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Dear Malviya Alankar,

My name is Snehansu Bhaduri and presently I work as the Program Coordinator at Snehalaya Charitable Trust of the Gwalior Children Hospital. I must appreciate you for putting this query at an appropriate time. My reply is to your sub-query:

Are the present guidelines prepared taking into account the existing institutional arrangements or does it require modifications?
The present Guideline of NACO and the practice currently followed is that every PLHIV must register with a network or any NGO in order to get ART from the Government ART Centres. This is to ensure adherence. However, there are PLHIV who may not like to be registered with a Network or NGO. In that case, they are unnecessarily denied ART. Hence if the guideline could accommodate such PLHIV, it would facilitate all the more PLHIV to get ART and better adherence.

What are the examples of integrated public health services that the DAPCU can follow to integrate NRHM, RCH and TB Control services with HIV prevention and Care?
Confidentiality and Counselling is an integral part of the services rendered to PLHIV. However, the large board put in front declaring, “ART Center”, itself is a give away of the confidentiality of us PLHIV passing through its doors. Therefore, serious consideration must be given to your point on integrating NRHM, RCH and TB Control services with HIV prevention and Care in a “one stop shop” or “single window” approach, which not only integrates physically, but also takes care of the confidentiality side by way of anonymity. 

In addition, attention must be paid to all Counselling rooms in ICTC and ART Centers where presently counselling is done in cubicles. While there is a modicum of visual privacy, the cubicles are open on the top and hence every one can hear the proceedings that are going on within the counselling room. This lack of audio privacy is detrimental to the quality of counselling services by way of lack of confidentiality.

As far as adherence counselling is concerned, in some places the tactic followed is one of threat of not issuing the ART to the PLHIV with poor adherence. Counselling per se must be one with a more positive attitude towards PLHIV and should never induce fear in the PLHIV.

What are the challenges faced in extracting, reporting and analyzing the data at the DAPCU level?
Counting the pills may not be a very good strategy for monitoring the adherence to Treatment. Presently, the system of M & E in adherence is to verify the stock of ART the PLHIV has. There are inherent loopholes in this type of check. For example, If I were to miss out a few doses of ART, I could hide exactly the same number of doses and present the altered stock for verification. I would be marked then as adherent, wherein in reality, I am not. Fear of ART cessation induces one to cheat on reporting adherence. Monitoring of Adherence must be with a more positive attitude to get the correct data.

Additionally, it is quite embarrassing for the PLHIV when the Out reach workers from the ART Center visit the home unannounced and demand to see the stock of ART drugs the PLHIV has and thereby determine the adherence. This may not be convenient for the PLHIV as the confidentiality is broken to guests and family members.

With best regards,

Snehansu Bhaduri,
Snehalaya Charitable Trust,
Gwalior Children Hospital,
Gwalior.
www.helpchildrenofindia.org.uk
snehansu.bhaduri@gmail.com