Anti Retroviral Therapy Centre (ART):

MSACS has established ART Centre in Government Medical Colleges, District Hospitals and certain Sub District Hospitals of Maharashtra. As per AAP 2011-12, Maharashtra had a target to open 3 new ART centres - which was sanctioned by NACO (DH Sindhudurg, GMC Miraj-Sangli, DH Beed). Currently 48 ART centre in Maharashtra excluding Mumbai. Out of which 39 NACO funded ART Centres. Now 30 districts of category A have at least one ART Centrs and 2 more ART Centres in Category C district excluding Sindhudurg District. 10 big districts have more than one ART Centres.

ART Plus:
It has been decided by NACO that patients who are stable on second line ART at COE for 6 months & have under gone repeat viral load test at 6 months may be referred back to the referring ART Centres by SACEP after considering the capacity of the referring Centres. Therefore NACO upgraded 3 ART Centres as ART plus Centres in Maharashtra.

 Staff Details at ART Centres:
Out of 48 ART Centres of Maharashtra, 452 staff is working at ART Centres excluding Mumbai.
In charge:
Nodal Officer (Govt. Employee)
Senior Medical Officer
Medical officer
1) Staff Nurse 2) Data Entry Operator 3) Pharmacist 4) Lab Technician 5) Counselor 6) Community Care Coordinator
Functions of ART centers
The main objective of Anti-retroviral Therapy (ART) is to provide comprehensive services to eligible persons with HIV/AIDS. The specific objectives of an ART center are to:

1. Identify eligible persons with HIV/AIDS requiring ART through laboratory services
2. (HIV testing, CD4 Count and other required investigations)
3.  Provide free ARV drugs to eligible persons with HIV/AIDS continuously
4. Provide counseling services before and during treatment for ensuring drug Adherence
5. Educate persons and escorts on nutritional requirements, hygiene and measures to prevent transmission of infection

 Refer patients requiring specialized services or admission.

6. Provide comprehensive package of services including.

Medical Functions

To diagnose and treat Opportunistic Infections
To screen PLHA for eligibility to initiate ART
To monitor patients on ART and manage side-effects, if any
To provide in-patient care as and when required.

Psychological Functions
To provide psychological support to PLHA accessing the ART center
To provide counseling for adherence to ARV drugs
To educate PLHA on proper nutrition
To advise for risk reduction behavior including usage of condoms

Social Functions
To facilitate PLHA to access available resources provided by government and NGO agencies.

To facilitate linkages between other service providers and patients, like educational help for the children and Income generation Programmes.

 Link ART centres
 To minimize the need for the patients stable on ART, it is envisaged to have identify and designate Link ART Centers (LAC) for distribution of ARV drugs and monitoring of drug adherence in stabilized patients. This center will be like an extension facility to the main ART center. LAC will be set up where patient load is high (>1000 PLHAs on ART) and there are minimum of 50 PLHAs on ART from the catchment area of LAC. Patients stabilized on ART for 6 months minimum and who are willing to be transferred will pick up ARV from LAC.
    There will be no additional human resource that shall be provided by NACO. Job-oriented training will be imparted to Doctor, Nurse, Counselor and Pharmacist (one each) in these facilities on the additional responsibility of ARV dispensing.
   As per AAP 2010-11, Maharashtra target is 38 of which 29 LACs were sanctioned by NACO. Currently 123 LACs are sanctioned by NACO and 4424 PLHA linked out from Nodal ART Centre to LAC Centres. Up till now MSACS opened LAC in 28 Category A districts & 1 LAC in Category C District.

  LAC Plus:
The existing LACs is upgraded to LAC Plus based on their patient load that is when these centres threshold 70 people alive on ART. In addition to this NACO decided to appoint one Staff Nurse at LAC plus Centres. In Maharashtara currently 16 LACs crossed 70 patients registered & alive on ART and MSACS recruited 17 nurses in these LAC plus Centres.
Funding Guidelines for LAC Centres:

• Internet Connection @Rs. 650/-pm * 12      = 7,800/- p.a.
• Cost of stationary, records, and contingency (including phone) = 10,000/-p.a.
• Cost of travel and drug transfer= 20,000/-p.a.
• Remuneration of Nurse @8000-12,000/- month(For LAC Plus only)- 96,000/- p.a

(Through E-payment)

Total recurring grant:
                            Link ART Centre (total 107) =37,800/p.a
                            LAC Plus (total 16) =1, 33,800/p.a
CD4 Machines

In Maharashtra, total 35 CD 4 labs are functional excluding Mumbai and 3 more will come up this year (including PPP Centres). Operational Cost @90,000 per FACS Calibur Sites of 5 ART Centres, Cost @50,000 per FACS Count Sites of 20 ART Centres and Cost @25,000 per Parte Sites of 8 ART Centres. CD4 Labs would need contingency grant for purchase of thermal role paper for printing, hypochlorite solution, micro tips, gloves, stationary etc. as per work load and these funding are only applicable for NACO funded ART Centres.

Centre Of Excellence (COE):

The HIV/AIDS epidemic has, over the past decade, evolved into a more complex one necessitating operational research. There is need for medical institutions which deliver high quality of care, treatment and support to People Living With HIV/AIDS (PLHA). Complex treatment schedules and patient management require constant training and upgrading of skills among providers. At the same time, being a lifelong therapy, it requires a comprehensive care approach that meets the range of needs of PLHA as well as high levels of drug adherence for anti retroviral treatment.

For focusing on both training and operational research, NACO has envisaged that 10 reputed centers that are currently providing training in ART would be developed and strengthened as Centers of Excellence (COE).

Rationale for Centers of Excellence

Requirement of a shift to chronic patient management approach.

Issues surrounding long term adherence and HIV drug resistance require constant training and upgrading of knowledge and skills among providers.

To address the need for capacity building of good quality, skilled and knowledgeable healthcare providers
.
Serve as models in HIV/AIDS care and support.

As per the approved Annual Action plan for year 2011-12, proposed to release the recurring for Coe (Recurring – Personnel, Research, Training, consumables, TA/DA & oper, Costs, Stationery etc.  Non-recurring- Renovation Furnishing, Equipment.)  Funds required for running an ART Centre are provided to each ART Center for utilization as per guidelines

Community Care Centers (GFATM Round VI)

Karnataka Health Promotion Trust has been selected as sub-recipient to NACO under the Global Fund Round-6  to set up and implement Community Care Centres in the states of Karnataka and Maharashtra. The project will  establish and implement 77 CCCs across Maharashtra and Karnataka (Maharashtra: 38). Currently 38 CCCs are already established in Maharashtra including Mumbai
Care and Support component under NACP–II focused only on treatment of common OIs. The CCC was seen as a standalone centre. with no links with other units of the same programme. NACP-III, apart from further improving the availability, accessibility and affordability of ART treatment to the poor, plans to strengthen family and community care through psycho-social support. Going beyond the individuals, it expands the scope by reaching to the marginalized women and children affected by the epidemic and depend it by improving compliance of the prescribed ART regimen and by addressing stigma and discrimination associated with the epidemic.

Revised Guidelines of CCC/CCSCs Under NACP –III : (October 2010)
The Concept of a CCC since NACP II has changed as the epidemic matured and the national response to HIV prevention, care and treatment has evolved. Over time and experience, the CCC is no longer a place where PLHIV are isolated by the community, With the roll out and rapid scale up of ART , More people are expected to lead a healthy life. Thus, the revised role of CCC/ CCSC will revolve mainly around effectively reintegrating PLHIV back into their respective families and communities. The CCC/CCSC will be a comprehensive facility providing medical, counseling, and referral and outreach services.
Concept of CCC and CCSC under NACP II and III
Thus, under NACP-II:

• Hospice
• Stand alone home
• High Stigma and denial attached
• Not linked with any other program activity

Concept of CCC/CCSC under NACP III

•  Short Stay home
• Advocating actively against stigma, discrimination and denial
• Actively linked with ARTC and LAC
• Linked with many other Government schemes and programs
• Centre with basic aim to recover, recuperate and reintegrate PLHIV back into active life.

They play a critical role in enabling PLHIV to access ART, as well as other units in the same programme such as ICTC, DOTS, PPTCT and other treatment services and interventions.
Goal and Objectives of CCC/CCSC
Goal
An increased number of PLHIV have access to better quality of life and reduced vulnerability through improved clinical and care services, linked with relevant social services, and community responses.

As on 31st March 2011, there are 38 functional CCCs in Maharashtra (including Mumbai)

Registrations of PLWHs in a year April 2010 to March 2011- 21959



Services given by CCC to PLWHAs	Apr 10- June 2010	Jul10 -Sep 2010	Oct 10 - Dec2010	Jan 2011 Mar 2011
OPD ( Total - 65454)	14055	17914	15822	1763
IPD (Total - 29438)	6684	7817	7559	7378
	Total Counseling Sessions	Drug Adherence counselling	Counseling of family members of PLHA
OIs Traated at community Care Centers	Male	Female	Total
Apr 10- March 2011	23723	20815	44538

DROP-IN-CENTRES

NACO GUIDELINES for Drop -in -Centers

The care of HIV infected people is the most challenging aspect in HIV/AIDS prevention. The Experience shows that to mobilize the Community Support, the advocacy among PLWHAs and networking among them for creating an enabling environment is essential. It is a good sign that Community Support groups of PLWHAs are coming forward to provide Emotional and social support to themselves, such community based organizations have the committed responsibility in developing the positive attitudes in the community towards Individuals and families living with HIV/AIDS. Apart from our continuous efforts still the stigma and discrimination exists in the society. There are many people living with HIV/AIDS hesitate to disclose their status due to fear of isolation and discrimination. It is important to address sustainable integrated approaches to improve quality of life and Increase the quality of life of the PLWHAs.

Objectives:

The objectives of the PLWHA drop in centers are as follows:

1. To promote positive living among PLWHAs and improve the quality of life of the infected.
2. To build the capacity and skills of PLWHAs to hope with the infection
3. To create an enabling environment for the PLWHAs
4. To establish linkages with PLWHAs with the existing health services, NGOs, CBOs and
Other welfare and development programmes.
5. To protect and promote the rights of the infected.

Criteria for the selection of the CBO
PLWHA group should be registered organization. These types of CBOs have to be Encouraged immediately after their registration.
PLWHA groups must have minimum 10 people and should be addressing 100 people living with HIV/AIDS and their families.

Key Indicators
1. Behavior Change Communication
2. Enabling Environment
3. Capacity Building
4. Advocacy

Following services provided to PLWHAs by Drop-In –Centers

1. Counseling
2. Self Help Group/ Establishing Pressure groups
3. Need based support by enrolling under Govt. schemes
4. Home visits
5. Providing Psycho social support.
6. Monitoring ART Adherence.


Sr.No.	cost of PLWHA Network Programme	Cost Calculation	Notes	Total Rs.
1.	Programme Management			212000
1.1	Programme Coordinator	1*6000*12	1 Senior staff full me	72000
1.2	Office Support Staff	1*3000*12	1 assistant to look after finance and other project needs.	36000
1.3	Office running expenses	2000*12	water @ Rs. 200p.m. electricity Rs. 300pm stationary 500 pm	24000
1.4	Communication	1000*12	Rs.3000 as tlephone deposit and Rs.750p.m.	12000
1.5	Office Space	4000*12	The office space will also be used for the meetings training community drops in centre drops in center counseling space etc	48000
1.6	Infrastructure	20000	Tables chairs, Cupboards, Partition for counseling drop in center ,(online)	20000
2	Behaviors changes communication
2.1	Emergancies/ Referrral Services	2000*12	Refer the terminally ill and PLWHAs wtih opportunistic infections to govt. hospitals and community care Centers.	24000
2.2	Communicatioins Materials	30000	Develop and dissminate IEC materials in consultation with state AIDS control societies regarding positive living.	30000
2.3	Field workers	Rs. 3000*12*1	Field workers have to work among plwhas and networking and establish linkages with care providers and other departments.	36000
2.4	Social Worker Counselor	Rs.5000*12*2	One male and one female Social worker will also provide counselling	120000
2.5	Travel Cost	Rs.2000*12	Social workers and field workers will have to travel widely and networking the PLWHAs	24000
3.	Enabling environmnet
3.1	Advocacy Programme	6 Program *5000	Area specifcs need based advocacy programme to be organized in collaboration with volunteers lawyers NYK, NSS Mahila Madal etc.	30000
3.2	Get together Programme	2 Programs * 10000	4 PLWHAs programmes once in three months	20000
3.3	Meeting any immediate needs	1000*12	Emergency Meeting	12000
4	Monitoring and Evalution
4.1	Annual Participatory evalution	10000	Yearly evalution	10000
4.2	Process documentation	10000	PLWHAs have to document the activites and programme	15000
			Total	533000/-

PLWHA networks have to be exempted from the 10% NGO contribution. The coverage may have flexibility of 100 PLWHAs on one large program (minimum membership –100)It does not mean that PLWHAs at small proportion need not be encouraged. The PLWHAs even if they are small in-group may also be encouraged and they have to networking among 100 PLWHAs during the project period.

This CBO have to constitute a committee of PLWHAs and SACS and religions and other important care providers and various relevant department representatives as the core group, which can continuously provide technical inputs.

 Guidelines:
          There are so many guidelines for Care Support & Treatment. All Guideline, information’s are available on web site of NACO http://www.nacoonline.org/NACO
 MSACS Website :  www.mahasacs.org
         The ART centre shall be headed by the department of medicine who will be Nodal Officer. ART centers can submit Issues & Application with the signature of Head of the Institution, Nodal Officer & Senior Medical Officer. MSACS will submit these applications & issues to NACO who will be the final authority to take the decision.