HIV and a battery of journalists and cameramen following them for a sound-byte. In this jamboree, the level to which the star has successfully managed to spread awareness about the real issue is questionable. But another important issue is how many residing in rural India, that has a bulk of HIV load, have even heard of this dramatised message. It is then that we realise and appreciate the importance of groundwork done by organisations like World Health Organisation (WHO) in nondescript villages in the districts of Davangere (Karnataka) and Karur (Tamil Nadu).

Says Dr L Ramakrishnan, Country Director, Programmes and Research, Solidarity and Action Against the HIV Infection in India (SAATHII), an NGO executing the WHO project, "Tamil Nadu has the maximum number of documented AIDS cases, in spite of wide Anti-Retroviral Therapy (ART) access. Access to treatment is largely restricted to urban populations, and HIV positive people from rural areas, often with limited financial resources, are forced to travel long distances to access treatment, care and support services."

Taking Care Deeper

India has the highest burden of Persons Living with HIV/AIDS (PLHA) in Asia, and third in the world with 2.5 million (UNAIDS 2007). Although the Indian HIV epidemic shows a stabilising of the epidemic trend, it is estimated that the need for HIV and ART care will increase as people infected about eight years ago will now start developing HIV/AIDS-related illnesses. Although the National AIDS Control Organisation (NACO) is scaling up its care and treatment programme to 147 ART centres nationally, the delivery of HIV care at district and sub-district level (primary healthcare level) is still inadequate, the WHO has found.

As part of de-centralisation of HIV services, Integrated Counselling and Testing Centre (ICTC) and Prevention of Parent To Child Transmission (PPTCT) services are established at district and sub-district levels, up to taluk, Community Health Centres (CHC) and 24-hour Primary Health Centres (PHC) in these two states. It was envisioned that the Integrated Management of Adult and Adolescent Illness (IMAI) training will support primary care management and allow most care, treatment and prevention to be delivered near the patient's home. IMAI is a training package developed by the WHO, which has been implemented extensively in African and Asian countries. Karur and Davangere are the first two districts selected for implementation in India, following country-specific adaptation by the WHO and state partners. Adapted materials have also been translated into Tamil and Kannada. The main purpose is that busy primary care providers should be able to manage most of the simple problems, while referring more complicated cases to the district hospital or ART centre if there is one.

"Access to treatment is restricted to urban area and HIV positive people from rural areas are forced to travel long distances to access treatment" - Dr L Ramakrishnan, Country Director, Programmes and Research SAATHII

"It trains the healthcare provider in a structured method to approach a patient, be it HIV or non-HIV, in a holistic way" - Dr Po Lin Chan Country Officer WHO

Holistic Approach

Under the leadership of the state governments of Karnataka and Tamil Nadu, and day-to-day supervision by the Karnataka State AIDS Control Society (KSAPS) and Tamil Nadu State AIDS Control Society (TNSACS) and their technical partners, this innovative project to mainstream HIV into the general health services and strengthen district healthcare was initiated in April 2007. Under this plan, a total of 159 doctors and 448 paramedical staff from the two districts' primary health centres and general hospitals underwent training in specific modules since April 2006. "The IMAI project in India is a capacity building project to mainstream and integrate HIV into the district and sub-district level primary health systems," says Dr Po Lin Chan, Country Officer, WHO. IMAI uses a standardised training package to train healthcare providers such as doctors, nurses, counsellors, laboratory technicians, peer educators, and Auxiliary Nurse Midwives (ANM) who each have a role in the delivery of specific HIV/AIDS care in their normal routine work.

The IMAI training covers a whole range of HIV/AIDS-related prevention, care, support and treatment issues from clinical aspects such as treatment of acute conditions and opportunistic infections (like fever, diarrhoea, respiratory complaints, reproductive tract symptoms, and malnutrition), to basic understanding of ART, skills for counselling, adherence support and palliative care with prevention integrated throughout. It incorporates chronic care principles which are relevant to not just HIV, but also the management of diabetes, hypertension, epilepsy, other chronic blood diseases like thalassaemia, cancers etc. "It emphasises core competencies and skill-based learning. It trains the healthcare provider in a structured method to approach a patient, be it HIV or non-HIV, in a holistic way," says Dr Chan.

One-of-a-kind

The best part about IMAI is that it's not just another regular training course that creates awareness and attempts to sensitise the caretakers on HIV. The IMAI uses the 'user of the health system' i.e. patients/PLHAs in the training of healthcare providers. "Today, our system is too verticalised and nobody has a team approach. Training programmes won't help as they are all forgotten once they are over. We know from past experience in training in many health programmes that despite the investment in training and capacity building, linkage and referrals between the healthcare services and community still do not routinely happen," says Dr Chan. After much brainstorming and examining the ground situation, WHO came up with a set of training methods that would make an impact and be fruitful as well. The approach of IMAI is unique.

The use of Expert-Patient Trainers (EPT): It involves training given by people living with AIDS as 'experts.' Their own illness is used as a valuable education strategy to support training of healthcare workers. "In the IMAI project, district-based AIDS patients are trained to play specific cases with the course participants during skill stations, in addition to joining small group discussions during the interactive classroom training," says Dr Ramakrishnan. Hence, the use of EPT adds a dose of reality to training and helps to bring attitude changes in reducing stigma and discrimination in healthcare workers. What is motivating is the observation that even after the IMAI training, the EPTs kept in touch with the medical and paramedical staff whom they trained and also refer other patients from their community for a wide range of services like counselling and testing of HIV, management of acute illnesses, tuberculosis testing, and antenatal/PPTCT services. EPTs are empowered to take care of their own health and equipped to provide information and act as links between their peers and the district health system, thereby generating demand from the community.

Says Dr Chan, "The IMAI training has Greater Involvement of People Living with HIV/AIDS (GIPA), which is a part of the solution to the challenge of linking the community (the demand) and the healthcare system (the 'supplier'). For example, in the pilot site of Karur - EPTs hail from Karur and neighbouring districts of Namakkal, Erode, Dindigul, Tiruchirapalli, Thanjavur, Theni, Perambalur and Coimbatore." 57 PLHIV have been trained as EPTs.

In return, benefits to the EPTs themselves from being part of the 'solution' meant improved knowledge about their own disease and treatment literacy, a change in their attitudes and a sense of worth-facilitating 'positive living.' Dr John Stephens, Training Coordinator, St John's HIV/AIDS Training of Trainers Centre, Karnataka, adds, "It also increased their confidence and enthusiasm to contribute and to participate in the activities of the positive network, and to provide information to other PLHAs. It gave them a better understanding of the limitations and difficulties faced by the healthcare staff."

Post-training mentoring on site: Mentoring by a senior clinician and district administration/health officer contributes to the continued reinforcement of translating knowledge and skills to local action by the healthcare staff, including local troubleshooting of problems. Post-training mentoring visits to the taluk/CHC/PHC have resulted in many significant changes. IMAI methodically uses structured 'sequence of care' to follow all chronic management patients in the PHCs, including diabetes, hypertension and HIV. This has resulted in reduced crowding of patients waiting for the doctor in the PHC setting. "The ANM, nurse and counsellor each play a part in the chronic care sequence and thus reduce the workload of the doctor," says Dr Chan.

"Furthermore, the diagnosis of unique HIV/AIDS opportunistic infection cases at the district hospital level after visits by the mentoring team, improved use of universal precaution, making post exposure prophylaxis, gloves and needle destroyers available at the primary healthcare centres with the support of the district collector's office have led to better quality of services at primary level," says Dr Ramakrishnan.

Team approach: During the IMAI training, the medical and paramedical staffs are trained to backup each other as a team. Some examples reported from the pilot sites include personal communication. The counsellor trained in IMAI identified a patient as having HIV-related illness, which was missed by the PHC doctor, and referred back to the doctor to double check. EPTs, even after the IMAI training finished, maintained strong links with the trained medical and paramedical staff. Dr Chan recalls, "After attending training, the doctor and staff nurse from a Karur district PHC have conducted a delivery for a HIV positive mother using adequate precautions. ICTC counsellors have reported being sensitised to MSM and transgender issues through skill-station simulations. ANMs refer PLHAs for health services and ensure patients are followed up regularly in the ART centre."

Overcoming Hurdles

Considering that India is actually many countries in one, there were genuine cultural, social and economical challenges unique to each state. "There were many challenges in the field as we piloted the IMAI training in two different states which had their unique strengths and weaknesses," Dr Chan concedes. The challenges varied from creating the human resource pool of facilitators and EPTs to overcoming the initial stigma and discrimination of the healthcare workers (trainees), deputation of healthcare providers for training and making available the essential drugs and post exposure prophylaxis at primary level. However, having a good rapport with the HIV patients did help a lot. "SAATHII has been active since 2001 in creating awareness about HIV. Hence that rapport helped a lot here," says Dr Ramakrishnan.

After much reflection, these challenges were overcome by constant advocacy with the state and district administration, motivating PLHAs and community as well as healthcare providers. "Leadership of the district collector's office was crucial in the translation from 'training' to 'providing services/action'," says Dr Chan. The technical and cultural adaptations were made by Indian health experts (doctor, nurses, counsellors, PLHAs) through a series of meetings and further during each field training in the pilot districts. Adaptations were also made in the operational components.

Piloting to Success

With its pilot projects a success, the WHO is looking into scaling up in other high HIV prevalence districts and states, and exploring the possibility of linking it with the National Rural Health Mission (NRHM) towards mainstreaming of HIV into general health services, as part of the national vision to strengthen primary healthcare. Dr Chan reveals, "Tamil Nadu is planning to up-scale the WHO IMAI approach to other districts, while in Karnataka, talks are under way to scale up to other districts with high HIV burden." IMAI has already been adopted in 32 countries mostly in Africa. In Asia, the IMAI training has been adopted by China, Cambodia, Indonesia, and Myanmar.

nancy.singh@expressindia.com