visit to ICTC, PPTCT & ART Centre

1. Integrated counselling & Testing
Centers
(NATIONAL AIDS CONTROL PROGRAM-Iv)

2. Overview:
National AIDS Control
Program
 1992: National AIDS Control Program Initiated
 1997: VCT services started in the country
 1999: NACP II Initiated (99-06)
 2000/2001: 11 centers of excellence conduct PPTCT
 2001: Operational guidelines for PPTCT and VCT (revised in ’04 & ’07)
 2002: PPTCT services started throughout the country
 2003: GFATM : support to PPTCT
 2004: GFATM : support to HIV-TB coordination
 2006: NACP-III framework designed, Integration of VCT and PPTCT
as ICTC
 2007: Provider Initiated testing for ANC mothers, TB patients, STI
patients, HRG population.
 2014 : NACP-IV launched for 5 years(2012-2017).

3. Packages of services under
NACP-IV :
 Prevention services
 Care, Support, and treatment services
Goals & Objectives
Objective 1: Reduce new infections by 50% (2007 Baseline
of NACP III)
Objective 2: Comprehensive care, support and treatment to
all persons living with HIV/AIDS

4. Components
 Component 1: Intensifying and Consolidating Prevention
services with a focus on HRG and vulnerable populations
 Component 2: Expanding IEC services for (a) general population
and (b) high risk groups with a focus on behavior change and
demand generation
 Component 3: Comprehensive Care, Support and Treatment
 Component 4: Strengthening institutional capacities
 Component 5: Strategic Information Management Systems
(SIMS)

5. Components
Component 1: Intensifying and Consolidating Prevention services with a
focus on HRG and vulnerable populations
This component will support the scaling up of TIs with the aim of reaching out
to the hard to reach population groups who do not yet access and use the
prevention services of the program, and saturate coverageamong the HRGs. In
addition, this component will support the bridge population, i.e. migrants and
truckers. Component 1 includes the following two subcomponents:
1.1 Scaling up coverage of TIs among HRG
The interventions under this sub-component will include:
 (i) the provision of behavior change interventions to increase safe practices,
testing and counseling, and adherence to treatment, and demand for other
services;
 (ii) the promotion and provision of condoms to HRG to promote their use in
each sexual encounter;
 (iii) provision or referral for STI services including counseling at service
provision centers to increase compliance of patients with treatment, risk
reduction counseling with focus on partner referral and management;
 (iv) needle and syringe exchange for IDUs as well as scaling up of Opioid
Substitution Therapy (OST) provision. This sub-component also includes the
financing of operating costs for about 25 State Training Resource Centers as
well as participant training costs over a period of 5 years.

6. 1.2 Scaling up of interventions among other vulnerable populations
The activities under this subcomponent will include:
 (i) risk assessment and size estimation of migrant population groups
and truckers at transit points and at workplaces;
 (ii) behavior change communications (BCC) for creating awareness
about risk and vulnerability, prevention methods, availability and
location of services, increase safe behavior and demand for services
as well as reduce stigma;
 (iii) promotion and provisioning of condoms through different channels
including social marketing;
 (iv) development of linkages with local institutions, both public and
NGO owned, for testing, counseling and STI treatment services;
 (v) creation of “peer support groups” and “safe spaces” for migrants at
destination;
 (vi) establishment of need-based and gender-sensitive services for
partners of IDUs; and(vii) strengthening networks of vulnerable
populations with enhanced linkages to service centers and risk
reduction interventions, specifically condom use.

7. Component 2: Expanding IEC services for (a) general
population and (b) high risk groups with a focus on
behavior change and demand generation
IEC has been an important component of the NACP. With the
expansion of services for counseling and testing, ART, STI
treatment and condom promotion, the demand generation
campaigns will continue to be the focus of the NACP-IV
communication strategy. IEC will remain an important
component of all prevention efforts and will include:
 Behavior change communication strategies for HRGs,
vulnerable groups and hard to reach populations
 Increasing awareness among general population, particularly
women and youth.

8.  Component 3: Comprehensive Care, Support and Treatment
NACP IV will implement comprehensive HIV care for all those who are in need
of such services and facilitate additional support systems for women and
children affected and infected with HIV / AIDS. It is envisaged that greater
adherence and compliance would be possible with wide network of treatment
facilities and collaborative support from PLHIV and civil society groups.
Additional Centers of Excellence (CoEs) and upgraded ART Plus centers will
be established to provide high-quality treatment and follow-up services, positive
prevention and better linkages with health care providers in the periphery.
 With increasing maturity of the epidemic, it is very likely that there will be
greater demand for 2nd line ART, OI management. NACP IV will address these
needs adequately. It is proposed that the comprehensive care, support and
treatment of HIV/AIDS will inter alia include: (i) anti-retroviral treatment (ART)
including second line (ii) management of opportunistic infections and (iii)
facilitating social protection through linkages with concerned
Departments/Ministries. The program will explore avenues of public-private
partnerships. The program will enhance activities to reduce stigma and
discrimination at all levels particularly at health care settings.

9.  Component 4: Strengthening institutional capacities
The objective of NACP IV will be to consolidate the trend of
reversal of the epidemic seen at the national level to all the key
districts in India. Programme planning and management
responsibilities will be strengthened at state and district levels to
ensure high quality, timely and effective implementation of field
level activities and desired programmatic outcomes.
 The planning processes and systems will be further strengthened
to ensure that the annual action plans are based on evidence, local
priorities and in alignment with NACP IV objectives. Sustaining the
epidemic response through increased collaboration and
convergence, where feasible, with other departments will be given
a high priority during NACP IV. This will involve phased integration
of the HIV services with the routine public sector health delivery
systems, streamlining the supply chain mechanisms and quality
control mechanisms and building capacities of governmental and
non-governmental institutions and networks.

10.  Component 5: Strategic Information Management
Systems (SIMS)
The roll-out of SIMS is ongoing and will be firmly
established at all levels to support evidence based planning,
program monitoring and measuring of programmatic
impacts. The surveillance system will be further
strengthened with focus on tracking the epidemic, incidence
analysis, identifying pockets of infection and estimating the
burden of infection. Research priorities will also be
customized to the emerging needs of the program. NACP IV
will also document, manage and disseminate evidence and
effective utilization of programmatic and research data. The
relevant, measurable and verifiable indicators will be
identified and used appropriately.

11. Targeted Interventions for
Prevention, Care and Treatment
 For the overall reduction in the epidemic, targeted interventions
(TIs) are aimed to effect behaviour change through awareness
raising among the high risk groups and clients of sex workers or
bridge populations. These interventions are aimed to saturate
three high risk groups with information on prevention; address
clients of sex workers with safe sex interventions, and build
awareness among the spouses of truckers and migrant workers,
women aged 15 to 49 and children affected by HIV or vulnerable
population groups.
 Apart from prevention of HIV infection, TIs facilitate prevention
and treatment of sexually transmitted diseases as they increase
the risk of HIV infection, and are linked to care, support and
treatment services for HIV infected.

12. Services for prevention
 Awareness RaisingManagement of STI/RTI
 Condom Promotion
 Access to Safe blood
 Integrated Counselling and Testing Centre
(ICTC)
 Post Exposure Prophylaxis (PEP)
 Prevention of Parent to Child
Transmission(PPTCT)

13. What is an Integrated counselling
and Testing Centre?
An integrated counselling and testing centre is a place where a person
is counseled and tested for HIV, on his own free will or as advised by a
medical provider.
The HIV counselling and testing services, started in the year 1997.
There are now more than 4000 Counselling and Testing Centres,
mainly located in government hospitals.
Under NACP-III, Voluntary Counselling and Testing Centres (VCTC)
and facilities providing Prevention of Parent to Child Transmission of
HIV/AIDS (PPTCT) services are remodelled as a hub or ‘Integrated
Counselling and Testing Centre’ (ICTC) to provide services to all
clients under one roof. An ICTC is a place where a person is
counselled and tested for HIV, of his own free will or as advised by a
medical provider.

14. The earlier Voluntary counselling and
Testing Centers (VCTCs) and facilities
providing Prevention of Parent-to-Child
Transmission of HIV/AIDS (PPTCT)
services are now remodeled as a hub to
deliver integrated services to all clients
under one roof and renamed as “Integrated
counselling and Testing Centers” (ICTCs).

15. Ideally, a health facility should have one integrated counselling and testing
centre for all groups of people. However, an ICTC is located in facilities that
serve specific categories such as pregnant women.
Accordingly, an ICTC is located in the Obstetrics and Gynaecology
Department of a medical college or a district hospital or in a maternity home
where the majority of clients who access counselling and testing services are
pregnant women. The justification for such a centre is the need for providing
medical care to prevent HIV transmission from infected pregnant women to
their infants.
Similarly an ICTC is located in a TB microscopy centre or in a TB sanatorium,
where the majority of clients are TB patients. As TB is the most common co-
infection in people with HIV, availability of HIV counselling and testing can
help patients to diagnose their status for accessing early treatment.

16. As of today, only 13 percent of HIV positive people in the country
are aware of their HIV status. The challenge before NACO is to
make all HIV infected people in the country aware of their status so
that they adopt a healthy lifestyle; access life-saving care and
treatment and help prevent further transmission of HIV. Thus,
counselling and testing services are important components of
prevention and control of HIV/AIDS in the country.
However, it is not the mandate of an ICTC to counsel and test
everyone in the general population. The sub-populations that are
more vulnerable or practice high risk behaviour or have higher HIV
prevalence levels are the target group for counselling and testing
services in the country.

17. HIV counselling and testing services are a key entry point to
prevention of HIV infection and to treatment and care of
people who are infected with HIV.
When availing counselling and testing services, people can
access accurate information about HIV prevention and care
and undergo HIV test in a supportive and confidential
environment.
People who are found HIV negative are supported with
information and counselling to reduce risks and remain HIV
negative.
People who are found HIV positive are provided psycho-
social support and linked to treatment and care.

18. The main functions of an ICTC are:
· Conducting HIV diagnostic tests.
· Providing basic information on the modes of HIV
transmission, and promoting behavioural change to reduce
vulnerability.
· Link people with other HIV prevention, care and treatment
services.

19.  Non Coercive, Confidential and Cost effective approach
 Promotes IEC to motivate behavior change in HIV
Positive Individual
 ICTC an entry point to continuum of care/home based
service
Integrated counselling
and Testing Centre

20. INFRASTUCTURE
 A counselling room
 Laboratory
 Sample collection room
 CD4 count room

21. WHO IS TO BE TESTED IN AN
ICTC?
 Not Mandatory to counsel and test everyone in the general
population.
 Vulnerable or groups that practice high-risk behavior:
 Sex workers and their clients
 Men who have sex with men (MSM)
 Trans genders
 Injecting drug users (IDUs)
 Truckers
 Migrant workers
 Spouses and children of men who are prone to risky behavior.

22. Different types of ICTCs?
ICTC
Fixed
Facility
Stand
Alone
Facility
Integrated
Mobile

23. MANPOWER IN AN ICTC
The ICTC requires a team of skilled persons consisting of
 ICTC manager
 Counselor
 Laboratory Technician
 Outreach workers

26. •Early detection of HIV.
•Provision of basic information on modes of
transmission and prevention of HIV/AIDS
•Promoting behavioural change and reducing
vulnerability.
•Link people with other HIV prevention, care and
treatment services.
ROLE OF AN ICTC

27. GATHER Approach
G = Greet the client
A = Ask about the problem
Active listener
Assess degree of risk behavior
Show respect and tolerance
Enable patient or client to express freely
Determine access to support and help in family
and community
T = Tell the client about specific information that he or
she desires
H = Help them to make decisions
E = Explain any myths or misconceptions(also known
as INFORMED DECISION MAKING)
R = Return for follow up or Referral

28. KITS USED FOR
TESTING
1) SD BIOLINE HIV-1/2 3.0 test
-is an immunochromatographic(rapid) test for qualitative
detection of antibodies specific to HIV-1 and HIV-2 in
plasma/serum/whole blood.
-Manufactured by SD BIO STANDARD DIAGNOSTICS PVT.
LTD.
- sensitivity=100%
-specificity=99.8%

29. SD BIOLINE HIV-1/2 3.0 test

30. SD BIOLINE HIV-1/2 3.0 test

31. 2) HIV-1/2 TRISPOT TEST KIT:
-it is a rapid Trispot test to detect antibodies to HIV-1
& HIV-2 in human serum/plasma.
-Manufactured by BHAT BIO-TECH INDIA(P) LTD.
-sensitivity=100%
-specificity=99.7%

32. HIV-1/2 TRISPOT TEST KIT

33. HIV-1/2 TRISPOT TEST KIT

34. COMBAIDS HIV-1/2 IMMUNODOT TEST KIT

35. STRATEGY 3
 For individual Dx of patients ,ICTC uses STRATEGY
3 which is as follows:
 All samples are tested with one rapid test.(SD BIOLINE
HIV-1/2 3.0 test).
 If test result is NON-REACTIVE : final report
NEGATIVE.
 If test result is REACTIVE then sample is tested
again by different systems(TRI-DOT &BI-DOT tests).

36.  Results can be REACTIVE or NON-REACTIVE.
 If result is REACTIVE with 2nd & 3rd antigen test then
report is POSITIVE.
 If result is NON-REACTIVE with either 2nd or 3rd
antigen test ,then report is INTERMEDIATE.
 If result is NON-REACTIVE with 2nd & 3rd antigen test
then report is NEGATIVE.

37. Three Tests Done:

38. TESTING ALGORITHM

40. The Prevention of Parent to Child Transmission of HIV/AIDS (PPTCT)
programme was launched in the country in the year 2002 following a
feasibility study in 11 major hospitals in the five high HIV prevalence states.
Currently, there are more than 15000 Integrated Counselling and Testing
Centres (ICTCs) in the country, most of these in government hospitals, which
offer PPTCT services to pregnant women. Of these ICTCs, nearly 550 are
located in Obstetrics and Gynaecology Departments and in Maternity Homes
where the client load is predominantly comprised of pregnant women.
The NACO Technical Estimate Report (2012) estimated that out of 27 million
annual pregnancies in India, 34,675 occur in HIV positive pregnant women. In
the absence of any intervention, an estimated cohort of 13,000 infected
babies will be born annually. The PPTCT programme aims to prevent the
perinatal transmission of HIV from an HIV infected pregnant mother to her
newborn baby. The programme entails counselling and testing of pregnant
women in the ICTCs.

41. With effect from 1st January 2014, pregnant women who are found to be HIV
positive are initiated on lifelong ART irrespective of CD4 count and WHO clinical
Staging; their newborn (HIV exposed) babies are initiated on 6 weeks of Syrup
Nevirapine immediately after birth so as to prevent transmission of HIV from mother
to child and is extended to 12 weeks of Syrup Nevirapine if the duration of the ART
of mother is less than 24 weeks.
The HIV exposed baby is initiated on Cotrimoxazole prophylaxis at 6 weeks and is
tested for HIV DNA PCR at 6 weeks by DBS9dry blood spot) collection. If the DBS
sample is positive for HIV DNA PCR, then a repeat sample is tested for HIV DNA
PCR through Whole Blood collection. The HIV exposed baby is then initiated on
lifelong ART at the earliest if confirmed HIV positive through 2 DNA PCR test.
The PPTCT services cover about 37 per cent annual estimated pregnancies in the
country. In the year 2013-14, nearly 10 million pregnant women accessed this
service. Of these, 12008 pregnant women were HIV positive. In order to provide
universal access to these services further scale up is planned up to the level of
Community Health Centre and the Primary Health Centre, as well as private sector
by forging public-private partnerships. Through these measures Government of
India is committed to work towards achievement of global target of “Elimination of
new HIV infections among children” by 2015.

42. Treatment
HIV infection is not the end of life. People can lead a healthy life for a long time with
appropriate medical care. Anti-retroviral therapy (ART) effectively suppresses
replication, if taken at the right time. Successful viral suppression restores the immune
system and halts onset and progression of disease as well as reduces chances of
getting opportunistic infections – this is how ART is aimed to work. Medication thus
enhances both quality of life and longevity.
Adherence to ART is Critical
Adherence to ART regimen is therefore very vital in this treatment. Any irregularity in
following the prescribed regimen can lead to resistance to HIV drugs, and therefore
can weaken or negate its effect.
ART is Accessible to All
ART is now available free to all those who need it. Public health facilities are
mandated to ensure that ART is provided to people living with HIV/AIDS (PLHA).
Special emphasis is given to the treatment of sero-positive women and infected
children.

43. When is ART Given?
ART is initiated depending upon the stage of infection. PLHA with less than 200 CD4 (while
blood cells/ mm3) require treatment irrespective of the clinical stage. For PLHA with 200-350
CD4, ART is offered to symptomatic patients. Among those with CD4 of more than 350,
treatment is deferred for asymptomatic persons.
Criteria for ART
* If CD4 is between 200-250, this should be repeated in four weeks and treatment to be
considered in asymptomatic patients.
There are 127 ART centres operating in the country as of June 2007. By 2012, 250 ART centres
will become functional across the country in order to provide people living with HIV/AIDS better
access to treatment.

44. Where are these ART Centres Located?
In order to make treatment more accessible ART centres are located
in medical colleges, district hospitals and non-profit charitable
institutions providing care, support and treatment services to PLHA. A
PLHA network person at each of the ART centre facilitates access to
care and treatment services at these centres. ART centres also
provide counselling and follow up on treatment adherence and support
through community care centres.
Paediatric Care and Support
The primary goal of paediatric prevention, care and treatment
programme is to prevent HIV infection to newborns through
Prevention of Parent to Child Transmission (PPTCT) and provide
treatment and care to all children infected by HIV.

45. HSS:
HIV Sentinel Surveillance (HSS) in India, since its inception in 1998, has
evolved into a credible and robust system for HIV epidemic monitoring
and acclaimed as one of the best in the world. Sentinel surveillance
provides essential information to understand the trends and dynamics of
HIV epidemic among different risk groups in the country. It aids in
refinement of strategies and prioritization of focus for prevention, care and
treatment interventions under the National AIDS Control Programme
(NACP). HIV estimates of prevalence, incidence and mortality developed
based on findings from HIV Sentinel Surveillance enable the programme
in assessing the impacts at a macro level.
During NACP-IV, HIV Sentinel Surveillance will be conducted once in two
years so that adequate time is spent on in-depth analysis and modeling,
epidemiological research and use of surveillance data for programmatic
purposes. The 13th round of sentinel surveillance will be conducted during
2012-13.

46. HIV counselling
HIV/AIDS counselling/education is a confidential
dialogue between a client and a counselor aimed
at providing information on HIV/AIDS and bringing
about behavior change in the client.
It is also aimed at enabling the client to take a
decision regarding HIV testing and to understand
the implications of the test results.

47. Counselling in HIV/AIDS
Concerned with preventing infection and transmission of
HIV/AIDS:
 Determine whether individual is of high risk behaviour
 Help people to understand their high risk behaviour
pattern
 Define how to change their lifestyle and self image are
linked to their behaviour.
 Help individual to change their behaviour
 Work with individual to introduce and sustain the
modified behaviour.

48. Counselling skills
 Listen actively
 Responding to clients feelings
 Questioning
 Paraphrasing and interpretation
 Interpretation

49. PRE- TEST COUNSELLING
 Provide individual being tested with
information on technical aspects of screening
and possible personal, medical, social,
psychological and least implications of being
tested positive or negative.
 Information should be simple and up to date.

50. Pre test counseling helps a person to understand the possible results of an
HIV test. It may be positive, negative or equivocal. The counselor must
explain the meaning of each such test result. This should be utilized as an
opportunity to assess the likely reaction of the client to a positive or
negative test result.
An essential element of post test counseling is breaking the news. It
requires special skills and right judgment about the client’s state of mind.

51. Types
• Assess the
preparednessProvider
Initiated
• Assess client’s
reasons and
motivation for
seeking a test
Self
Initiated

52. Issues in pre test
counselling
1) Personal history and assessment of
RISK:
 Sexual behaviour, multiple partners,
prostitutes, unprotected sex, homosexuality,
bisexuality
 Drug users
 Blood trasnfusion
 Organ transplant

53. 2) Assessment of factors and
knowledge:
Why test is being requested?
What behaviour/ symptoms are of concern to
the client?
What the client know about test and its
uses?
What will the client do if test is positive or
negative?
Beliefs regarding HIV transmission
What role will family play?

54. POST TEST
counselling

55. Test Result?
Positive
Equivocal
Negat
ive

56. WHAT IF NEGATIVE
RESULT
Window period
Prevention of further exposure
Behavior modification

57. WHAT IF POSITIVE RESULT
Immediate reporting
Time to get over shock
Explain Implications
Encouragement
Possible treatment and efficacy

58. WHAT IF EQUIVOCAL
RESULT
• Window period
• Related HIV virus
• Cross reaction with Non viral protein
Cause of Equivocal result
• Retesting
Alternative methods

59. FOLLOW-UP counselling
In follow-up counselling there is a re-emphasis on
adoption of safe behaviors to prevent transmission of
HIV infection to others.
Follow-up counselling also includes establishing
linkages and referrals to services for care and support
including ART, nutrition, home-based care and legal
support.

60. WHAT IS COUNSELLING?
Counselling has been defined as a process of helping/enabling a person/people
solvecertain interpersonal, emotional and decision-making problems. A counsellor’s role is
to help clients help themselves. Counselling can be done with an individual, group, with
couples or families.
Counselling involves
Supporting individuals to take charge of their own life by:
• Providing information,
• Facilitating emotional adjustments, and
• Enhancing mental health.
and enabling them to:
• understand and accept the problem,
• develop resources to take adaptable and realistic decisions, and
• alter their own behaviour to produce relatively enduring, desirable consequences.

61. Counselling is .
• Specific to the needs, issues and circumstances of each individual client
• An interactive, mutually respectful collaborative process
• Goal-directed
• Oriented towards developing autonomy, self-responsibility and confidence in
clients
• Sensitive to the sociocultural context
• Eliciting information, reviewing options and developing action plans
• Inculcating coping skills
• Facilitating interpersonal interactions
• Bringing about attitudinal change
Counselling is not
• Telling or directing
• Giving advice
• A casual conversation
• An interrogation
• A confession
• Praying
Some common errors in counselling
• Judging and evaluating
• Moralizing and preaching
• Labelling
• Unwarranted assurance

63. AIMS AND IMPORTANCE OF HIV/AIDS COUNSELLING
HIV/AIDS is a life-threatening, life-long illness. Diagnosis of HIV/AIDS has many
implications—psychological, social and physical. Preventive counselling and
behaviour change can prevent transmission of HIV and improve the quality of life.
HIV/AIDS counselling is a process with four general objectives:
1. Facilitating decision to undergo HIV test
2. Providing psychological, social and emotional support for
• People who have contracted the virus and
• Others affected by the virus.
3. Preventing transmission of HIV by
• Providing information about risk behaviours (such as unsafe sex or needle
sharing),
• Motivating people to take good care of their health,
• Assisting them to develop personal skills necessary for behaviour change,
and
• Adopting and negotiating safe sexual practices.
4. Ensuring effective use of treatment programmes by
• Establishing treatment goals and
• Ensuring regular follow-up.

64. Issues to be addressed by HIV/AIDS counselling
HIV/AIDS counselling is intended to address the physical, social, psychological and
spiritual needs of the client. Besides, the following issues should also be addressed:
• Problems related to infection and illness
• Death, bereavement
• Social discrimination
• Sexuality
• Lifestyle
• Prevention of transmission
• Meaning to life
It is important to note that, in addition to the issues directly related to HIV/AIDS,
clients may be dealing with a range of issues that are pre-morbid or indirectly related
to HIV/AIDS, such as alcoholism, drug use, personality problems, unhealthy sexual
practices, etc.
Specific therapy may be required to assist clients with pre-morbid or co-existing
psychiatric illnesses, emotional and behavioural problems, or specific problems such
as sexual dysfunction, management of sleep difficulties, panic attacks, etc.
HIV/AIDS may also re-activate previously unresolved issues such as those of
sexuality, sexual identity (homosexual or bisexual), guilt or shame of being a sex
worker, drug addiction or family problems unrelated to HIV.

65. Counseling becomes necessary because people are at a loss and unable to
decide what to do with their lives, once they are found to be HIV positive.
Those who have practiced high risk behavior are unable to take a decision
whether to go for HIV test or not. Another important issue is breaking the news
to the family members and sex partners. In such circumstances, counseling
helps a person to come to term with the realities of HIV/AIDS and act in a
balanced way.

66. Behavior change communication (BCC) is an interactive process of any
intervention with individuals, communities and/or societies (as integrated
with an overall program) to develop communication strategies to promote
positive behaviors which are appropriate to their settings.