Care Support & Treatment Program (CST)
Introduction
The care, support and treatment need of HIV positive people vary with the stage of the infection. The HIV infected person remains asymptomatic for the initial few years; it manifests by six to eight years. As immunity falls over time the person becomes susceptible to various opportunistic infections (OIs). At this stage, medical treatment and psycho-social support is needed. Access to prompt diagnosis and treatment of OIs ensures that PLHAs live longer and have a better quality of life.
Under NACP–II, focus was given on low-cost care, support, and treatment of common OIs. Apart from further improving the availability, accessibility and affordability of ART treatment to the poor, NACP-III plans to strengthen family and community care through psycho-social support to the individuals, more particularly to the marginalized women and children affected by the epidemic, improve compliance of the prescribed ART regimen, and address stigma and discrimination associated with the epidemic.
Care Support and Treatment services for PLHIV are provided through a network of ART centers. ART centers have been mostly established at medical colleges and district level hospitals to provide “Pre-ART” and ART services. A few ART centres have also been established at sub-district level in the high HIV prevalence states. Each ART centre has been further linked with a Centre of Excellence (CoE) and ART plus centre to ensure assessment and initiation of second line ART to the eligible patients. As ART centres are manadatory in medical colleges,new ART centres will be established in the current year. A proposal for establisghment of Centre of Excellence at Trissur has already been forwarded.
Objective
“To improve the survival and quality of life of people living with HIV/AIDS by scaling up Care, Support & Treatment Services for the People Living with HIV( PLHIV ) community.”
Services
Care Support and Treatment services for PLHIV are provided through a network of ART centers. ART centers have been mostly established at medical colleges and district level hospitals to provide “Pre-ART” and ART services. A few ART centres have also been established at sub-district level in the high HIV prevalence states. Each ART centre has been further linked with a Centre of Excellence (CoE) and ART plus centre to ensure assessment and initiation of second line ART to the eligible patients. CoEs have been established at the regional level in select medical colleges.
However, in order to increase availability, accessibility and improved drug adherence, Link ART centres (LACs) and LAC plus have been established at sub-district and block level hospitals. The LACs are linked to a Nodal ART centre and function as extended units.
Scaling up of ART services in the State
| Facility for CST | Existing | Hospitals where Located |
| ART centres | 5 | MCH Alappuzha MCH Kottayam DH Palakkad GH Ernakulam GH Kasaragod |
| ART Plus centre | 3 | MCH Thrissur MCH Trivandrum MCH Kozhikode |
| Link ART Centres | 14 | PH Lab Kollam, DH, Neyyatinkara, THQH Punalur, THQH Kottarakara,GHPathanamthitta, DH Malappuram, DH Mananthavady, DH Painav, DH Kanjangad,THQHChalakudi,THQHChavakkad,THQHIrijalakuda,THQHKodugaloor&Tirbal Hospital - Attapadi |
| FI ART centers | 2 | DH Kannur & DH Kollam |
| CD-4 Machines | 9 | MCH Alappuzha,MCHKottayam,DHPalakkad,GHErnakulam GH Kasaragod,MCHThrissur,MCH Trivandrum MCH Kozhikode & FI – Kannur. |
| Viral Load Machines | 1 | MCH Thrissur |
| Care Support Centers - VIHAAN | 7 | Trivandrum,Alapuzha,Kottayam,Thrissur,Kozhikode,Kasargod,Palakkad |
Functions of ART service delivery units
In addition to providing the complete complement of services provided at the ART centres, the CoE and ART plus centres provide specialized care for severe Opportunistic Infections (OIs) and toxicity; carry out eligibility assessment for second line treatment; and provide second line ART. CoEs also have the mandate to build the capacity of ART centres and LACs/LAC plus through training, on-going mentoring and operations research.
ART centres provide the full spectrum of Anti-Retroviral Treatment services for the PLHIV. They provide services (counsel, monitor, manage and follow up of patients); screen PLHIV for HIV-TB co-infection; refer, diagnose and treat for OIs (including primary and secondary prophylaxis); provide baseline investigations; and carry out CD4 cell count. ART centres screen PLHIV for clinical and ART eligibility; counsel the patients on treatment preparedness and adherence to therapy; monitor and provide laboratory support; screen for side-effects; and facilitate easy access to specialist care and in-patient care. In case a patient is suspected of drug toxicity and/or treatment failure, they refer the PLHIV to the State AIDS Clinical Expert Panel (SACEP). They also provide PPTCT and pediatric ART services.
Apart from the above stated medical function’s, ART centres also provide psychological support through counselling and education; and social support by linking the PLHIV with District Level Positive Networks and other concerned departments. They have an important role in tracking the LFU cases and PLHIVs not initiated on ART to ensure retrieval and retained in care. They are also responsible for mentoring and supervising the LAC/LAC plus.
Current Scenario
Currently we have 24781 PLHIVs registered at the ART centres and out of which 20002 PLHIVs ever started ART. Status of registration of PLHA at the 10 ART centres in the State for the period from April 2019 to March 2020 and April 2020 to June 2020 are given below.
Details of PLHIV registered (April 2019 –March 2020)
| No | ART Centre | April 2019-March 2020 | April 2020-June 2020 | ||
| PLHIVs Registered at ART Centers | PLHIVs Initiated on ART | PLHIVs Registered at ART Centers | PLHIVs Initiated on ART | ||
| 1 | Alappuzha | 47 | 40 | 15 | 12 |
| 2 | Kozhikode | 146 | 126 | 27 | 24 |
| 3 | Ernakulam | 144 | 125 | 21 | 17 |
| 4 | Kannur | 62 | 59 | 19 | 19 |
| 5 | Kasaragod | 45 | 40 | 8 | 7 |
| 6 | Kollam | 62 | 60 | 9 | 9 |
| 7 | Kottayam | 121 | 107 | 15 | 6 |
| 8 | Palakkad | 132 | 115 | 19 | 15 |
| 9 | Thrissur | 127 | 101 | 33 | 30 |
| 10 | Trivandrum | 196 | 167 | 19 | 13 |
| Total | 1082 | 940 | 185 | 152 | |
Link ART Centers (LAC)
The main functions envisaged for LAC/LAC plus are - providing ARV drugs to patients on ART; monitoring patients on ART; treating minor OIs; identifying and managing side-effects; and reinforcing drug adherence on every visit. All the LACs are attached to their Nodal ART center. There are 14 Link ART centers in Kerala, & of which were managaed by alliance and 7b were amamged by BPCL, At present BPCL: has withdrawn the funding for these 7.
LAC Details as of August 2020
| No. | Name of LAC | Date of initiation | Nodal ART |
| 1 | Government Hospital,Neyyattinkara Thiruvananthapuram |
Feb-09 | MCH Trivandrum |
| 2 | Taluk Head Quarters Hospital Kottarakkara,Kollam |
2014 | MCH Trivandrum |
| 3 | Taluk Head Quarters Hospital Punalur, Kollam |
Feb-09 | MCH Trivandrum |
| 4 | General Hospital, Pathanamthitta. |
Jan-09 | MCH Kottayam |
| 5 | District Hospital, Painavu,Idukki. | Jun-09 | MCH Kottayam |
| 6 | District Hospital,Manjeri, Malappuram | Jan-09 | MCH Kozhikode |
| 7 | District Hospital,Kanjangad,Kasargod | Jan-09 | MCH Kozhikode |
| 8 | District Hospital,Mananthavady , Wayanadu | Jun-09 | MCH Kozhikode |
| 9 | District Hospital,Tirur, Malauppuram | 2014 | MCH Kozhikode |
| 10 | Taluk Head Quarters Hospital Irinjalakkuda, Thrissur |
Sep-12 | MCH Thrissur |
| 11 | Taluk Head Quarters Hospital Chavakkadu, Thrissur |
Aug-12 | MCH Thrissur |
| 12 | Taluk Head Quarters Hospital Chalukkudy, Thrissur |
Sep-12 | MCH Thrissur |
| 13 | Taluk Head Quarters Hospital Kodungalloor, Thrissur |
Oct-12 | MCH Thrissur |
| 14 | Govt.TribalHospital,Attapadi | DH Palakkad |
CD4 machines:
The CST programme provides facility for baseline investigations and CD4 cell count free of cost to all PLHIVs registered at the ART Centres. Currently, there are 9 CD4 machines in the State installed at ART centres, Thiruvananthapuram, Alappuzha, Kottaym, Thrissur, Kozhikode, GH Ernakulam, DH Palakkad,GHKasargod& DH Kannur.
HIV-TB Coordination
The HIV-TB collaboration have been introduced and built upon in the program since NACP-II and there are established guidelines, operational plans and monitoring mechanisms to assess the evolution and collaboration. This is also evidenced by an improving retention cascade. The use of CBNAAT for the diagnosis of TB in PLHIV has been introduced and all the patients visited the ART Centers are screened for TB
ARV Drugs
Antiretroviral drugs are medications for the treatment of infection by retroviruses, primarily HIV. Different classes of antiretroviral drugs act on different stages of the HIV life cycle. These drugs act at various stages of the life cycle of HIV in the body and work by interrupting the process of viral replication.
OI drugs used in ART Centers:
immunodeficiency syndrome (AIDS) is defined as the occurrence of life threatening OIs, malignancies, neurological diseases and other specific illnesses in patients with HIV infection
The OI drugs were supplied by the Government of Kerala through Kerala Medical Services Corporation at free of cost to the ART centers.
Viral load testing for AIDS patients:
At present we have installed one viral load machine at Medical College, Thrissur.
Positive Prevention and Linking PLHIV to Social Schemes
Under NACP-IV, the positive prevention of PLHIV, positive living and to link them to existing social protection and benefit schemes were envisaged as key component of the strategy for care, support, and treatment of PLHIV. Counsellors at the ART centres, are expected to provide psychosocial support and counselling to all the PLHIV about ART eligibility, CD4 testing, regular follow up, positive living, positive prevention, nutrition & hygiene.
PLHIV are referred to Care & Support Centres (CSC) where they are linked to Social Welfare Schemes. CSC’s are doing LFU tracking, providing peer and psychosocial counselling, treatment literacy/adherence, home visits, stigma reduction, advocacy with other line department to increase the access, partner testing, local resource mobilization, and Intensive case finding for HIV as well as TB.
Care & Support Centres (CSCs) – Vihaan programme
The Vihaan Programme is implemented in seven districts through the Care & Support Centres (CSCs). CSCs are selected and formed based on the ART load in the concerned district. At present the programme has 7 CSCs functioning at Trivandrum, Kottayam, Alappuzha, Thrissur, Palakkad, Kozhikkode and Kasaragod districts. All the CSCs are associating and coordinating with the concerned ART centres for implementing the programme.
Recently in the Vihaan Programme, NACO has added one more component ‘Tuberculosis’ since the same it has a major relevance along with other routine programmes on Care & Support. To address the TB component an HIV/TB coordinator also is appointed at the Vihaan Central office.
Objectives of the VIHAAN programme
- Early linkages of PLHIV to Care, Support, and treatment services
- Improved treatment adherence and education for PLHIV
- Expanded positive prevention activities
- Improved social protection and wellbeing of PLHIV
- Strengthened community systems and reduced stigma and discrimination
Linkages with existing Social Welfare Schemes