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  • 1. AIDSTAR-One | CASE STUDY SERIES July 2012Linking Resources forAntiretroviral Therapy AdherenceThe Samastha Project in Karnataka, India A 10-year-old girl and several field workers are sitting in a room in the village of Kurugodu in the southwestern state of Karnataka, India. The girl looks happy and healthy. However, Courtesy of Herman Willems the small green booklet she carries shows that she is a child living with HIV. She is on antiretroviral therapy (ART) and outreach workers from Vimukthi, a nongovernmental organization (NGO) and partner in the Samastha project, have identified adherence problems. Because she accompanied her mother on a trip to a neighboring district and ran out of medication, the girl has missedMeeting of Samastha link workers,accredited social health activist, her ART drugs for a number of weeks. The outreach workers areand Vimukthi supervisors in Bellary talking to her and her guardian to help determine the best way toDistrict. get her back on treatment and avoid missing ART doses in the future. Her situation is not unusual: adhering to long-term HIV care and ART is challenging for all people living with HIV (PLHIV). It is especially so for PLHIV in rural villages such as those in Kurugodu, which is about three hours away from the nearest HIV care and ART center. Though the number of ART centers in Karnataka has increased dramatically over the past years, such problems as transport and incomplete information remain obstacles to care for PLHIV, and many are lost to follow-up (LFU) after diagnosis. Those who drop out of care will not receive the care or treatment for which they are eligible. And those who are on ART may have adherence problems or may default, rendering them more likely to transmit HIV or become ill.By Herman Willems Keeping PLHIV adherent to treatment was a key goal of Samastha, a five-year project that was launched in January 2007 with support from the U.S. President’s Emergency Plan for AIDS Relief through the U.S.AIDSTAR-OneJohn Snow, Inc. This publication was made possible through the support of the U.S. Agency for Interna-1616 North Ft. Myer Drive, 16th Floor tional Development under contract number GHH-I-00-07-00059-00, AIDS Support andArlington, VA 22209 USA Technical Assistance Resources (AIDSTAR-One) Project, Sector I, Task Order 1, fundedTel.: +1 703-528-7474 January 31, 2008, and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR).Fax: +1 703-528-7480 Disclaimer: The author’s views expressed in this publication do not necessarily reflect the views of the United Agency for International Development or the United States Government.
  • 2. AIDSTAR-One | CASE STUDY SERIESAgency for International Development. Implemented Indian Council of Medical Research and Familythrough a consortium of international and Indian Health International 2009).partner NGOs, including Vimukthi, Samasthasought to provide comprehensive HIV services The HIV epidemic in Karnataka has a strong ruralin 12 high-prevalence rural districts and 3 urban component (Becker et al. 2007), driven by migratorycenters in Karnataka, as well as 5 coastal districts labor and the availability of cash that attractin neighboring Andhra Pradesh. The project was commercial sex workers. In many parts of northerndesigned to reduce the risk of HIV transmission Karnataka, sex work in the context of the Devadasi1among the most at risk populations, as well as tradition is socially accepted (O’Neil et al. 2004).vulnerable populations in rural areas, while building Devadasi female sex workers are more likely tothe capacity of existing health care institutions to work in rural areas compared to other female sexprovide quality HIV care, support, and treatment workers (Blanchard et al. 2005).services (Karnataka Health Promotion Trust [KHPT]2008) and to promote the utilization of these Samastha worked in several ways. The projectservices by PLHIV. trained, collaborated with, and coordinated existing community-based services (ASHA,2 anganwadi,3 and auxiliary nurse midwives), government cadresSamastha used a number of innovative strategies and structures (such as the District AIDS Preventionto improve access and adherence to treatment, and Control Unit [DAPCU] and integrateda particular challenge in rural areas. The project counseling and testing centers [ICTCs]), NGOs,developed networks that helped government and PLHIV networks. Samastha also providedagencies and NGOs coordinate their work, which preventive services directly and strategicallyenhanced their capacity to recruit new patients, deployed a number of trained outreach and linkkeep them in care, and monitor their status at the workers (see Box 1).district level. Procedures developed by Samasthaalso helped HIV workers to track and retrievepatients who had been LFU, a difficult population inthese remote areas. Implementation Samastha developed a network in which trainedKarnataka’s Rural HIV workers, village health committees, government facilities, PLHIV networks, and participating NGOsEpidemic collaborated to improve recruitment and retention 1A 2008-2009 survey estimated HIV prevalence 1 Traditionally, Devadasi were girls who were dedicated to marriagein Karnataka’s adult population at 0.63 percent, to a god and were required to perform duties at temples. Thesecompared to 0.31 percent in India overall (National duties commonly included sexual favors to priests and patrons of theInstitute of Medical Statistics and National AIDS temple. Over time the system has changed, but sexual exploitation of the Devadasi, especially those from lower castes and economicallyControl Organization [NACO] 2010), while other vulnerable families, is common (Halli et al. 2006).studies document a high prevalence among certain 2 One of the key components of the National Rural Health Mission is to provide every village in the country with a trained female communitypopulations, such as women in antenatal care (1.1 health activist or accredited social health activist (ASHA). Selectedpercent; National Institute of Health and Family from the village itself and accountable to it, the ASHA has been trainedWelfare and NACO 2007) or female sex workers to work as an interface between the community and the public health system (National Rural Health Mission n.d.).(ranging between 9.5 to 34.2 percent by district; 3 Government sponsored child- and mother-care center.2 AIDSTAR-One | July 2012
  • 3. AIDSTAR-One | CASE STUDY SERIESof PLHIV while strengthening and supporting their adherence totreatment. BOX 1. MAIN COMPONENTS OF SAMASTHA PROJECT IN SUPPORTLink Workers and Outreach Workers: OF ADHERENCECoordinating Treatment, Care, and 1. Link workers and otherAdherence outreach workers coordinate follow-up andThe “link worker” model was a central component of Samastha’s rural tracing activities accordingoutreach. Link workers were PLHIV who were selected by Samastha to geographic areasfrom a small number of HIV-positive candidates proposed by theircommunity; they received an allowance for their work. The link 2. Community- and facility-workers’ key tasks revolved around prevention, stigma reduction, and based care for PLHIVsupport for PLHIV that included adherence support to both treatment 3. Detailed mapping, micro-and care. planning, and home visitsWhile link workers were recruited in rural high prevalence areas, 4. Organizational capacitySamastha supported HIV-positive outreach workers at community care building and training ofcenters and at integrated positive prevention and care drop-in centers. outreach workersOutreach workers’ main task was to support PLHIV’s adherence tocare and treatment. Community care centers are hospitals that provide 5. Support groupsinpatient and outpatient care for PLHIV, including ART. The community 6. Support to village healthcare center outreach workers operate in a 30 kilometer radius around committeesthe hospital. The drop-in centers were Samastha centers that initiallyprovided non-ART care for PLHIV. As government facilities gradually 7. Links to governmentincreased their provision of clinical services for PLHIV, Samastha programsprogressively shifted drop-in center focus to outreach. The drop-in center outreach workers have a strong link with the numerous 8. Facility-based adherenceICTCs. This made the ICTCs into entry points for Samastha outreach provided the outreach and link workers with a five-dayinduction training in mapping, micro-planning, the basics of HIV,sexually transmitted infections and HIV care, needs assessment,and counseling. The induction training was followed by three days ofcommunication skills training. Link workers were also introduced tothe concept of “shared confidentiality” (sharing medical informationwith family, health workers, and others as needed) and many receivedadditional training packages.Coordination: Over the course of the project, it became clear thatnumerous public, private, and community resources were available. Linking Resources for Antiretroviral Therapy Adherence: The Samastha Project in Karnataka, India 3
  • 4. AIDSTAR-One | CASE STUDY SERIESScores of NGOs and local networks of PLHIV Home visits: Samastha provided home visitswere working in rural areas; the government had through three different cadres of field workers.strong programs, all providing community outreach Home visits to consenting PLHIV were aservices; and village-level organizations had access fundamental part of the link workers’ certain local resources—but these organizations They maintained a set of maps of their catchmentwere not working together. Samastha worked with villages: a social map identifying formal andall of the local human resources and developed informal facilities and services in the village (Figuremechanisms to bring all players together, initially 1), and detailed maps indicating the houses of thein two pilot districts, and expanded the model different types of clients—PLHIV, orphans andthroughout the 12 Karnataka districts. vulnerable children, widows, female sex workers, pregnant women, and others (Figure 2). The mapsUltimately, the link workers’ coordinating role were updated every quarter. PLHIV who fearedbecame a hallmark of Samastha’s interventions HIV-related stigma, a significant issue in Karnataka,in high prevalence rural areas. Link workers could also opt to meet the link workers at otherformed the essential connection between PLHIV, locations. Those who refused home visits weregovernment and community structures, and mapped but not visited.HIV care and treatment services, commonly During visits, the workers checked the government-accompanying persons from their catchment area issued “Green Book” (the clinical log), discussedto these services. past and upcoming clinical appointments, and conducted and documented a pill count toNewly diagnosed clients who consented to shared check adherence. The pill count was institutedconfidentiality were connected at public ICTCs withlink workers for community-based follow-up. Wherepossible, Samastha worked through pairs of link BOX 2. LINK WORKERS’workers to enhance accessibility to both genders. RESPONSIBILITIESA pair of link workers typically covered three to five ●● Monitoring ART adherencevillages. These workers followed all PLHIV in theircatchment villages based on continually updated ●● Tracing missing and LFU clientslists from the ICTC registers. ●● Caring for orphans and vulnerable children ●● Promoting positive prevention for people whoThe link workers helped PLHIV connect with tested positive for HIVgovernment and community agencies, kept trackof adherence, provided home care, and performed ●● Reducing stigmanumerous other tasks as necessary (see Box 2). To ●● Linking PLHIV with government and otherensure quality and consistency, Samastha project programssupervisors—one for every 8 to 10 link workers— ●● Liaising with ART centersmonitored the workers’ activities. Supervisors alsohelped to plan activities, conduct village training, ●● Mobilizing community resourcesestablish connections with resources such as the ●● Providing home-based careICTCs and social welfare agencies, and collect ●● Spearheading prevention activities at thebasic statistics on the number of clients and visits to community level.clients.4 AIDSTAR-One | July 2012
  • 5. AIDSTAR-One | CASE STUDY SERIESmid-project because the previous approach, a Figure 1. Social map of a participating village.three-day recall, appeared to be unreliable. TheSamastha database, which collected informationon all adherence assessments performed by linkworkers, showed that overall adherence was high:nearly all (95 percent) of over 24,000 PLHIV onART who participated in the project showed goodadherence (adherence greater than 95 percent).4Another 2.7 percent had some adherence problems(80 to 95 percent), while 2.3 percent had pooradherence (less than 80 percent adherence).When link workers found inconsistent compliancewith treatment, they provided extra counseling andhelped clients identify ways to improve adherence.Outreach workers’ home visits largely focused onretrieving PLHIV who were missing or LFU. Theydid so in villages that were not covered by linkworkers and in urban areas where no link workerscheme was implemented. While both link workersand outreach workers would respond to adherenceproblems that were identified at the facility level, linkworkers would provide more continuous supportthrough regular visits to homes of PLHIV.The female sex worker peer educators were a thirdtype of field worker that Samastha used. Their rolein adherence support was similar to that of theoutreach workers and link workers, but limited to the Figure 2. Detailed village map showing locations and types of Samastha clients.female sex worker community.Documenting clinical care andcompliance: Link workers documented theirwork systematically in handwritten registers. Theregisters record how long it took to get clients intothe clinical care system after being diagnosed withHIV, when each client’s last clinical visit took place,and when they last collected their antiretroviraldrugs, among a string of other important facts aboutthe medical follow-up for each patient. 14 However, accurate documentation of adherence proved problematic(see the “Challenges” section). Linking Resources for Antiretroviral Therapy Adherence: The Samastha Project in Karnataka, India 5
  • 6. AIDSTAR-One | CASE STUDY SERIESFrom October 2009 to September 2010, over 350 that were organized by Samastha (KHPT 2011b).Samastha link workers reached more than 45,000 ART adherence is one of the areas that werePLHIV in the state of Karnataka (KHPT 2011a). The covered in detail during this training. Samastha’sadherence of pre-ART clients—those who have capacity building has provided strong support forbeen diagnosed but are not eligible for ART—was the establishment of 93 link ART centers duringnot monitored at all facilities. In such cases, link the life of the project. These centers are located inworkers provided the only systematic monitoring of taluka (subdistrict) hospitals and continue ART foradherence to care. patients who are stable and have no adherence problems. Thus, the link ART centers bring ARTLinking PLHIV with other services: Link closer to patients and provide an incentive for goodworkers commonly helped their clients obtain a food adherence.ration card or a widow’s pension, arranged links togovernment agencies to ensure care for pregnantwomen, linked beneficiaries to the orphans and Supporting Adherencevulnerable children scheme of the Women andChild Welfare Department, and occasionally through Village Healthguided a client through the process of applying forgovernment housing. Anecdotal responses from CommitteesPLHIV suggested that assistance such as this Link workers were assisted in their work byindirectly supported their adherence to treatment. village health and sanitation committees made up of community leaders, representativesEstablishing support groups: Samastha from community-based organizations, NGOs,helped PLHIV improve their own lives by disadvantaged communities, other communityestablishing support groups, often with help from representatives, and village health workers.government or community workers or from NGOs Samastha’s link workers initiated community(thus helping to build the NGOs’ capacity as well). discussion to improve understanding of HIV andSupport groups can help PLHIV regain self-esteem provided a monthly report to the committee onand confidence. the latest HIV statistics, PLHIV needing support, adherence problems, and other issues.Building Local Capacity to Link workers approached the village health and sanitation committee as needed to obtain supportProvide HIV Treatment for PLHIV. For example, the committee might pay bus fare or school fees, or provide foodSamastha’s capacity building efforts helped to support. Funding was provided by the village’sestablish and scale-up a network of lower-level cooperative society, which gathers financial supportcenters for HIV care in Karnataka. Initially ART was from business people, wealthier villagers, andprovided by government ART centers at the district neighboring industries; this funding has enabledlevel. By the end of 2010, Samastha had conducted some villages to maintain successful activitiesbasic six-day training sessions for 359 clinical beyond the end of the projects that initiated them.staff members from both private and government The visibility of Samastha’s link workers, and theirinstitutions, many of whom went on to benefit from efforts to combat HIV-related stigma, probablyclinical mentorship or practice at learning sites contributed to the growing number of village-6 AIDSTAR-One | July 2012
  • 7. AIDSTAR-One | CASE STUDY SERIESinitiated volunteer activities that directly or indirectly the registration of newly diagnosed PLHIV at thesupport PLHIV adherence. In one village, some of ART center was tracked. As clients were contactedthe students who owned scooters agreed with the by phone and came back for follow-up, or did notvillage health and sanitation committee to provide return, the lists were adapted.PLHIV with transport to the ART center, and inanother, a private bus company provided free Once a month these lists of missing and LFUtransport to PLHIV. Initiatives like these that emerge clients, including newly diagnosed, pre-ART, andspontaneously are among the most likely to be ART, were discussed at a meeting at the DAPCUsustained. office of each participating district. Representatives from all organizations engaged in tracing missing clients attended these meetings. ParticipantsFacility-based Adherence separated into breakout groups to discuss the lists from their geographic region, sort data, andMonitoring compare lists (see Figure 3). The result of each meeting was a series of clean and corrected listsWhile link workers maintained contact with their that were handed out to participating organizationsclients and supported their adherence through based on where they worked. Together with thecommunity-based initiatives, ART center and ICTC DAPCU, Samastha carefully coordinated completestaff systematically monitored adherence at the geographic coverage of a district. Typically,institutional level. Ensuring adherence entailed Samastha link workers would trace missing andnot only helping clients stay with their medication LFU clients in the villages under their responsibilityregime, but also finding and recovering those who while outreach workers based at community carewere “missing” (missed a scheduled appointment centers and ICTCs covered the area aroundfewer than 90 days ago) or LFU (have not returned their center. NGOs, PLHIV networks, and drop-since missing an appointment more than 90 days in centers (places where PLHIV can meet andago). A major innovation by Samastha was to have receive psychosocial support, usually managed bythe medical staff of DAPCU, the key government PLHIV networks) would ensure coverage of thoseagency for HIV-related activities in Karnataka, take areas that were not serviced by Samastha andon a central coordinating role in the identification that were too far from community care centers orand recovery of these clients. ICTCs. Participating organizations paid their own costs for tracing defaulters, and most organizationsDAPCU relied on a three-level tracking system incorporated this task in their daily work so that itimplemented at ART centers. In these centers, daily did not require additional funding.adherence monitoring and support were routine.Each day, pharmacists kept track of expected At the same meeting, participants discussed theART clients who did not show up to receive their outcome of efforts to recover missing and LFUpills. At ART centers, counselors tracked patients’ clients identified during the previous month’scompliance with their clinical visit schedule, and meeting, and checked to make sure that thelaboratory technicians did a similar exercise for lists also included the names of those who werepre-ART clients with a CD4 count < 350 cells/mm3. diagnosed at the ICTC but did not register for ARTThe result was a series of “due lists” for people services. New diagnoses were a problematic areawho were scheduled to come in for a clinical visit, where much LFU occurred. In some cases, link orreceive ART, or check CD4 counts. On a third level, outreach workers accompanied newly diagnosed Linking Resources for Antiretroviral Therapy Adherence: The Samastha Project in Karnataka, India 7
  • 8. AIDSTAR-One | CASE STUDY SERIESclients to the ART center so that they could beregistered immediately. As a result, the proportionof newly diagnosed PLHIV who are registered atthe ART center increased from 47 percent in 2007to 98 percent in 2010 (NACO 2011). This improvedlinkage had the additional effect of strengtheningART centers and the counseling that PLHIVreceived.This coordination among various actors during themonthly meetings at DAPCU was a major factor Herman Willemsin Samastha’s success in retaining or recoveringPLHIV who were missing or LFU in this challengingrural area. At the start of the Samastha project,limited data were available on LFU clients. A vital Figure 3. Comparing the pharmacy and antiretroviralelement in Samastha’s adherence efforts was to registers to clarify status of people living with HIV in Karnakata.ensure that state-level agencies also understoodthe need for accurate data on missing and LFUclients. To this effect, project staff members request for transfer and submitted this to the ARTcollaborated with officials at the Karnataka State center, which issued a referral letter. However, it isAIDS Prevention Society, who subsequently began clear that not all transfers worked well. Transfersto request district-level data on LFU clients from across state borders posed more problems thanthe DAPCUs. These requests spurred DAPCUs to those between districts within Karnataka—in theimprove and coordinate the collection and use of case of seasonal laborers for instance, who maydata on missing and LFU. migrate for three to six months at a time. Continuity of services for such cases still needs to be workedAs a result, some districts were able to account out.for all of the PLHIV who had initiated ART sincethe beginning of the ART program. Verification of Also, not all pre-ART clients are accounted for.the missing and LFU client lists in various districts For example, an estimated 3,500 to 4,000 pre-shows that most clients who had ever initiated ART clients who initiated care prior to 2006, whenART were accounted for. They were categorized the ART program began in Karnataka, were notaccording to six categories (died, transferred out, accounted for in the district of Bagalkot (out of astopped treatment, missing, LFU, and alive and on total of more than 14,400 ever enrolled). Most ofART). The proportion of LFU clients reduced from these were clients who were LFU between the start5.4% to 3.4% and has been stable over the past few of the HIV program in 2002 and the start of the ARTyears (NACO 2011). program in 2006. Until recently, pre-ART clients were only traced through the activities of the linkThe “transfer” category—meant to maintain workers and the integrated positive prevention andcoverage when a patient moved permanently or care drop-in center outreach workers. However, intraveled temporarily to another district—proved 2010-2011, some ART centers started adding pre-more difficult. When a patient traveled to another ART clients with a CD4 count < 350 cells/mm3 todistrict, a Samastha link worker helped write a the list of clients to be traced.8 AIDSTAR-One | July 2012
  • 9. AIDSTAR-One | CASE STUDY SERIESWhat Worked Well The state level, district, and visited ART centers reported stable numbers of LFU clients. This suggests that the majority of missing clients areLinkages and local support for being retrieved before they qualify as LFU.adherence: In many areas where Samasthaworked, the linkages between PLHIV and existing Enhanced relationships and trust:government schemes were successful—though, Samastha built trust with ICTC counselors byunfortunately, their effect on adherence cannot be referring clients to them, including pre- andquantified. Nevertheless, it is likely that Samastha’s postnatal women and their infants, and bylinking strategies contributed substantially to patient organizing testing “camps” with ICTCs. Campsadherence to ART and care. The link workers’ provided opportunities for ICTCs to educateactivities also increased local understanding of and establish contacts with people who wantedHIV and helped to spur community initiatives to testing, and enhanced the relationship betweenassist PLHIV, some of which directly supported ICTC staff and communities. Finally, Samastha’sadherence. role in strengthening the connections betweenImproved documentation: The combination DAPCU and local NGOs helped to build trust andof Samastha’s efforts, including mapping villages, collaboration between government and community-standardizing and coordinating documentation, and based organizations at the district and state levels.facilitating tracking, significantly improved the abilityof government agencies and NGOs to identify,recover, and retain PLHIV who needed care and Challengestreatment. Stigma: Though Samastha’s link workersImproved tracking: It seems clear that improved local understanding of HIV, stigmaSamastha’s work significantly improved efforts to remained a major challenge with particulartrack down rural clients who needed HIV services relevance for adherence to treatment. While theand increased the capacity of PLHIV to adhere proportion of people who provided the correctto their treatment regimes. Also, while the project address for home visits increased considerablylinked PLHIV with various types of resources, the (from an estimated 10 percent at the start of thelinkages maintained the confidentiality of PLHIV project to an estimated 30 to 40 percent in laterand, with few exceptions, facilitated communication years), a large number of people still did not wantof each patient’s wishes regarding contacts with to be contacted at home. In other areas (e.g.,support services. Mysore rural), an estimated 70 percent provided theSamastha may have influenced state-level correct address, while in areas like Bagalkot, wherestatistics on LFU clients. During the project KHPT had been active well before the start of theperiod, the number of people who were receiving Samastha project, the proportion of PLHIV whoART increased from about 3,000 to over 83,000 were open to home visits was estimated at aroundstatewide. In Karnataka overall, the proportion of 90 percent.PLHIV who were LFU began to decrease soonafter Samastha started, dropping from 5.4 percent Expansion: District-level DAPCUs need supportin spring 2008 to 3.4 percent in late 2010 (NACO in managing and coordinating the activities that2011). were implemented in Samastha-supported districts. Linking Resources for Antiretroviral Therapy Adherence: The Samastha Project in Karnataka, India 9
  • 10. AIDSTAR-One | CASE STUDY SERIESThe large numbers of PLHIV who need follow-up, Refine systems to safeguardand the considerable number of local organizations confidentiality: Samastha link workerswhose activities need to be coordinated, make it earned the confidence of ICTC counselors andvery challenging for DAPCUs to expand this kind other government HIV service providers throughof program without intensive support. At the end of careful implementation of a well-designed system.the project, Samastha used considerable resources Individuals’ confidentiality requests should befor its activities in fewer than half of the districts carefully documented, communicated to allin Karnataka. A wider scale-up would require concerned, and respected. Programs shouldadditional resources. systematically look for any negative side effects of shared confidentiality, especially if it is extended toUnderstanding adherence: Training link a wider cadre of health care workers.workers to recognize adherence problems wasnot always easy. Adherence issues are likely to Ensure adherence management at abe underestimated for several reasons. Samastha sufficient level of authority: Intensiverecognized that the three-day recall was not reliable adherence monitoring work needs to be guided byand changed their assessment method. The pill a skilled manager who is capable of bringing allcount however, requires considerably more calculus concerned parties together at regular intervals andskills and may cause a lack of confidence among motivate them to do a thorough review and comparelink workers to use the method or to correctly lists of clients. In Karnataka, this task was takenassess adherence problems. Data from the link on by the DAPCU directors, most of whom provedworkers’ adherence assessment show that almost to have sufficient levels of authority to manage this100 percent of their clients on ART achieve greater process. Senior Samastha staff stressed that it isthan 95 percent adherence. However, checks of the important that whoever takes on this coordinatingGreen Books of clients encountered during village role should have the authority to make the systemmeetings (and comparing the dates of antiretroviral work.drug pickups with the number of tablets received)showed that roughly one out of six had adherence Develop adherence procedures forissues that would rate them below 95 percent migratory PLHIV: Special attention may beadherence. required to guarantee continuity of services for migratory laborers, especially those who migrate for long periods of time and those who migrate across state borders.Recommendations Make sure that outreach workers canSamastha’s multipronged approach to adherence identify adherence problems: Supervision ofmonitoring and improvement is promising. The link workers should regularly focus on adherencecombination of interventions to prevent, identify, assessment. Supervisors can improve link workers’and remedy adherence problems has the potential assessment skills by observing adherencefor maximum impact. The scale at which Samastha assessments, double-checking the link worker’simplemented the interventions required the assessments, and performing assessmentsorganization of a large support and supervision along with the link worker. Whenever link workersnetwork, and the project showed that this can be overestimate adherence or fail to recognizedone. The following are some recommendations to adherence problems, opportunities for patientconsider when implementing similar interventions. education and adherence support are missed. g10 AIDSTAR-One | July 2012
  • 11. AIDSTAR-One | CASE STUDY SERIESREFERENCES National Institute of Health and Family Welfare and National AIDS Control Organisation. 2007. AnnualBecker, M. L., B. M. Ramesh, R. G. Washington, HIV Sentinel Surveillance Country Report 2006.S. Halli, J. F. Blanchard, and S. Moses. 2007. New Delhi, India: NACO.Prevalence and Determinants of HIV Infection inSouth India: A Heterogeneous, Rural Epidemic. National Institute of Medical Statistics and NationalAIDS 21:739–747. AIDS Control Organization. 2010. Technical Report, India HIV Estimates. Government of India.Blanchard, J., J. O’Neil, B. M. Ramesh, P.Bhattacharjee, T. Orchard, and S. Moses. 2005. National Rural Health Mission. n.d. Home Page.Understanding the Social and Cultural Contexts Available at Female Sex Workers in Karnataka, India: (accessed January 2012)Implications for Prevention of HIV Infection. TheJournal of Infectious Diseases 191(Suppl 1):S139– O’Neil, J., T. Orchard, R. C. Swarankar, J. F.S146. Blanchard, K. Gurav, and S. Moses. 2004. Dhandha, Dharma and Disease: Traditional SexHalli, S. S., B. M. Ramesh, J. O’Neil, S. Moses, and Work and HIV/AIDS in Rural India. Social Science &J. F. Blanchard. 2006. The Role of Collectives in Medicine 59:851–860.STI and HIV/AIDS Prevention Among Female SexWorkers in Karnataka, India. AIDS Care 18(7):739– ACKNOWLEDGMENTS749. The author owes a debt of gratitude to theIndian Council of Medical Research and Family leadership and staff of the Samastha project forHealth International. 2009. India Integrated their support in the development of this case study,Behavioral and Biological Assessment, Round 1 as well as to Samastha’s partner organizations and(2005-2007), National Summary Report. Pune, beneficiaries for sharing their experiences. ManyIndia: National AIDS Research Institute and Family thanks also to the leadership of the KarnatakaHealth International. State AIDS Prevention Society for their input and openness. Thanks also to the U.S. AgencyKarnataka Health Promotion Trust. 2008. “Our for International Development/India, especiallyProjects.” Available at Sangeeta Kaul and Anand Rudra, for their(accessed June 2011) assistance, advice, and helpful feedback.Karnataka Health Promotion Trust. 2011a. AnnualProgress Report of Samastha Project, 2011. RECOMMENDED CITATIONKarnataka Health Promotion Trust. 2011b. Building Willems, Herman. 2012. Linking Resources forCapacity for Sustainability: Capacity Development Antiretroviral Therapy Adherence: The SamasthaStrategy for Samastha’s Care and Support Project in Karnataka, India. Arlington, VA: USAID’sInitiatives. Bangalore, India: KHPT. AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1.National AIDS Control Organisation. 2011. ARTScale up in Karnataka: Best Practice Document.Bangalore, India: KHPT. Linking Resources for Antiretroviral Therapy Adherence: The Samastha Project in Karnataka, India 11
  • 12. AIDSTAR-One’s Case Studies provide insight into innovative HIV programs and approachesaround the world. These engaging case studies are designed for HIV program planners andimplementers, documenting the steps from idea to intervention and from research to practice.Please sign up at to receive notification of HIV-related resources,including additional case studies focused on emerging issues in HIV prevention, treatment,testing and counseling, care and support, gender integration and more.