AIDSTAR-One Mobile Clinics in India Take to the Road

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In India, most new HIV infections are concentrated in specific groups within the population and in certain areas of the country. To effectively reach most-at-risk populations, including sex workers, people who inject drugs and men-who-have sex with men, the Mumbai-based Avert Society is working with other nongovernmental organizations in five districts of Maharashtra to deliver HIV and STI testing via mobile testing clinics. Although the mobile clinic program is less than a year old, it has shown promising results to date.

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AIDSTAR-One Mobile Clinics in India Take to the Road

  1. 1. AIDSTAR-One | CASE STUDY SERIES October 2011Mobile Clinics in India Take to theRoadBringing HIV Testing and Counseling and SexuallyTransmitted Infection Services to Those Most at Risk S anjay takes his lunch break at his construction job near the city of Nagpur, in the state of Maharashtra, India. He migrated here in search of work from his home in the northern state of Madhya Pradesh. He is 23 years old, single, and hopes to earn enough to get married, start a family, and help his parents back home. During his break, Sanjay (not his real Ed Scholl name) decides to visit the big van parked near the construction site, where an outreach worker told him he can get free testingMobile clinic in the Nagpur Districtof Maharashtra, India. for HIV and other sexually transmitted infections (STIs). He is curious and a bit concerned about his HIV status, because he knows that visiting sex workers back in town, as he and his fellow workers occasionally do, puts him at risk for HIV. Sanjay enters the van and is greeted by the counselor, who explains how HIV and STIs are transmitted and what he can do to avoid them. The counselor shares some pamphlets, printed in the local language of Marathi, that give him additional information about HIV and STI prevention. She shows him how to use a condom and offers him some. Sanjay then signs a consent form to obtain an HIV test. Next, he walks to the rear of the van to visit a doctor, who goes through a checklist of STI symptoms and provides a physical exam. Finally, he goes to the laboratory in the front of the van, where blood is drawn. He is told to come back in four hours for the test results. At the end ofBy Edward Scholl and his shift, he returns to the van and the counselor tells him, much to hisJamine Peterson relief, that he is HIV-negative and does not have an STI. She reminds him how he can stay healthy and avoid HIV and STIs and answers all of his additional questions.AIDSTAR-OneJohn Snow, Inc.1616 North Ft. Myer Drive, 11th Floor This publication was produced by the AIDS Support and Technical Assistance ResourcesArlington, VA 22209 USA (AIDSTAR-One) Project, Sector 1, Task Order 1.Tel.: +1 703-528-7474 USAID Contract # GHH-I-00-07-00059-00, funded January 31, 2008.Fax: +1 703-528-7480 Disclaimer: The author’s views expressed in this publication do not necessarily reflect the views of the United Stateswww.aidstar-one.com Agency for International Development or the United States Government.
  2. 2. AIDSTAR-One | CASE STUDY SERIESScenes such as this play out every day at the the state has the highest reported rates of HIVNagpur mobile clinic and the five other mobile among FSWs (7.4 percent). Similarly, high ratesclinics that are part of an innovative program are found among PWID (20 percent), MSM (11.2supported by the U.S. President’s Emergency percent), and TG people (16.4 percent; MaharashtraPlan for AIDS Relief (PEPFAR) through the U.S. State AIDS Control Society 2009). The IndianAgency for International Development (USAID) Government considers men who buy sex to be theand the National AIDS Control Organization single most powerful driving force in India’s HIV(NACO), in coordination with the Maharashtra epidemic (U.N. General Assembly Special SessionState AIDS Control Society (MSACS). One of 2010), given their role in HIV transmission to theUSAID/India’s key partners, the Mumbai-based general population.Avert Society, implements the program with othernongovernmental organizations (NGOs) in fivedistricts of Maharashtra, which were chosen for Launching Mobile Clinicstheir high rates of HIV prevalence. While mobileclinics have been used before in India to provide Recognizing the high HIV prevalence amonghealth services, the Avert Society program is one of MARPs in Maharashtra and the importance ofthe first programs to offer both HIV testing and STI targeting bridge populations such as migrants andtesting and treatment to most-at-risk populations truckers, USAID/India, in collaboration with the(MARPs). The program is also innovative in the way Government of Maharashtra and NACO, sought tothat it partners with government and other NGOs expand HIV testing and counseling and prevention-who work closely with the populations most affected oriented outreach to these populations through theby HIV and STIs. use of mobile clinics. A mobile clinic demonstration program was approved for implementation by the Avert Society (an NGO based in Mumbai), withIndia’s Epidemic funding provided by PEPFAR. NACO plans to adopt the lessons learned from the demonstrationGiven the nature of the HIV epidemic in India, with program and scale it up nationally.most infections concentrated in specific groupswithin the population and in certain areas of the The rationale for using mobile clinics, insteadcountry, USAID/India supports interventions of referring clients to existing HIV testing andfocused on MARPs, such as female sex workers counseling centers, was based on several(FSWs), men who have sex with men (MSM), assumptions. One was that it would be easier fortransgender (TG) individuals, and people who MARPs and bridge populations (both groups areinject drugs (PWID). Also targeted are “bridge hereafter referred to as “targeted populations”) topopulations,” who have intimate contact with access services if a mobile clinic came to selectMARPs. These may include the clients of sex locations near them (e.g., near brothels, cruisingworkers, many of whom, like Sanjay, are migrants, spots, truck stops, and migrant workplaces, suchor the wives of MSM. as construction sites, brick kilns, and small scale industries) and during convenient times (e.g.,The state of Maharashtra, encompassing India’s evening hours for MSM and mid-morning forlargest city, Mumbai, is one of the states most truckers). Another was that targeted populationsaffected by HIV in the country. Though HIV would find it more acceptable to visit mobileprevalence in antenatal clinics is only 0.55 percent, clinics where they could be assured of greater2 AIDSTAR-One | October 2011
  3. 3. AIDSTAR-One | CASE STUDY SERIES ABOUT THE AVERT SOCIETY In 1999, the Government of India signed a bilateral agreement with the U.S. Government to establish the Avert Project, to complement the AIDS control efforts of the Government of Maharashtra. The Avert Society supports the National AIDS Control Program and works in collaboration with the Maharashtra State AIDS Control Society (MSACS). MSACS is implementing a comprehensive HIV prevention, care, and treatment program throughout the state of Maharashtra and is supported by the Mumbai District AIDS Control Society. The Avert Society focuses on most-at-risk populations, such as female sex workers, men who have sex with men, and transgender individuals, as well as on bridge populations such as migrants. They implement community mobilization activities to increase HIV testing and counseling, prevention of parent-to-child transmission, and treatment services in five high-prevalence districts. Additionally, they implement workplace interventions throughout the state of Maharashtra. The project supports the Technical Support Unit in Maharashtra and Goa states, supporting the scale-up and strengthening of HIV programs in accordance with the strategies outlined in the third National AIDS Control Program. The National AIDS Control Organization (NACO) selected the Avert Project as the lead agency to implement the Round Seven grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria to expand an outreach worker (“link workers”) program in the state of Maharashtra. In addition, the Avert Project was identified by NACO as the State Training Resource Center for training nongovernmental organizations on core skills in targeted intervention programs for most-at-risk populations.anonymity, respect, and attention than at venues was provided by MSACS for the counselors andsuch as government hospitals. STI screening and lab technicians and by the Avert Society for thetreatment were also added to the mobile clinic doctors. All staff also received periodic refresherservice package, because these are not offered at trainings.government HIV testing and counseling centers. The mobile clinic program in Maharashtra officiallyTo implement the mobile clinic program, the Avert began in July 2010 in the district of Aurangabad.Society procured six large vans from Eicher Motors, By September, a total of five mobile clinics werean Indian manufacturer of vans, trucks, and buses. operating, one in each of the five priority districts.Each van was remodeled and subdivided into A sixth mobile clinic was inaugurated in June 2011three rooms: one for counseling, one for medical in Thane district, which now has two mobile clinicsexams, and one for collecting and processing blood given its large geographic area.samples using HIV rapid tests and rapid plasmareagin (RPR) tests for syphilis. ImplementationAfter procuring and equipping the mobile clinics,the Avert Society selected a sub-grantee in each Planning and promotion: Careful schedulingof the five priority districts (Nagpur, Thane, Jalna, and advance outreach and promotion among theAurangabad, and Solapur) to operate the mobile targeted populations are key to the successfulclinic. These sub-grantee NGOs then hired the staff implementation of the mobile clinics. At thefor each mobile clinic, including a full-time doctor, beginning of each month, the NGO responsiblecounselor, lab technician, and driver. Training for the mobile clinic in each district convenes a Mobile Clinics in India Take to the Road: Bringing HIV Testing and Counseling and STI Services to Those Most at Risk 3
  4. 4. AIDSTAR-One | CASE STUDY SERIESscheduling meeting for all of the NGOs workingwith the targeted populations in that district.Together, they work out a schedule with a detailedlist of locations, days, and hours when the mobileclinic will arrive at a given location and the type oftarget group expected to attend. For example, inThane district, the NGO Udaan Trust, which serves Jamine Petersonthe MSM community, proposed scheduling andlocations that would best serve that community;namely evening hours near MSM cruising spots.NGOs serving other targeted populations also Mobile clinic with driver and promotional materials atpropose dates, times, and locations until the a construction site in Nagpur. Many migrant workersmonthly schedule is complete. attend the clinic during their lunch break.Following completion of the schedule, each NGO’s see the doctor for a regular medical checkup andoutreach workers and peer educators spread the an exam to look for signs of STIs. Currently, theword and encourage their contacts to visit the gynecological exams are external only. However,mobile clinic for HIV and STI testing on the dates the Avert Society has ordered specula to allowselected. If the NGO has done its advance work for internal vaginal/cervical examinations, whichproperly, there will be clients waiting when the the doctors will begin performing followingmobile clinic arrives in a community. Sometimes, training. Though migrants and truckers are notthe collaborating NGOs also set up a tent at the automatically seen by the doctor, they are givenlocation to promote the services of the mobile clinic, a medical examination if they exhibit any signsregister clients with the NGO, and do advance or symptoms of an STI. When a new client fromcounseling using the NGO’s own counselors and a core group is seen by a doctor, he or she ispeer educators. also given presumptive treatment for STIs, in accordance with NACO norms. The doctor givesClient flow: Work begins immediately on arrival other clients a prescription for STI treatment if theyof the mobile clinic in a community. Clients, entering have symptoms consistent with an STI syndromethe van one by one, or in small groups if the client (a discharge, an ulcer of the genital tract, or lowerload is high, are seen first by the counselor. The abdominal pain in women). Treatment (eithercounselor greets the client, explains the services directly by the mobile clinic doctor for core groupsavailable, obtains consent for HIV testing, provides or through a prescription for migrants or truckers)pre-test counseling and information about HIV and is one of seven prepackaged STI kits that containSTI prevention, conducts condom demonstrations, medicine specific to the STI syndrome detected.and shares informational brochures.Next, the client may see the doctor or go directly After counseling and possibly a medical exam,to see the lab technician. All FSWs, MSM, TG the client goes to the laboratory room for HIV andpeople, and PWID (referred to in the program as STI testing. Blood is collected, according to NACO“core groups,” as opposed to other targeted groups, guidelines, through venipuncture; 4 mL is stored insuch as truckers and migrants, who are presumed a blood collection tube for later testing. The clientto be at less risk of an STI) are encouraged to is asked to return for the results, typically three4 AIDSTAR-One | October 2011
  5. 5. AIDSTAR-One | CASE STUDY SERIESto four hours later. The lab technician usually waitsuntil all of the clients have been seen before he or Resultsshe begins testing all of the samples collected. The Client volume and services provided:blood is first separated in a centrifuge and the serum Although the mobile clinic program has only beenis used to perform both syphilis and HIV testing. operating for about a year, it has shown promisingSyphilis testing is performed using the RPR test and results. A typical day brings in 35 to 40 clients fromHIV testing is done using the Standard Diagnostics high-priority groups, more than are usually seenBio-line HIV ½ 3.0 rapid test. Confirmatory tests may daily in government HIV testing and counselingvary, but are also rapid tests. centers. The NGOs and their outreach workers and peer educators assert that they are reaching greaterWhen clients return for their results, the counselor numbers of high-risk clients than they did beforeprovides individual post-test counseling. If a client the program began. The mobile clinics also offerfails to return for test results or if services were the advantage of STI screening and syphilis testing,provided in the evening, the results are given to the which are not available at government or NGOcounselor of the collaborating NGO who originally testing and counseling centers.referred the client, and that counselor will seekout the client and provide the results and post-test There were start-up challenges, including frequentcounseling. Following NACO norms, all clients from turnover of staff during the first six months, andcore groups who test positive for syphilis receive some problems with NGO management of the mobileimmediate treatment; other clients are given a clinics. All six mobile clinics have been operatingprescription for treatment. Any client who tests since June 2011, but for most of the year before, onlypositive for HIV is given post-test counseling and four mobile clinics were operating continuously.then referred to the nearest government treatmentcenter that offers free drugs and medical care for Data reported by the NGOs operating the mobilepeople living with HIV. clinics in each of the program’s five priority districts are shown in Table 1.Commodity procurement: Most of thecommodities and HIV test kits used in the mobileclinics are provided by NACO, through MSACSand the District AIDS Prevention and Control Units(DAPCU), as part of the host country contribution.These include all the HIV test kits, medical supplies,such as gloves and syringes, STI treatment kits, andmale condoms. Female condoms are not provided,but many of the collaborating NGOs obtain themfrom a social marketing entity (Hindustan LatexFamily Planning Promotion Trust) and sell them tointerested clients. RPR tests are typically purchasedby the Avert Society directly from the manufacturer Ed Scholland distributed to the mobile clinics. The AvertSociety also makes emergency purchases ofselected commodities when shortages occur. Counselor on the Nagpur mobile clinic. Mobile Clinics in India Take to the Road: Bringing HIV Testing and Counseling and STI Services to Those Most at Risk 5
  6. 6. AIDSTAR-One | CASE STUDY SERIES TABLE 1. MOBILE CLINIC SERVICES BY DISTRICT, JULY 2010 TO JUNE 2011 Aurangabad Nagpur Solapur Jalna Thane Total Clients that attended 6,046 2,893 58 2,648 5,378 17,023 mobile clinics Regular medical 4,547 680 0 313 1,652 7,192 checkups conducted STI cases treated* 293 361 1 109 435 1,199 HIV tests given 5,321 8,943 3,663 4,422 4,970 27,319 HIV-positive tests 35 (0.7%) 87 (1.0%) 24 (0.7%) 22 (0.5%) 103 (2.1%) 271 (1.0%) RPR tests given 2,730 1,588 37 2,842 2,570 9,767 Positive for syphilis 40 (1.5%) 6 (0.4%) 0 (0%) 25 (0.9%) 17 (0.7%) 88 (0.9%)*Per syndromic management of STI guidelines.One problem that the program has experienced is report back on their experiences). However, theincomplete reporting by some of the NGOs who collaborating NGOs who work closely with theoperate the mobile clinics in each district. This has targeted populations and refer clients to the mobileresulted in some of the services presented in Table clinics report very positive comments from their1 being underreported. In addition, some NGOs clients. The authors also conducted several focushave selectively reported services (e.g., HIV tests), groups among FSWs, MSM, and migrant workerswhile failing to report others.1 The Avert Society has and heard positive reports about the services theyrecently begun asking mobile clinic staff to email received, as well as the interaction they had withtheir daily report of activities in an effort to improve staff. The most common feedback heard fromreporting. these clients was appreciation for the convenience of the mobile clinics and the fact that its servicesThe Avert Society and its NGO collaborators were free. Several participants also noted thatconsider the mobile clinics a good complement to they were treated with dignity by the mobile clinicthe fixed testing and counseling centers operated staff; something they had not always experiencedby the government and NGO providers. Indeed, the when seeking health services. Suggestions formobile clinics are responsible for providing nearly improvement included having a female physicianhalf of all HIV testing and counseling services for available and having a larger exam room.MARPs in Maharashtra, according to PEPFARreports. Another measure of quality, particularly for services that include HIV testing and counseling, is theQuality of services: Client satisfaction is quality of the laboratory and accuracy of the results.one measure of the quality of services. The Avert To assure laboratory quality control, the mobileSociety has not yet conducted any evaluation of clinic program sends 5 percent of all negative HIVclient satisfaction (through post-visit interviews or samples and 20 percent of all positive HIV samples“mystery clients” recruited to pose as clients and to a district hospital for retesting four times per year. To date, there has been 100 percent correlation1 One reason the number of HIV tests given is higher than the number ofclients reported in Table 1 is that client data is generally recorded by the between mobile clinic and reference laboratoryattending doctor and some of the mobile clinics operated without a doctor results. Personnel from the reference laboratoriesduring part of the reporting period. HIV tests are recorded by the laboratorytechnician. also make periodic supervisory visits to the mobile6 AIDSTAR-One | October 2011
  7. 7. AIDSTAR-One | CASE STUDY SERIESclinic to observe laboratory procedures and ensure conducted per month in each district (455, asthat they comply with NACO standards. calculated from Table 1) yields $3.41 per test. This cost is an overestimate, given that the number ofCosts: The operating costs of the mobile clinics, HIV tests is underreported, as previously noted. Onwhich are paid by the NGO sub-grantees who the other hand, if start-up costs and the value ofoperate them (and reimbursed by the Avert donated tests and supplies were included, the figureSociety), include the salaries of the mobile clinic would be higher. In addition, the clinics providepersonnel, fuel, travel for training and meetings, medical checkups and STI screening and testingand other costs, as outlined in Table 2. and these other services should be taken into account when considering the costs and benefits ofThese monthly operating costs do not include initial the mobile clinics.start-up costs, such as the purchase of the mobileclinic (approximately U.S.$26,000 per clinic) and The doctor working for the mobile clinic inits equipment and supplies (about U.S.$7,000 per Aurangabad independently analyzed the cost-clinic). Nor do they factor in the value of donated effectiveness of HIV services provided by thecommodities, including the HIV and RPR tests, STI mobile clinic in Aurangabad compared to stationarytreatment kits, and other donated consumables. government testing and counseling centers and special field-based “camps” where governmentDividing the illustrative monthly operating costs health personnel conduct testing and counselingof $1,553 by the average number of HIV tests in the community. His calculations, which include indirect costs such as client costs for travel (to TABLE 2. ILLUSTRATIVE MONTHLY government centers) and lost wages (for time COSTS FOR A MOBILE CLINIC (U.S.$) attending both government centers and camps), Personnel show the cost per HIV test to be $1.04 for a mobile Doctor 409 clinic, $10.93 for a field-based camp, and $14.02 Counselor* 193 for a government testing and counseling center. If Lab technician† 170 the indirect costs borne by the client are removed Driver 114 from the calculations, the three modalities are much Subtotal personnel 886 closer in cost per HIV test, though the mobile clinic Fuel 426 remains the most cost-effective. Travel of project staff 45 In Kenya, a cost-effectiveness study comparing Other 26 mobile- and facility-based counseling and testing Subtotal 1,383 services found similar results, with mobile-based NGO contributions‡ 170 testing and counseling having lower costs per client Total 1,553 tested (Grabbe et al. 2010).* Per NACO guidelines, counselors receive a variable salary of $148-$227/month based on performance as measured by the number of clients counseledand tested, the percentage of clients who return for post-test counseling, andthe results of a knowledge, attitudes, and skills test given every semester. What Has Worked Well† Per NACO guidelines, lab technicians receive a variable salary of $148-$182/month based on performance as measured by the number of clients tested per NGO coordination: Key to the success of theday, the accuracy of test results compared to the reference laboratory, and theresults of a written and practical test given every semester. mobile clinic in each district is a close working‡ For example, project director visits, mobile clinic parking, tax/bank charges/ relationship among the Avert Society, the NGOtolls, electricity, NGO office space, office expenses. responsible for operating the mobile clinic and hiring Mobile Clinics in India Take to the Road: Bringing HIV Testing and Counseling and STI Services to Those Most at Risk 7
  8. 8. AIDSTAR-One | CASE STUDY SERIES district-based NGOs, and the government is also good. There is strong government support for, and involvement with the mobile clinic program, with NACO, MSACS, and DAPCU representing the government at the federal, state, and district levels, respectively, and each playing a role. NACO established the national procedures for HIV testing and counseling that guide implementation of the mobile clinics. Most of the commodities used in Ed Scholl the mobile clinics (including HIV test kits and STITruck stop in Nagpur. Long distance truckers are one kits) are donated by NACO through MSACS andgroup targeted by the mobile clinics. DAPCU. Government support and coordination are also evident through the government referencestaff, and the NGOs that work with MARPs in each laboratories that retest samples of HIV testsdistrict and refer clients to the mobile clinic. It was conducted on the mobile clinics.observed that good communication and relationswere present among these three entities in each Referrals from the mobile clinics to governmentdistrict. antiretroviral therapy programs also exemplify successful coordination. This involves much moreThe monthly scheduling meetings are especially than handing a referral slip to a client who testsimportant to this coordination. The NGOs positive for HIV and hoping for the best. Everyappreciate the participatory process and report that month, the NGO operating the mobile clinic intheir suggestions are implemented and that the each district meets with the DAPCU and otherschedules reflect efforts to ensure that the mobile stakeholders in the district. At this meeting, theclinic’s visits are timed to maximize convenience for mobile clinic NGO will find out whether or not all oftheir clientele. the clients who were referred to the antiretroviral therapy clinic actually attended. If the client didAnother example of effective coordination not attend, or missed the six-month follow-upbetween the NGOs who refer clients and the appointment, he or she will be contacted or visited.NGO that operates the mobile clinic can be seenin the vicinity of the mobile clinic. As mentioned Productivity and quality: Avert Society staffpreviously, the referring NGO often sets up a tent and participating NGOs stated that the mobileoutside the mobile clinic, staffed by one of their own clinics are reaching a higher proportion of targetedcounselors, who hands out educational materials populations than would be reached in their absenceand talks to clients before or after their consultation (as opposed to merely drawing clients away frominside the mobile clinic. Educational messages government-run testing and counseling centers).given in the mobile clinic are reinforced by the However, this is difficult to document because ofreferring NGO and vice versa. Also, counselors incomplete reporting by the NGOs in the mobilefrom the referring NGO sometimes make home clinic program and the absence of pre- and post-visits to provide test results to clients who do not intervention data from government testing andreturn to the mobile clinic to receive them. counseling centers, which could show whether overall numbers of clients increased after theGovernment support and coordination: mobile program began. In focus group discussions,Coordination among the Avert Society, the NGOs and clients expressed the view that the8 AIDSTAR-One | October 2011
  9. 9. AIDSTAR-One | CASE STUDY SERIESmobile clinics are generating new clients, primarily clinic in Jalna, for example, only gets 400 to 500because of their free services and convenience. In kits per month, but feels it could provide up to 1,000terms of numbers of clients, the mobile clinics are tests per month if the supply were increased. Theseeing an average of 35 to 40 clients per day, which Avert Society plans to request 1,000 test kits peris reportedly higher than that of typical stationary month for all of the mobile clinics to make sure thatgovernment testing and counseling centers. stockouts do not occur.As noted under the “Results” section, the quality Personnel compensation and workingof the mobile clinic program appears high, both conditions: Both NGOs operating the mobilein terms of client satisfaction and the quality and clinics and the mobile clinic staff themselvesaccuracy of the laboratory services. Clients in reported that staff salaries are low and workingparticular value the convenience of the mobile conditions are hard. A typical day for the doctor,clinics, the anonymity they afford, and the counselor, lab technician, and driver who work oncourteous treatment provided by staff members. the mobile clinic entails arriving at the NGO office where the mobile clinic is parked during off hours; driving the vehicle (sometimes for several hours) toChallenges reach the site of the “camp” where they will provide services that day; providing services for aboutReporting: Incomplete reporting by some of four hours; completing paperwork and makingthe NGOs operating the mobile clinics has been sure that all clients receive their test results, or willa challenge. The incomplete reporting appears to receive them through the referring NGOs; and thenbe due to a combination of factors, including staff driving back to the NGO office. Frequently, theturnover, late reporting, or failure to understand or staff works longer than eight hours each day andfully complete the reporting (reporting on HIV tests, staff often work evenings to be more accessible tofor example, but not other services provided). The certain client groups. The work conditions are alsoAvert Society is working to address this problem challenging. Staff are confined to the mobile clinic’sby increasing monitoring visits and requesting daily three small rooms. A single air conditioning unitreports at the conclusion of each day’s work. helps, but it is insufficient to cool all three rooms and only operates if the generator is functioning.Stockouts and supplies: The mobileclinics depend on donated commodities from thegovernment for many of their services, including As noted in Table 2, salaries for staff range fromHIV and syphilis testing, STI treatment, condoms, $114 to $409 per month. These salaries are lowand supplies such as syringes and gloves. The even by Indian standards but they are set by NACO,commodity that suffered recurring stockouts in and the Avert Society does not have the authority to2010 was HIV rapid test kits. These are donated raise them. Doctors working in government testingby the Global Fund to Fight AIDS, Tuberculosis and counseling centers, for example, make aboutand Malaria and distributed to the mobile clinics 50 percent more than those working in mobilethrough NACO, MSACS, and DAPCU, making for a clinics. The Avert Society attributes the relativelycomplicated distribution system. high staff turnover they experienced during the first year of the program, especially during the first sixStockouts of HIV rapid tests occurred less months of the program when they lost about 70frequently in 2011. However, mobile clinics in some percent of their personnel, to both low staff salariesdistricts cite it as a continuing problem. The mobile and hard working conditions. Mobile Clinics in India Take to the Road: Bringing HIV Testing and Counseling and STI Services to Those Most at Risk 9
  10. 10. AIDSTAR-One | CASE STUDY SERIESFuture Programming andRecommendationsNACO plans to scale-up the mobile clinic approachbased on the lessons learned from the AvertSociety-supported mobile clinic program. Thefollowing recommendations, therefore, are offeredfor consideration by NACO and the National AIDSControl Program-IV planners who may wish toincorporate mobile clinic HIV and STI service Ed Scholldelivery to MARPs in Maharashtra or other states.Some recommendations are also intended for other Lab technician drawing blood in a mobile clinic in Jalna.implementing organizations considering the use ofmobile clinics for HIV or STI services. use fingerstick testing. They found that this change allowed them to provide test results more quicklyTesting protocols: The protocol for HIV (20 minutes versus 45 minutes when serum wasand syphilis testing in the mobile clinics, which collected), so that clients did not have to returnis stipulated by NACO, requires that blood be later for the results. MSACS, which has four of itscollected through venipuncture, stored in a blood own mobile clinics that do HIV testing only (no STIcollection tube, and centrifuged. The serum then testing), has plans to switch from collecting bloodmust be tested for HIV using a rapid test. The same intravenously to using fingersticks.serum is used to test for syphilis using the RPRtest. This process requires more time than a simple Besides offering test results sooner, fingerstickfingerstick and most mobile clinics ask the clients to testing can be done by lower-level personnelreturn after four hours to get their results. and does not necessarily require lab technicians. Furthermore, fingerstick testing does not requireAn alternative approach would be to do fingersticks refrigeration, centrifuges, or electricity. Thoughand immediately test for HIV (rapid tests are electricity is available through the mobile clinicequally accurate when using whole blood from generator, a generator malfunction or lack of fuelfingersticks or serum that has been separated using would shut down testing.a centrifuge). Another drop of blood via fingerstickcould then be used to test for syphilis using one NACO should explore this issue further andof the rapid syphilis tests available2 instead of consider changing its testing protocols to allowthe RPR test, which requires venipuncture and for fingerstick testing for both HIV and syphilisseparation of the serum via a centrifuge. Population (substituting the RPR test for another rapid syphilisServices International’s Operation Lighthouse test). The World Health Organization has producedProject, supported by USAID/India from 2002 to a very useful summary of the pros and cons of RPR2006, also provided HIV testing and counseling testing versus rapid syphilis testing (World Healthvia mobile clinics but changed their procedures to Organization/Special Programme for Research and Training in Tropical Diseases 2006).2 One such rapid syphilis test that can use whole blood is Syphicheck-WB,manufactured by Qualpro Diagnostics in Goa, India. A study carried out inBrazil found that this test, and three other similar rapid syphilis tests, had high STI treatment: At present, clients are assessedsensitivity, specificity, and positive predictive value (Benzaken et al. 2007). for STIs using the syndromic management10 AIDSTAR-One | October 2011
  11. 11. AIDSTAR-One | CASE STUDY SERIESapproach, complemented with RPR testing for which puts a limit on the number of clients who cansyphilis. Treatment via prepackaged STI kits are be tested. NACO could consider the Avert Society’sgiven to all “core groups” (FSWs, MSM, TG people, request to provide 1,000 test kits per month forand PWID) as presumptive treatment. If clients each mobile clinic, though it is appropriate tofrom noncore groups (migrants and truckers) have subtract the stock remaining at the end of the montha syndrome consistent with an STI, they are given from the next month’s request.a prescription for STI medication, but not the STIkits themselves. NACO policy is to make these kits Another recommendation is for NACO toavailable only to core groups. This policy should consider simplifying the supply chain for donatedbe reviewed, as it seems unnecessarily restrictive. commodities to the mobile clinics. Currently, HIVBecause most of the clients who attend the mobile test kits, STI kits, and other consumables areclinics are migrants and truckers, many of whom distributed through MSACS and DAPCU. Severalare at high risk for STIs, free STI kits should be NGOs felt that the process would be more efficientmade available to those who have STI syndromes. and result in fewer stockouts if NACO donated theThis will help the mobile clinic program increase its commodities directly to them instead. gimpact on STI prevalence in the districts while alsohelping to prevent HIV, given the role of STIs as REFERENCEScofactors in HIV transmission. Benzaken, A. S., E. Galban Garcia, J. C. Gomes Sardinha, J. C. Dutra Junior, and R. Peeling. 2007.Compensation and payments: In view of Rapid Tests for Diagnosing Syphilis: Validation in anthe high turnover of staff during the first year of STD Clinic in the Amazon Region, Brazil. Cadernosthe mobile clinic program, the difficulty of working de Saude Publica 23(Supp 3):S456–S464.conditions, and feedback from program staff,program managers should consider increasing staff Grabbe, K. L., N. Menzies, M. Taegtmeyer, etsalaries. This is a recommendation for NACO to al. 2010. Increasing Access to HIV Counselingexamine, because NACO determines the salaries and Testing Through Mobile Services in Kenya:of personnel in the program. Salaries should at Strategies, Utilization, and Cost-Effectiveness.least be equivalent to that of similar staff working in Journal of Acquired Immune Deficiency Syndromespublic sector testing and counseling centers. 54(3):317–323.An alternative to increasing salaries is to provide Maharashtra State AIDS Control Society. 2009.travel stipends. Unlike staff who work near their State HIV Sentinel Surveillance Data. Unpublishedhome or in an office with many amenities, mobile raw data.clinic staff must travel long distances in a vehicle U.N. General Assembly Special Session. 2010.that lacks the facilities to store and prepare food. India–2010 Country Progress Report. Available atThis requires them to spend money at restaurants www.unaids.org/en/dataanalysis/monitoringcountror fast food establishments. Travel stipends could yprogress/2010progressreportssubmittedbycountminimize these out-of-pocket expenses. ries/india_2010_country_progress_report_en.pdf (accessed May 2011)Logistics: As noted in the “Challenges” section,stockouts of HIV rapid test kits have been a World Health Organization/Special Programmeproblem, though the stockouts have become less for Research and Training in Tropical Diseases.frequent. The supply of HIV test kits continues to be 2006. The Use of Rapid Syphilis Tests. Geneva,capped, however, at about 400 to 500 per month, Switzerland: World Health Organization. Mobile Clinics in India Take to the Road: Bringing HIV Testing and Counseling and STI Services to Those Most at Risk 11
  12. 12. AIDSTAR-One | CASE STUDY SERIESACKNOWLEDGMENTS Finally, the authors would like to thank the USAID/ India Mission for their support and guidance,AIDSTAR-One would like to thank the staff of including Sanjay Kapur and Sangeeta Kaul, and tothe Avert Society who generously provided their Sampath Kumar for his technical review and editing.time and insights in the development of this casestudy, particularly Smriti Archaya, Anna Joy, RECOMMENDED CITATIONAmita Abichandani, Rajrattan Lokhande, VaibhaviBhalekar, Ranga Limaye, and Kunal Kale. Special Scholl, Edward, and Jamine Peterson. 2011. Mobilethanks to the Director of the Maharashtra State Clinics in India Take to the Road: Bringing HIVAIDS Control Society, Dr. Ramesh Devkar, and to Testing and Counseling and Sexually Transmittedthe Assistant Director, Dr. Santosh Wani, for their Infection Services to Those Most at Risk. Caseguidance and reflections. Thanks also to Shyami Study Series. Arlington, VA: USAID’s AIDS SupportDeSilva and Sharlene Bagga-Taves with USAID/ and Technical Assistance Resources, AIDSTAR-Washington for their review of the case study. One, Task Order 1. AIDSTAR-One’s Case Studies provide insight into innovative HIV programs and approaches around the world. These engaging case studies are designed for HIV program planners and implementers, documenting the steps from idea to intervention and from research to practice. Please sign up at www.AIDSTAR-One.com 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.12 AIDSTAR-One | October 2011

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