Scale-up of OST services under the National AIDS Control Programme

How is India doing it?

WORKSHOP“OST in Developing Countries:

A Primer”Atul Ambekar, Alok Agrawal (India)

Contents

Background: PWID-HIV situation in India

OST service delivery models

Capacity Building, Monitoring and Quality Assurance of OST

PWID – HIV situation in India

• Estimated PWID

~ 200,000~ 95% male~ 8% living with HIV

• Heterogeneity of epidemic – ‘Old’ versus ‘New’

epidemics – Drugs injected: Heroin /

Brown Sugar; Buprenorphine, Pentazocine, D-propoxyphene

– Wide variations in sero-positivity (1% to 50%)

OST in India

• Buprenorphine for treatment of Opioid dependence – In existence since 1989– At a smaller scale

• OST as HIV prevention intervention for PWID– Since 2007 – Undergoing scale–up

OST scale-up in India - Buprenorphine

Year 2007-10 Year 20140

2000

4000

6000

8000

10000

12000

14000

16000

3000

15000

Number of PWID on OST

Year 2007-10 Year 20140

20

40

60

80

100

120

140

160

51

150

Number of OST centres

OST scale-up in India - Methadone

• Initiated as a Pilot Project – 2012 – 5 sites, all government hospitals – About 600 PWID initiated on Methadone – On the verge of scale-up

2010: The Watershed year

• Introduction of new model of OST service delivery

HOSPITAL

NGONGO

OLD MODEL OF OST SERVICE DELIVERY

PWID

NSEP and other Harm reduction services

OST services Other Health services

NEW MODEL OF OST SERVICE DELIVERY

HOSPITAL with OST

NGONGO

Outreach worker from NGO takes PWID to the OST center in govt. hospital

PWID

NSEP and other Harm reduction services

Mechanisms for Capacity Building on OST

1. Induction Training 2. Quality assurance3. Accreditation

Mechanisms for building capacities and ensuring

quality

1. Induction Training

2. Quality Assurance / Mentoring

3. Accreditation

Capacity Building

Evaluation

Mechanisms for building capacities and ensuring

quality

1. Induction Training

2. Quality Assurance / Mentoring

3. Accreditation

Capacity Building

Evaluation

Induction Training on OST0A five day training programme 0Conducted soon after recruitment of staff 0Conducted for a mixed group of staff (nodal officers,

doctors, nurses, counselors, data managers, programme managers and outreach workers)

0Class-room type training 0 Highly interactive and participatory 0 Exposure visit – an essential component

0BASED UPON A MANUAL 0Outcome:

0 Trained staff who begin service delivery after receiving a certificate

Mechanisms for building capacities and ensuring

quality

1. Induction Training

2. Quality Assurance / Mentoring

3. Accreditation

Capacity Building

Evaluation

Quality Assurance of OST

0 In the form of ‘visits’ by OST experts / mentors 0 Visits aimed at:

0 Assessment of the quality of services0 Interaction with and guidance to the staff on ensuring

adequate quality 0 Mentors / experts: Doctors; experience / expertise in

OST; trained on QA guide0 Outcome: Staff receives hands-on guidance; SACS /

NACO receive a report on performance

Quality Assurance of OST

0 In the form of ‘visits’ by OST experts / mentors 0 Visits aimed at:

0 Assessment of the quality of services0 Interaction with and guidance to the staff on ensuring

adequate quality 0 Mentors / experts: Doctors; experience / expertise in

OST; trained on QA guide 0 Outcome: Staff receives hands-on guidance; SACS /

NACO receive a report on performance

Atul Ambekar, Ravindra Rao, Alok Agrawal, Anju Dhawan, Rajat Ray, (2013), Quality Assurance of OST in India: A reference guide for mentors, NDDTC, AIIMS and NACO, Government of India, New Delhi

QA Guide: Contents

0 Introduction / About the Reference Guide 0 Conducting a Quality Assurance Visit0 Preparing a Quality Assurance Visit Report0 Tool for OST Quality Assurance Visit0 OST Quality Assurance Visit Report - Proforma0 Annexures: List of common problems and their

solutions; Steps for Planning and Managing QA Visits,

Conducting a QA visit0 Inform the centre staff and concerned SACS prior to visit 0 During visit

0 Observation of the centre, including functioning of the staff and service delivery processes

0 Review of records0 Interaction with

0Staff – OST centre 0Staff – linked IDU TI 0Beneficiaries0Other stakeholders

0 Use the prescribed format to conduct the visit 0 Use the prescribed format to report the visit

Tool for OST quality assurance visit

Section 1: Background information

Section 2: Details of the OST centre

Section 3: Staff-related Details

Section 4: Implementation Of OST

Section 5: Record Keeping-related Details

Section 6: Feedback from Clients and their Families

Section 7: Stock Maintenance & Programme Management

Section 8: Gaps Identified and Addressed

Section 9: Impression on Quality of OST Centre

Tool for OST quality assurance visit

Impression on Quality of OST centre

016 - item scoring scale 0Each item can be scored 1, 2 or 3 0Option for giving remarks for each item0Quality grading depends upon the total %

score obtained

Item 1: OST uptake

Item 2: Recruitment and training of staff

Item 3: Knowledge and confidence of staff on OST issues

Item 4: Role clarity

Item 5:Initial assessment of clients before OST initiation

Item 6: Stabilisation dose of buprenorphine

Item 7:Follow-up of OST clients

Item 8:Changes in dose of buprenorphine

Impression on Quality of OST centre

Item 9:Duration of maintenance phase of treatment

Item 10:Follow-up of LFU/irregular clients in the field

Item 11:Dispensing-related protocols

Item 12:Record maintenance

Item 13:Stock management

Item 14:Satisfaction of clients and family members

Item 15:Client retention

Item 16: Treatment adherence and compliance

Impression on Quality of OST centre

OST Quality Assurance visit report

0Observations/findings and specific recommendations on specific areas of OST implementation

0Other specific inputs provided0Issues for consideration by

programme authorities

Annexures

0List of common problems and possible solutions

0Planning and managing the OST QA visits

Mechanisms for building capacities and ensuring

quality

1. Induction Training

2. Quality Assurance / Mentoring

3. Accreditation

Accreditation 0 All NGO OST centres expected to undergo Accreditation

0 Accreditation for Government centres also on the anvil 0 Conducted by an independent agency: National

Accreditation Board for Hospitals (NABH) 0 Through trained team of two experts (Technical +

Programme) 0 Using a especially prepared tool

0 Report provides 0 Scores0 Qualitative / descriptive information

Accreditation 0 All NGO OST centres expected to undergo Accreditation

0 Accreditation for Government centres also on the anvil 0 Conducted by an independent agency: National

Accreditation Board for Hospitals (NABH) 0 Through trained team of two experts (Technical +

Programme) 0 Using a especially prepared tool

0 Report provides 0 Scores0 Qualitative / descriptive information

The Accreditation Tool0 In the form of an excel sheet 0 Filled by both the experts through observations and

interaction

The Accreditation Tool0 In the form of an excel sheet 0 Filled by both the experts through observations and

interaction0 Sections

0 Infrastructure 0 Staff 0 Service Delivery Process 0 Performance 0 Qualitative information 0 “Essential Items”

Accreditation: Essential items Infrastructure Storage of Medications

Staff DoctorOST Nurse

OST Service Delivery Processes

Regularity of functioningAdherence to DOTSDosage ChangeDispensing RecordsStock recordsMechanisms to check diversion

Programme Performance Service utilization

Resource Materials developed for Capacity Building and Quality Assurance

1. Training Manual

2. SOPs 3. Practice Guidelines

4. QA Guide

Thank you