Handbook Counsellor Training Draft - 24.11.23
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jensenloqueroHandbook Counsellor Training Draft - 24.11.23
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jensenloqueroHANDBOOK
FOR
HIV & STI
COUNSELLORS
OCTOBER 2023
NATIONAL AIDS CONTROL ORGANISATION
Ministry of Health and Family Welfare 1
Government of India
2
GUIDANCE NOTE
The Handbook for Counsellors is designed to serve as a comprehensive guide and reference
manual for counsellors who are involved in the delivery of counselling services within the
framework of National AIDS Control Program (NACP). This handbook aims to ensure that
counsellors are well-equipped with the necessary knowledge, skills, and resources to effectively
contribute to the prevention and management of HIV/AIDS in their respective communities.
Counselling is one of the key pillars of HIV services. Under NACP, the counsellors work at
Integrated Counselling and Testing Centres (ICTC), Targeted Interventions (TI) programmes,
Anti-retroviral Therapy (ART) centres, Designated STI/RTI Clinic (DSRCs), Opioid
Substitution Therapy (OST) centres, Sampoorna Suraksha Kendras (SSKs), and for 1097
helpline.
Breaking the Silos and Building Synergies is one of the important guiding principles of NACP-
V (2021-26). Break the silos, and build the synergies aims to promote coordinated actions,
through single window delivery systems along with functional and measurable referrals and
linkages, within NACP and across national health programmes and related sectors, for efcient
service delivery. This will ensure a suitable, functional, and sustainable model.
The handbook aims to empower counsellors by equipping them with up-to-date knowledge,
practical skills, and resources. This handbook will serve as a reference document for all
counsellors under NACP, providing a unied approach to counselling, ensuring that all
counsellors adhere to the same high standards of care and ethics and establish a single window
service delivery to all PLHIV as well as at-risk populations. The document guides the
counsellors in providing comprehensive, complete, rightful, and quality care to all the
individuals “Infected” and “Affected” with HIV. The handbook is a ready reckoner for both
experienced as well as entry-level counsellors to improve their knowledge and skills for
providing effective service delivery across the prevention-to-treatment continuum. The
Handbook covers various aspects of the NACP, such as HIV counselling & diagnosis, STI
treatment & management, ART initiation, OI management, special populations, monitoring,
community engagement strategies, data recording and reporting mechanisms etc. It also
mentions the recent initiatives undertaken by NACO under NACP V for providing a
comprehensive package of services as well as reaching the population at risk, which is not
covered under TI or other prevention programmes, thus boosting the national level progress on
HIV prevention. Each chapter in the handbook provides technical information regarding the
topic along with key messages for easy reference. The handbook has been written in simple and
easy-to-understand language for the convenience of all counsellors. At the end of each chapter,
a reference list is also provided for further reading.
By promoting standardized, high-quality counselling services, empowering counsellors, and
emphasizing a client-centred approach, this handbook contributes to the overall success of
NACP in its mission to prevent and control HIV/AIDS in communities.
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HANDBOOK FOR HIV & STI COUNSELLORS
ABBREVIATIONS
AIC Airborne Infection Control
AIDS Acquired Immune Deciency Syndrome
Al, A2, A3 Assays 1,2,3
ANC Antenatal Care
ANM Auxiliary Nurse Midwife
ART Anti-retroviral Therapy
ART Centre Anti-retroviral Therapy Centre
ART Plus Anti-retroviral Therapy Plus Centre
ARV Anti-retroviral Drugs
ASHA Accredited Social Health Activists
AWW Anganwadi Worker
BCC Behaviour Change Communication
CABA Children Affected by AIDS
CB NAAT Cartridge-Based Nucleic Acid Amplication Test
CBS Community Based Screening
CBO Community Based Organization
CDC Centres for Disease Control and Prevention
CHC Community Health Centre
CSC Care & Support Centre
DAPCU District AIDS Control and Prevention Unit
DISHA District Integrated Strategy for HIV/AIDS
DMC Designated Microscopy Center
DNA Deoxyribonucleic Acid
DPM District Programme Manager
DR TB Drug Resistant TB
DSRC Designated STI/RTI Clinic
EID Early Infant Diagnosis
ELISA Enzyme Linked Immunosorbent Assay
ELM Employee-Led Model
Emtct Elimination of Mother-To-Child Transmission
EQAS External Quality Assessment Scheme
F-ICTC Facility-Integrated Counselling and Testing Centres
FIDU Female Injecting Drug Users
FSW Female Sex Worker
4
HBV Hepatitis B Virus
HCV Hepatitis C Virus
HIV Human Immunodeciency Virus
HRG High Risk Group
HCTS HIV Counselling and Testing Services
ICTC Integrated Counselling and Testing Centre
IDU Injecting Drug User
IEC Information, Education and Communication
IPT Isoniazid Preventive Therapy
IQC Internal Quality Control
IVD In Vitro Diagnostic Medical Device
JSY Janani Suraksha Yojana
LAC Link ART Centre
LAC + Link ART Plus Centre
LPA Line Probe Assay
LT Laboratory Technician
LWS Link Workers Scheme
MARPs Most At Risk Populations
MMR Maternal Mortality Rate
MMU Mobile Medical Unit
MO Medical Ofcer
MoHFW Ministry of Health and Family Welfare
MSM Men Who Have Sex with Men
MTB Mycobacterium Tuberculosis
NACO National AIDS Control Organization
NACP National AIDS Control Programme
NASBA Nucleic Acid Sequence-Based Amplication
NAT Nucleic Acid Testing
NGO Non-Governmental Organization
NHM National Health Mission
NRL National Reference Laboratory
OI Opportunistic Infection
OPD Out-Patient Department
ORW Outreach Worker
OST Opioid Substitution Therapy
PCR Polymerase Chain Reaction
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HANDBOOK FOR HIV & STI COUNSELLORS
PE Peer Educator
PEP Post-Exposure Prophylaxis
PHC Primary Health Centre
PHN Public Health Nurse
PLHIV People Living with HIV/AIDS
PMTCT Prevention of Mother-To-Child Transmission
PPP-ICTC Public Private Partner ICTC
POC Point of Care
PrEP Pre-Exposure Prophylaxis
PW Pregnant Women
PWID People Who Inject Drugs
QA Quality Assurance
QC Quality Control
QI Quality Improvement
QMS Quality Management System
RCH Reproductive Child Health
RDT Rapid Diagnostic Test
Rif Rifampicin
RNTCP Revised National Tuberculosis Control Programme
SACS State AIDS Control Society
SA-ICTC Stand-Alone Integrated Counselling and Testing Centre
SHG Self Help Group
SOP Standard Operating Procedure
STI/RTI Sexually Transmitted Infection / Reproductive Tract Infection
TB Tuberculosis
TI Targeted Intervention
TNA Total Nucleic Acid
TG Transgender
ToR Terms of Reference
USP Universal Safety Precautions
UWP Universal Work Precaution
WBFPT Whole Blood Finger Prick Test
WLHIV Women living with HIV
6
INDEX
Chapter No. Topic Page No.
Chapter 1 Introduction to the National HIV/AIDS Control Program
and National AIDS Control Organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Chapter 2 Basics of HIV and AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Chapter 3 Drivers of HIV epidemic. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Chapter 4 The HIV and AIDS (Prevention and Control) Act, 2017 . . . . . . . . . . . . . . . . . . 25
Chapter 5 Introduction to Prevention Programme under NACP . . . . . . . . . . . . . . . . . . . . 33
Chapter 6 Substance Use in Context of HIV/AIDS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Chapter 7 Counselling and Testing for HIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Chapter 8 Basic Counselling Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Chapter 9 Risk assessment, Pre and Post-test Counselling and Index Testing. . . . . . . . . 78
Chapter 10 Condom Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Chapter 11 Screening and Management of Sexually Transmitted Infections and
Reproductive Tract Infections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Chapter 12 Post Exposure prophylaxis, Universal Work Precautions
and Pre-Exposure Prophylaxis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Chapter 13 Antiretroviral Treatment and Management of PLHIV . . . . . . . . . . . . . . . . . . 116
Chapter 14 Prevention and Management of Opportunistic Infections
and Co-morbidities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Chapter 15 Nutrition in the Context of HIV and Adherence. . . . . . . . . . . . . . . . . . . . . . . . 172
Chapter 16 Elimination of Vertical Transmission of HIV and Syphilis . . . . . . . . . . . . . . . 183
Chapter 17 Family Planning Methods for PLHIV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
Chapter 18 Counselling of Children and Parent/Guardian . . . . . . . . . . . . . . . . . . . . . . . . . 204
Chapter 19 Counselling for Adolescents Living with HIV (ALHIV)
and Adolescents at Risk . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Chapter 20 Newer Interventions in NACP-V . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 227
Chapter 21 Mobile outreach services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241
Chapter 22 Linkages and Referrals for PLHIVs & At Risk Negative Clients . . . . . . . . . . 248
Chapter 23 Breaking the Silos- Counselling Needs and Terms of Reference
of the NACP Counsellors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Chapter 24 Data Safety and Management at Facilities under NACP . . . . . . . . . . . . . . . . 261
7
HANDBOOK FOR HIV & STI COUNSELLORS
Introduction to the National HIV/AIDS
1 Control Program and National AIDS
Control Organization
HIV Epidemic in India
As per the 2021 epidemiological data, India is estimated to have around 24.01 lakh (19.92 to
29.07 lakh) people living with HIV/AIDS (PLHIV) with an overall adult prevalence of 0.21%
(0.17–0.25%).
Around 63 thousand (36.72–104.06 thousand) new HIV infections were estimated in 2021.
Almost 92% of total new infections were reported to be among the population aged 15 years or
older, including around 24.55 thousand (14.27–40.69 thousand) among women. Around 42
thousand PLHIV died of AIDS-related mortality in the same reference period.
Figure 1 - Adult prevalence (%) in India by state, 2021
HIV Prevalence in riskgroups
In 2021, the 17th round of HIV Sentinel Surveillance was implemented across eight population
groups comprising pregnant women, single male migrants (SMM), long-distance truckers
(LDT), prisoners, female sex workers (FSW), men who have sex with men (MSM),
hijra/transgender (H/TG) people and injecting drug users (IDU) collecting almost ve lakh bio-
behavioural samples. Pregnant women are considered as a proxy for general population while
SMM and LDT are proxy for bridge population. FSW, inmates, MSM, H/TG people and IDU
represent high-risk groups in the disease transmission dynamics in India. As per the
preliminary analysis of data from HSS 2021, there is an increasing trend of HIV infection
among high-risk and bridge population.
Genesis of NACP
In 1986, following the detection of the rst AIDS case in the country, the National AIDS
Committee was constituted in the Ministry of Health and Family Welfare. As the epidemic
spread, the need was felt for a nationwide programme and an organization to steer the
programme. In 1992 India’s rst National AIDS Control Programme (1992–1999) was
8
Introduction to NACP and NACO
launched, and the National AIDS Control Organization (NACO) was constituted to implement
the programme.
The rst phase contained initial interventions focused on understanding modes of transmission
and on prevention, blood safety and information, education and communication (IEC) strategy
to increase awareness. This was followed by NACP-II (2000–2005), NACP-III (2006–2011) and
NACP-IV (2012–2017), which was extended for a further four years till March 2021.
Figure shows different phases of NACP implementation in India
NACP-IV
Initial NACP-I NACP-II NACP-III NACP-IV NACP-V
Extension
Response (1992-1999) (1999-2007) (2007-2012) (2012-2017) (2021-2026)
(2017-2021)
NACP-V (2021 to 2026)
Currently, NACP is in its fth phase, which started in 2021.It aims to reduce annual new HIV
infections and AIDS-related mortalities by 80% by 2025-2026 from the baseline value of 2010.
It also aims to attain dual elimination of vertical transmission of HIV and syphilis and
elimination of HIV/AIDS-related stigma while promoting universal access to quality STI/RTI
services for at-risk and vulnerable populations.
Goals of NACP V
Figure 1.3 - Goals of NACP V
Promote
Reduce Eliminate
Reduce universal access to Eliminate
annual new vertical
AIDS-related quality STI/RTI HIV/AIDS related
HIV transmission
mortalities services for at-risk stigma and
infections by of HIV and
by 80% and vulnerable discrimination
80% syphilis.
populations
The specic objectives of the NACP Phase-V are as below:
a. HIV/AIDS prevention and control
I. 95% of people who are most at risk of acquiring HIV infection use comprehensive
prevention.
ii. 95% of HIV-positive people know their status, 95% of those who know their status are
on treatment and 95% of those who are on treatment have suppressed viral load.
iii. 95% of pregnant and breastfeeding women living with HIV have suppressed viral load
towards attainment of elimination of vertical transmission of HIV.
iv. Less than 10% of people living with HIV and key populations experience stigma and
discrimination.
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HANDBOOK FOR HIV & STI COUNSELLORS
b. STI/RTI prevention and control
i. Universal access to quality STI/RTI services to at-risk and vulnerable populations
ii. Attainment of elimination of vertical transmission of syphilis
NACO Organogram
Minister of Health & Family Welfare
Additional Secretary & Director General, NACO
Joint Secretary/Director, NACO
Divisions
NACO Implementation Structure
Ministry of Health & Family Welfare
National AIDS Control Organization Technical Resource Groups
State AIDS Control Society (37) Technical Support Units
Community Engagement in Design, Implementation and Monitoring
Key Messages
India is estimated to have around 24.01 lakh PLHIV. Around 63 thousand new HIV
infections were estimated in 2021. Almost 92% of total new infections were reported to be
among population aged 15 years or older, including around 24.55 thousand among
women.
HIV prevalence is high among high-risk groups and bridge population.
India is committed to ending the AIDS epidemic as a public health threat by 2030 by
working towards ensuring that 95% of those who are HIV positive in the country know
their status, 95% of those who know their status are on treatment and 95% of those who
are on treatment experience effective viral load suppression.
India’s response to HIV/AIDS started in 1985 and from 1992, the NACP was launched
and we are currently in NACP Phase V which started in 2021.
10
Introduction to NACP and NACO
Starting from NACP Phase I to NACP IV (Extension), the HIV/AIDS programme has
evolved from large-scale awareness generation campaigns to game-changing initiatives
such as, to name a few, enactment of the HIV/AIDS (Prevention and Control) Act, 2017,
mission Sampark to bring back lost-to-follow-up PLHIV on antiretroviral therapy (ART),
universal viral load testing for on-ART PLHIV, differentiated service delivery models
(DSDMs) for PLHIV to strengthen follow-up, ART adherence and retention and
interventions in prisons and other closed settings
NACP-V aims to reduce annual new HIV infections and AIDS-related mortalities by 80%
by 2025–2026. Additionally, it seeks to eradicate the vertical transmission of both
syphilis and HIV and the stigma associated with HIV/AIDS.
To respond to the challenge, the Government of India established the National AIDS
Control Organization (NACO, a division of the Ministry of Health and Family Welfare)
in1992 to oversee the policies for prevention and control of the HIV infection through 35
HIV/AIDS Prevention and Control Societies across India.
References
National AIDS Control Organization (2022). Strategy Document: National AIDS and STD Control
Programme Phase-V (2021-26). New Delhi: NACO, Ministry of Health and Family Welfare,
Government of India.
National AIDS Control Organization (2020). Sankalak: Status of National AIDS Response (Second
edition, 2020). New Delhi: NACO, Ministry of Health and Family Welfare, Government of India.
National AIDS Control Organization (2022). Sankalak: Status of National AIDS Response (Fourth
edition, 2022). New Delhi: NACO, Ministry of Health and Family Welfare, Government of India.
National AIDS Control Organization (2022). Integrated and Enhanced Surveillance and Epidemiology
of HIV, STI and related Co-morbidities Under the National AIDS and STD Control Programme:
Strategic Framework. New Delhi: NACO, Ministry of Health and Family Welfare, Government of
India.
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HANDBOOK FOR HIV & STI COUNSELLORS
2 Basics of HIV and AIDS
What is HIV and AIDS
Table 2.1- What is HIV and AIDS
HIV AIDS
H - Human, A - Acquired (meaning to get from someone)
I - Immunodeciency, I - Immune (meaning body’s defence to ght diseases or
body’s resistance)
V - Virus
D - Deciency (meaning lack of resistance or decreased
A virus that attacks the
level of functioning)
immune system and makes
a person more vulnerable to S - Syndrome (meaning signs and symptoms of disease
other infections.
AIDS is a group of diseases resulting from HIV infection
PLHIV/HIV positive: left untreated for a long time. It can be fatal.
people infected with HIV
Being diagnosed with HIV does not mean the person has
virus.
AIDS. Healthcare professionals diagnose AIDS only when
people with HIV infection begin to get severe opportunistic
infections (Ois), or their CD4 cell counts fall below a
certain level.
Immune System - It defends the body against infections.
White blood cells (WBCs) are the most important part of this system.
WBCs ght and destroy bacteria, fungi and viruses that may enter the body.
Progression from HIV to AIDS (without ART)
AIDS is a disease (syndrome) caused by HIV, which on entering the human body, attacks the
WBCs, multiplies and infects the other WBCs. The infected WBCs are eventually destroyed,
which leads to a reduction in the number of WBCs and nally to greatly reduced immunity.
This opens the gateway to various infections (UNODC & TISS, 2011).
1. 80–90% of HIV infected are typical progressors with survival time of approximately 11
years.
2. 5–10% are ‘rapid progressors’ with median survival time of 3–4 years.
3. 7–10% of HIV-infected individuals do not experience disease progression for extended
period of time and are called ‘long-term non progressors’ (LTNPs).
12
Basics of HIV and AIDS
Signs and symptoms of HIV and AIDS
The symptoms of HIV depend on the stage of infection. As the infection progressively weakens
the immune system, an individual can develop other co-infections.
Table 2.2 - Co-infections developed with HIV progression
During the rst few After the infection Without treatment,
weeks after the initial progressively weakens develop severe illnesses
infection: the immune system: such as:
No symptoms or Swollen lymph nodes Herpes Zoster
Inuenza-like illness Weight loss Tuberculosis (TB)
including fever Fever Oral candidiasis
Headache Diarrhoea Pneumocystis
Rash Cough jiroveciipneumonia
Sore throat Cryptosporidiosis
Progressive multifocal
leukoencephalopathy (PML)
How does HIV spread?
Main causes of the spread are as follows:
a) Unsafe sexual intercourse
b) Sharing of needles and injecting equipment
c) Unsafe blood transfusion
d) Vertical transmission: from infected mother to child during pregnancy, labour, delivery or
breastfeeding
HIV must be present for transmission
Transmission can occur only from an HIV-infected individual to another individual. A small
amount of blood is enough to infect. Healthy, unbroken skin does not allow HIV to get into the
body.
HIV survival outside the body
For transmission to occur, the body uid which contains the virus must enter the body of
another individual. It must be noted that in an infected individual, not all body uids contain
enough HIV to be able to infect another. Both infectious and non-infectious body uids are
explained further.
How is HIV not transmitted?
HIV virus does not spread in the following ways:
Kissing and touching: Social kissing and hugging pose no risk of transmission.
Sharing living space: Any casual contact with someone who has HIV, including sharing
bathrooms and toilets, is safe.
Sharing food or utensils: The virus cannot survive on surfaces, so sharing utensils and
other household items will not spread HIV.
13
HANDBOOK FOR HIV & STI COUNSELLORS
Saliva, sweat or tears: An infected person’s saliva, sweat and tears do not put anyone at
risk.
Helping an injured person with HIV: Wearing gloves while doing so is ideal; but even if
the person’s blood comes into contact with your intact skin, you should not worry.
Mosquitoes and other insects: The virus is not viable in insects or ticks.
HIV survival outside the body
Length of time HIV can survive outside the body: HIV is very fragile, and many common
substances, including hot water, soap, bleach and alcohol will kill it.
Exposure to air: Air does not ‘kill’ HIV, but exposure to air dries the uid containing the
virus, which destroys and breaks up the virus very quickly.
Needles: HIV can survive for several days in the small amount of blood that remains in a
needle after use. Thus, for transmission to occur, the body uid which contains the virus must
enter the body of another individual. It must be noted that in an infected individual, not all
body uids contain enough HIV to be able to infect another, as listed below.
Risk of HIV transmission
Table 2.3- Risk of HIV Transmission
Exposure route Risk of transmission
Blood transfusion >98 %
Perinatal 20–40%
Sexual intercourse 0.10–10%
- Vaginal 0.05–0.10%
- Anal 0.065–0.50%
- Oral 0.005–0.01%
Injecting drug use 0.67%
Needle stick exposure 0.30%
Mucous membrane splash to eye, oronasal 0.09%
(NACO, 2021 – National Guidelines for HIV Care and Treatment)
Prevention of HIV Transmission:
The following care should be taken for prevention:
Regular and consistent use of condom: Regular use of condom at every sexual
encounter provides protection from transmission of HIV virus as well as unwanted
pregnancy and other sexually transmitted infections.
Correct use of condoms: The use of condom has to be accurate and consistent. A new
condom after the due check of its expiry date should be used before every sexual encounter.
Non-usage of used syringe: The reuse of a HIV infected blood-contaminated needle or
syringe by another drug injector has some quantity of the HIV-infected blood present in the
hollow of the needle and the base of the syringe cylinder. Hence the reuse of such needles
and syringes carries high risk of HIV transmission or any other blood-borne virus when
pushed into the blood stream of the next user.
14
Basics of HIV and AIDS
Proper and just use of post-exposure prophylaxis (PEP): PEP is a regimen where
antiretroviral medicines are taken after potential exposure to HIV to prevent being infected
by HIV. PEP should be used as early as possible and denitely within a stipulated time of 72
hours (3 days).
Know your status and that of the partner: It is imperative to know one’s HIV status in
order to assure speedy access to treatment and medication. Timely testing and treatment
can ensure a healthy life. With Government of India’s (GoI’s) ‘Test and Treat’ programme in
place, a person tested positive for HIV is immediately put on ART, which suppresses the
virus and stops the progression of HIV disease.
Obtaining blood and components from a licensed blood bank: Only registered
medical practitioners should procure and transfuse blood/blood components that has been
screened for HIV and other infections to any patient who needs it.
Everyone should remember that
HIV can affect anyone;
HIV infection is largely silent except when OIs/AIDS set in;
There is no cure for AIDS and it is the responsibility of each one of us to prevent and stop
HIV transmission. We should stay away from high-risk behaviours that put us at risk of
HIV infection;
One has a right to get oneself tested without disclosing one’s identity;
People infected with HIV can also lead a positive and productive life by adopting a healthy
lifestyle and by taking anti-retroviral medicines;
Women are more vulnerable to HIV because of biological and social factors;
Adolescents/youth are much more vulnerable to HIV because of lack of correct information,
experimentation in risk taking and peer pressure (NACO, 2019).
Stages of disease progression:
Typically, PLHIV go through the following stages of disease progression:
Primary HIV Clinically asymptomatic Symptomatic HIV
infection stage infection and AIDS
Infected person is HIV-infected person may Over time, HIV multiplies
highly infectious but take from 6 months to 10 in the body.
looks healthy years to develop AIDS
CD4 count decreases
High viral load HIV antibodies are
Immune system weakens
detectable
Flu-like symptoms
Skin, nail and mouth
May have swollen glands
Window period infections develop
Healthy, positive living can
Lose weight
make this stage last a long
time
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HANDBOOK FOR HIV & STI COUNSELLORS
Link between HIV/AIDS and STIs
STIs, especially genital ulcer disease (with 10 times higher chances) and genital discharges
(ve times more chances), are strongly associated with the occurrence of HIV infection. ,. Early
diagnosis and effective treatment of such STIs isan important strategy for the prevention of
HIV transmission (NACO, 2019).
Myths and Misconceptions:
Some common myths and misconceptions about HIV are listed below:
HIV always leads to AIDS.
HIV can be transmitted through hugs and kisses.
HIV can spread by breathing the same air
HIV can spread via infected water or food.
HIV cannot spread through a needle.
HIV can be contracted by touching a toilet seat or door handle touched by a HIV-positive
person.
HIV can spread by sharing eating utensils with a HIV-positive person.
HIV can spread by using exercise equipment used by a HIV-positive person at a gym.
HIV can spread through touching, shaking hands, hugging, making friends, eating,
drinking, studying, working, sharing clothes, toilets, towels or a house with a HIV-positive
person.
HIV can be cured but not AIDS.
HIV-positive people cannot safely have children.
Blood donation can lead to HIV infection.
It is not good for women to ask for condoms. It shows that she is unfaithful and also does not
trust her partner.
Caring for people with HIV/AIDS is risky.
HIV will not be contracted if one has sex once or twice with anyone without a condom.
There is no risk of HIV if anal sex and oral sex happen without a condom.
HIV risk is there only for the receiver during sex, not for the inserter.
HIV will not be contracted if private parts are cleaned with Dettol immediately after sex.
If you and your partner seem healthy, then it is not necessary to know the HIV status of
either of you.
I do not require HIV testing as I have not done any such thing.
If I take any type of blood test, I can get to know HIV automatically.
HIV is transmissible via infected insects and pets.
If my HIV test returns negative the rst time, then I do not need HIV test ever again.
16
Basics of HIV and AIDS
If I have committed any mistake unknowingly that leads me to believe I could get HIV, then
I should get HIV tested as soon as possible.
HIV test is too costly.
My HIV test will come to the knowledge of everyone.
Condom reduces sexual pleasure.
Use of condom is not necessary while on ART.
Nothing will happen if ART dosage is stopped.
Use of double condom provides more safety from HIV.
HIV cannot spread if syringe is shared only once.
If I’m HIV positive, I’ll have to take dozens of pills every day.
Key Counselling Messages
Counsellors should know the basics of HIV AIDS. This will help them to educate clients
about it. This is an important part of pretest counselling. Counsellors may use visual
material like booklets/ipcharts or a drawing of a human gure to explain the details.
Ensure that the following points are explained to the clients:
HIV stands for H– Human, I - Immunodeciency, V – Virus.
This is a virus that attacks the immune system (which defends the body against
infections) and makes a person more vulnerable to other infections.
WBCs are an important part of the immune system that protect the body from external
infections by destroying bacteria, fungi and viruses that may enter the body. Thus, they
work as soldiers. HIV kills these WBCs. So, the person succumbs to various infections like
TB, severe bacterial infections, cryptococcal meningitis and cancers such as lymphomas
and Kaposi's sarcoma.
AIDS is a group of diseases which results due to HIV infection if left untreated.
AIDS stands for A-Acquired (meaning to get from someone) I - Immune (meaning body’s
defence to ght diseases or body’s resistance) D - Deciency (meaning lack of resistance or
decreased level of functioning) S - Syndrome (meaning signs and symptoms of disease).
HIV infection is life threatening if not treated.
HIV can affect anyone. There is no cure for AIDS, and it is the responsibility of each one
of us to prevent and stop HIV transmission. We should stay away from high-risk
behaviours that put us at risk of HIV infection.
Routes of transmission: Main causes of the spread are unsafe sexual intercourse
(without condom use), sharing of needles and injecting equipment, unsafe blood
transfusion (blood not tested for HIV) and vertical transmission i.e., from parent to the
child during pregnancy, during birth or through breastfeeding. Reiterate that
breastfeeding is still a safer option because there are multiple benets of breast milk.
How HIV does not spread: It does not spread through mosquito bites, social
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HANDBOOK FOR HIV & STI COUNSELLORS
interaction, by eating together, by touch or by using toilets used by HIV-infected person.
It does not spread by donating blood.
Signs and symptoms of HIV infection are swollen lymph nodes, weight loss, fever,
headache, diarrhoea and cough. Co-infections are TB, cryptococcal meningitis, severe
bacterial infections, cancers such as lymphomas and Kaposi's sarcoma, among others.
However, some clients with infection do not experience any symptoms for a
longer time. So, though the person is looking healthy she/he may be infected. So,
it is always advised to use condoms and follow safe sex practices.
Infectious uids are blood (including menstrual blood), semen, vaginal secretions, breast
milk and pre-seminal uids. Non-infectious uids are saliva, tears, sweat, faeces and
urine.
Methods of protection from HIV infection are abstaining from casual and
unprotected sex, being faithful to your partner, consistent and correct use of condoms,
obtaining blood or blood products only from licensed blood banks, ensuring the use of
disposable/disinfected injecting equipment and surgical blades, ensuring HIV test during
pregnancy and timely initiation of treatment to prevent transmission to the child.There is
a strong association between the occurrence of HIV infection and the presence of certain
STIs.
References
NACO. (2012). Refresher Training Programme for Counsellors in STI/RTI Services – Trainee's
Handouts. New Delhi, India: National AIDS Control Organization, Ministry of Health & Family
Welfare, Govt. of India. www.naco.gov.in
NACO. (2014). Induction Training Module for Counsellors Under National AIDS Control Programme:
An Integrated Training Module for ICTC, ART and STI Counsellor: Learner Manual/ Handouts. New
Delhi: National AIDS Control Organization (Basic Service Division) & GFATM-Project Saksham
(HIV/AIDS Counselling Under NACP, Tata Institute of Social Sciences, Mumbai).
NACO. (2015). National Guidelines for HIV Testing. New Delhi, India: National AIDS Control
Organization, Ministry of Health & Family Welfare, Govt. of India.
NACO. (2016). National HIV Counselling and Testing Services (HCTS) Guidelines. New Delhi, India:
National AIDS Control Organization, Ministry of Health & Family Welfare, Govt. of India.
NACO. (2020). HIV/AIDS MODULE for Ombudsman & Complaints Ofcer, National AIDS Control
Organization, Ministry of Health & Family Welfare, Govt. of India
NACO. (2019, April). NACO Brochure – Protecting Lives from HIV and AIDS: Role of Panchayat Raj
Institutions and Elected Bodies. Retrieved from
http://www.naco.gov.in:http://www.naco.gov.in/sites/default/les/Naco%20brochure%20English.p
df
NACO. (2019, April). Training Module on HIV/AIDS: Mainstreaming Cell, National AIDS Control
Organization. Retrieved from http://naco.gov.in:
http://naco.gov.in/sites/default/les/Training%20Module%20on%20HIV%20AIDS.pdf
NACO. (2021). National Guidelines for HIV Care and Treatment. New Delhi, India: National AIDS
Control Organization, Ministry of Health & Family Welfare, Govt. of India.
WHO. (2019, April). Home/News/Fact sheets/Detail/HIV/AIDS/HIV/AIDS. Retrieved from World
Health Organization: https://www.who.int/news-room/fact-sheets/detail/hiv-aids
WORDPRESS. (2019, April). Methods of Transmission. Retrieved from HIV/AIDS Raise Awareness:
https://hivnaids.wordpress.com/2016/02/23/how-to-cont
18
3 Drivers of the HIV epidemic
Determinants of health
The determinants of health are a range of social, economic and environmental factors that
determine the health status of individuals or populations. These are the conditions and
circumstances into which people are born, grow and live. Determinants of health play a role in
HIV infection and the ability of PLHIV to seek care, support and treatment.
HIV epidemic by High-risk groups
Certain populations are more vulnerable to HIV infection because of sexual practices, poverty,
physical and sexual abuse, lack of education, homelessness, stigma, addiction, violence,
untreated mental health problems, lack of employment opportunities, powerlessness, lack of
choice and lack of social support. As per the HIV sentinel surveillance (HSS), 2021 data HIV
prevalence among high-risk groups [FSWs, hijra/transgenders (H/TG), MSM, IDU, prisoners]
and bridge population [single male migrants (SMM), and long-distance truckers (LDT)]
remains very high.
Route of HIV transmission (self-reported)
Analysis of the self-reported route of HIV transmission (RoT) indicates that the HIV epidemic
in India, 2019–2020 is still primarily driven through the heterosexual route (84%). Around 6%
of the positive cases were reported to have acquired the infection through infected syringes and
needles. Rest of the transmissions are acquired through homosexual/bisexual route, parent to
child transmission, blood and blood products etc.
Factors affecting the HIV epidemic
a) Multiple Partners
Multiple sexual partnerships are a major driver of the HIV epidemic. Multiple partnerships
can be concurrent (someone initiates a new sexual relationship before a previous sexual
relationship has ended) or sequential (when a person completely stops having sex with one
partner before starting to have sex with another).
Concurrent relationships increase the number of people who are connected in a ‘sexual
network’ where new HIV infections might still be transmitted rapidly.
Counsellors should advocate during the counselling sessions that reduction in number of
sexual practices reduces the risk of HIV/STI infection. Consistent and correct use of condom
with every single partner reduces the risk of HIV/STI infection even more.
b) Substance Use
Drug use and sharing of contaminated injecting equipment/sex work has fuelled the spread
of HIV epidemic among injecting drug users (IDUs) and onwards to the general population.
Injection is the most efcient route for transmission of HIV. Later on, it can spread through
sexual transmission to spouses and other sexual partners.
Challenges and Difculties of Female Injecting Drug Users (FIDUs): Women as
IDUs have separate and more challenges than their male counterparts. These are:
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HANDBOOK FOR HIV & STI COUNSELLORS
Social factors like inequality towards providing education, healthcare and employment,
little or no power status in society or social expectations;
Biological factors like being physically less strong than men make women vulnerable to
physical violence.
Studies show that FIDUs have a higher risk of getting HIV due to sharing needles and
syringes and due to unsafe sex. Many female drug users have IDU partners, and many of
them sell sex to nance their own and their partner’s drug use. Many sex workers use
drugs in order to forget the problems in their lives.
c) Changing Pattern of Networking/Solicitation – High-risk Groups or Other At-risk
Population Operating through Virtual platform
With the advent of mobile and newer communication technologies, the patterns of sex
work have also changed and evolved. Mobile phones act as a tool for networking and
soliciting. So, there are difculties to connect with them.
Similarly, the MSM population is also using virtual platforms for solicitation, and they
are becoming all the more unreachable by the traditional peer-led approach, as they are
congregating less at physical hotspots/locations to meet sexual partners.
Less visibility of SWs and MSM in hotspots has become a challenge in the traditional
hotspot-focused peer-led outreach model.
d) Gender-Sex-Sexuality and Vulnerability to HIV
Table 3.1- Gender, Sex, Sexuality and Vulnerability to HIV
Denition It is a societal construct with roles and behaviours assigned by the society. A
of gender gender is assigned to the individual at the time of birth. Then society starts
treating them as males/females. E.g., society decides how females/males
should dress, what responsibilities they should full (such as women should
cook and take care of children and men should be the bread earners of the
family, etc.) and how they should behave. Thus, social norms are developed.
Difference Sex refers to biological make-up of a person, usually determined based on
between external and internal parts, hormones, tissues and chromosomes.
sex and Gender is a social construct. Gender roles and behaviours are assigned by
gender society and are learned rather than innate. These vary from society to
society, and at different times in history.
Why Understanding gender norms and gender inequality is essential to reduce
should we HIV risk among men, women and T/G people. Though there are similarities
understan in HIV risk factors and behaviours across genders, differences exist, and
d gender some gender groups are far more affected than others.
Gender Gender roles are not inherited. Socialization towards gender roles begins
roles early in life. Children are systematically taught gender differences. Through
institutions, society prescribes specic roles for girls and boys but values
them differently. Roles can be unlearned. Unequal value is the source of
discrimination and oppression for women and accounts for the inferior
status given to women in society.
20
Drivers of the HIV epidemic
Gender Gender identity refers to how people perceive their own gender: whether
identity they think of themselves as men, women, both or as a different gender.
and
Gender identities are not static. Individuals can change their gender
gender
expression identity throughout their lives.
Gender expression are the ways in which a person manifests masculinity,
femininity, both, or neither, through appearance.
Sexual An individual's conception of themselves
identity
Sexual A person’s actual act of having sex and/or stimulation (with a person of the
behaviour same gender or opposite gender or both or none) for pleasure
Sexual Orientation
To whom the person is attracted to romantically, emotionally, and sexually. There are various
types of sexual orientations: e.g.,heterosexual, homosexual, gay, lesbian, asexual, bisexual,
pansexual.
Types of sexual orientation
Heterosexual: An individual who is sexually attracted to people of sex other than their own
and/or who identies as being heterosexual
Homosexual: An individual who is sexually attracted to people of the same sex as their
own, and/or who identies as being homosexual
Lesbian: A woman who is sexually attracted to other women and/or identies as a lesbian
Gay: A man who is sexually attracted to other men and/or identies as gay. This term can
also be used to describe any person (man or woman) who experiences sexual attraction to
people of the same gender.
Asexual: An individual who is not sexually attracted to other individuals
Bisexual: Identity corresponding to signicant (not necessarily equal) attraction to more
than one gender
Pansexual: Similar to bisexual, sometimes used to denote identity corresponding to
attraction INDEPENDENT of gender.
Figure 3.1 - Sexuality Wheel
Sexuality SEXUALITY WHEEL
Sexuality is not about who the person has sex with, or
how often he/she has it. Sexuality is about a person’s
Body
sexual feelings, thoughts, attractions and behaviour Thoughts &
towards other people. Sexuality is diverse and personal, Feelings
and it is an important part of a person’s personality.
Discovering one’s sexuality can be a very liberating, Values & SEXUALITY
exciting and positive experience. However, Human Beliefs
sexuality = Sexual behaviour + Sexual identity + Sexual Gender
orientation.
Relationships
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HANDBOOK FOR HIV & STI COUNSELLORS
Gender-Sex-Sexuality and Vulnerability to HIV
Several norms and attitudes related to gender roles and relations have been critical in
determining an individual’s vulnerability to infection.
Physiological vulnerability: The risk of HIV transmission during sexual intercourse is
almost twice for women because women have a larger mucosal surface where micro-lesions
can occur and facilitate the transmission of HIV.
Gender norms related to sexuality: Common gender norms in our country require
women/girls or any feminine person to remain ignorant, passive, subordinate and faithful in
sexual relations. The dominant ideal of masculine behaviour and sexuality promotes men
and boys as assertive, independent and strong. These notions of gender and sexuality make
it very difcult for women/girls and men/boys to access reliable information about sexuality
and reproductive health services, openly discuss sexual matters, practise safer sex and
promote more gender-equitable relations.
Gender power equation in accessing SRH services:
Figure 3.2- Gender power Equation in accessing SRH services
Can threaten physical or emotional violence Believes husband Cannot discuss Do not know
can demand sex sexual matters with about HIV and
whether he wants how to protect
Perceives wife as Is physically
his property stronger and can Fears violence
impose himself Economic
MAN WOMEN
Is the breadwinner Condoms are dependence
Owns the house
and decision-maker not available
Is expected to Earns some money,
Condoms are produce many but is expected to
Is expected to have
not available children/wants hand this over to her
children/wants to
children
have children
Thinks condoms Believes he is not at
risk because he has Feels that using
are wasteful or Embarrassment in
regular girlfriends condoms equates her
diminish sexual procuring condoms
(ignorance) with a sex worker
pleasure in ANC
Lack of negotiation power regarding safer sex measures: Women have less
negotiation power in sexual relations.
- Promote ABCD model: A stands for abstinence, B for be faithful, C for correct and
consistent condom use and D for do not penetrate.
- Address misconceptions such as condoms reduce sexual pleasure, sex means peno-
vaginal penetration, men can get sex whenever they want, customer can decide on
anything during paid sex.
Gender-based violence (GBV) increases the possible risk of HIV infection:
- GBV is any act that results in, or is likely to result in, physical, sexual or psychological
harm or suffering that is directed against a person because of their biological sex, gender
identity or perceived adherence to socially dened norms of masculinity and femininity.
- GBV includes intimate partner violence and can be physical, sexual, emotional, economic
or structural where that violence targets someone because of their gender or non-
compliance with gender norms.
22
Drivers of the HIV epidemic
- It can be experienced by women and girls, men and boys, and transgender T/G and
intersex people of all ages and has direct consequences on health, social, nancial and
other aspects of their lives.
- GBV increases the risk of HIV infection as sexual violence can lead to HIV infection
directly and trauma increases the risk of transmission. Trauma of forced sex of any kind –
rape, dry sex or lack of readiness – with an infected partner increases the risk of
transmission, but the fear and power differentials associated with GBV also limit the
ability to negotiate safer sex.
- It increases the gender inequalities and is an important cause of ‘choice disability’.
Victims of childhood sexual abuse are more likely to be HIV positive, and to have high-
risk behaviours.
Role of migration in increasing HIV-related vulnerability
Poverty and the lack of economic opportunities often result in migration of men, women and
transgender persons in search of income and employment, which disrupts stable social and
familial relationships and exposes them to increased risk of infection. In case of transgender
people, domestic violence and familial discrimination causes them to leave their houses.
Migrant populations are often socially marginalized.
(I) Possible reasons behind migration
Poor economic situation; PLHIV migrate in fear of disclosure of their HIV status;
temporary migration of pregnant women during and after pregnancy; queer people
migrate in fear of family pressure for marriage; transgender individuals migrate after
they are thrown out of their families.
(ii) How migration enhances the risk of HIV infection
People who migrate without family due to limited home visits resorting to paid sex.
They experience loneliness. Also, there is reluctance to discuss sexual health.
Truckers are mobile by trade and engage with ying sex workers and companions.
They are untraceable due to constant travel.
Young girls migrate to cities to work as maids in households. Their chances of sexual
abuse and harassment increases because the perpetrators know the girl is needy and
stays alone.
Transgender/effeminate boys who are thrown out/disowned by their families. They may
earn money through sex work.
Among MSM and transgender transgender women, pressure to marry leads them to
migrate for work and exposes them to higher sexual risk in new locations.
(iii) How to address the issues of increasing HIV risk among migrants
Understand migration reasons and risks.
Improve outreach to overcome sexual health discussion avoidance.
Provide effective counselling for connecting to sexual health services.
Scaling up primary prevention awareness campaigns.
Link migrants to other services for motivation (e.g., entitlements, welfare schemes).
Strengthen referral system and coordination with TI agencies for tracking the cases
and connect them with Sampoorna Suraksha Kendras.
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HANDBOOK FOR HIV & STI COUNSELLORS
Key Counselling Messages
Social, economic and environmental factors impact the health status of individuals or
populations. Such determinants play a vital role in HIV infection and the ability of PLHIV to
seek care, support and treatment. Because oower socio-economic conditions, people do not
have the resources for better health. For example, it is difcult to access healthcare due to
the cost of treatment, travelling expenses, missing daily wages, not getting facilities like
leave etc. The socio-economic status impacts the level of education which leads to a lack of
awareness about health issues. They cannot afford expenses on preventive health (e.g.,
having nutritious food, boiling drinking water, etc.). Housing also plays an important role in
health. Unclean areas, lack of facilities like water and electricity and high density of
population makes the environment vulnerable to various illnesses and epidemics. The
counsellor’s role is to understand these issues and counsel while considering the clients’
situation. For instance, while talking about nutrition, the counsellor should take into
consideration what they can afford. In the rst session itself, the counsellor should gather
information about the client’s socio-economic condition. They may ask some questions like
what is the source of income, how much is the monthly/annual income, who all are there in
the family, what is the education, where do you stay etc. This will help to assess the socio-
economic status of the clients.
Gender-Sex-Sexuality and Vulnerability to HIV in social structures like marriage and
family, men have more power than women. This affects the overall health status of women.
Many women have no control over nances. Hence, healthcare access is difcult. Women
have less exposure. So, they are dependent on others to access the health facilities. As per
traditional roles, they are expected to give priority to other family members and take a
secondary role themselves. So, they tend to neglect health. Traditionally, they hardly have
any role in decision making. Because of this and social norms, they cannot make decisions in
their own life. Thus, they have less power in sex. So, it is difcult for them to negotiate for
condoms or safe sex practices
People from non-conforming gender and queers face discrimination. They do not have
social acceptance and so they hardly have any power or control over their own situation.
People with other sexualities are not accepted by society. They face a lot of stigma and
discrimination; e.g., MSM. They cannot discuss their issues in society, with family or with
healthcare providers. Their relationships are hidden, their behaviour is hidden. Thus,
access to healthcare is difcult.
Gender power dynamics affect the accessibility of treatment, support and care.
Counsellors should understand these factors when women or queers come for counselling.
Counselling for gender-based violence -Be with the client and be empathetic. Offer water and
ask them to relax. Let the client express their feelings. Ask whether they would like to
speak. However, do not force them to speak. Assess the symptoms. Send for a medical check-
up if the client is ready. Consult your medical ofcer. Refer to the trained psychologist and
legal expert for legal support.
Migration-Due to poverty, lack of resources and other reasons, people from some locations
and people from marginalized sections migrate to other places for better opportunities. The
process of migration enhances the risk of HIV infection for such populations: e.g., migrant
workers, truckers, transgenders, MSM and young girls working as maids are vulnerable and
are at high risk.
24
Drivers of the HIV epidemic
Migrants are away from home for many months. They must earn and send money to their
native place.Their living conditions are not suitable for good health. They are considered
‘outsiders’. Many a time, no awareness about health facilities, no connection with local
people, loneliness and feeling of isolation makes them vulnerable. Girls and other gender
people may experience sexual abuse because social support is not available in the new place.
Counsellors should encourage the clients to speak freely about their issues. Understand
their life challenges. Be empathetic. Provide emotional support. Show acceptance through
behaviour. Discuss various possibilities with them with reference to their problems. Do
not impose anything on them or do not blame them: e.g., “You never come on time”;
“Every time I tell you but you don’t improve!”; “Last time I told you and still you have not
understood this simple thing!” Never make such statements. Inform them that you/your
centre is there to help them. Scale up awareness programmes, strengthen outreach
services, provide a referral system and coordinate with TI agencies for tracking the cases.
Connect them with Sampoorna Suraksha Kendras. Connect them with various social
protection schemes.
References
National AIDS Control Organization (2020). Sankalak: Status of National AIDS Response (Second
edition, 2020). New Delhi: NACO, Ministry of Health and Family Welfare, Government of India.
National AIDS Control Organization (2022). Sankalak: Status of National AIDS Response (Fourth
edition, 2022). New Delhi: NACO, Ministry of Health and Family Welfare, Government of India.
Induction training module for Counsellors under National AIDS Control Programme, an Integrated
Training Module for ICTC, ART and STI counsellors, NACO-Saksham, TISS, 2014
Promoting Partner Reduction - By: Douglas Kirby, Robyn Dayton, Kelly L’Engle, and Allison Pricket,
FHI 360, 2012
https://www.itspronouncedmetrosexual.com/about/
http://centervideo.forest.usf.edu/qpi/California/toolkit/lgbtsensitivity/GenderbreadPerson.pdf
25
HANDBOOK FOR HIV & STI COUNSELLORS
The HIV and AIDS
4 (Prevention and Control) Act, 2017
Genesis of the HIV and AIDS Act
The Human Immunodeciency Virus and Acquired Immune Deciency Syndrome Bill, 2014
was passed by the Parliament the HIV and AIDS (Prevention and Control) Act came into force
from September 10, 2018. The objective of the HIV and AIDS (Prevention and Control) Act is to
prevent and control the spread of HIV and AIDS and for reinforcing the legal and human
rights of persons infected with and affected by HIV and AIDS. It also seeks to protect the rights
of healthcare providers.
Figure 1: HIV and AIDS Act timeline
Under the HIV and AIDS (Prevention and Control) Act 2017, the central government has
notied the HIV and AIDS policy for establishments, 2022 to generate awareness on HIV
and AIDS in establishments, prevent transmission of HIV infection among workers, protect
rights of those infected with and affected by HIV to ensure safe, non-stigmatized and non-
discriminating environment. This policy guides employer and worker organizations to establish
a better workplace for people affected by HIV. The Act consists of 50 sections, divided into
14 chapters.
Table 4.1 - Chapters of HIV and AIDs Act
Chapter I – Preliminary
Chapter II – Prohibition of Certain Acts
Chapter III – Informed Consent
Chapter IV – Disclosure of HIV Status
Chapter V – Obligation of Establishments
26
The HIV and AIDS (Prevention and Control) Act, 2017
Chapter VI – Anti-Retroviral Therapy and Opportunistic Infection Management for
People Living with HIV
Chapter VII - Welfare Measures by the Central Government and State Government
Chapter VIII – Safe Working Environment
Chapter IX – Promotion of Strategies for Reduction of Risk
Chapter X – Appointment of Ombudsman
Chapter XI – Special Provisions
Chapter XII – Special Procedure in Court
Chapter XIII – Penalties
Chapter XIV – Miscellaneous
Figure 4.2- Highlights of HIV and AIDS Act
What does the Act seek to provide?
Figure above shows the highlights of the Act
Important provisions of the Act (Referring to relevant sections from the Act)
(I) Address stigma and discrimination
Section 3: Prohibition of discrimination
For the purpose of this section, the denitions of ‘protected person’ and ‘discrimination’ need to
be referred to.
As per section 2 (d) of the Act, discrimination is dened as any act or omission which directly or
indirectly, expressly or by effect, immediately or over a period of time,
(i) imposes any burden, obligation, liability, disability or disadvantage on any person or
category of persons, based on one or more HIV-related grounds;
or
(ii) denies or withholds any benet, opportunity or advantage from any person or category of
persons, based on one or more HIV-related grounds.
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HANDBOOK FOR HIV & STI COUNSELLORS
As per section 2 (s) of the Act, protected person means a person who is HIV-Positive; or
ordinarily living, residing or cohabiting with a person who is HIV positive; or ordinarily
lived, resided or cohabited with a person who was HIV-positive.
Section 3 of the Act provides that no person shall discriminate against the protected
person on any ground including any of the following:
The denial of, or termination from, or unfair treatment in, employment or occupation
unless, in the case of termination, the person who is otherwise qualied, is furnished with
a copy of the written assessment of a qualied and independent healthcare provider
competent to do so that such protected person poses a signicant risk of transmission of
HIV to other persons in the workplace, or is unt to perform the duties of the job; and a
copy of a written statement by the employer stating the nature and extent of
administrative or nancial hardship for not providing them reasonable accommodation.
Section 2(t) denes reasonable accommodation as minor adjustments to a job or work that
enables an HIV-positive person who is otherwise qualied to enjoy equal benets or to
perform the essential functions of the job or work as the case may be.
iii. The denial or discontinuation of, or unfair treatment in, healthcare services, educational
establishments and services;
iv. The denial or discontinuation of, or, unfair treatment with regard to, the right of
movement, the right to reside, purchase, rent, or otherwise occupy, any property;
v. The denial of access to, removal from, or unfair treatment in, Government or private
establishment in whose care or custody a person may be
vi. The denial of, or unfair treatment in, the provision of insurance unless supported by
actuarial studies the isolation or segregation of a protected person;
vii. HIV testing as a prerequisite for obtaining employment, or accessing healthcare services
or education, or for the continuation of the same, or for accessing or using any other
service or facility.
Section 5: Informed consent for undertaking HIV test or treatment
As per section 2 (n) of the Act, informed consent means consent given by any individual or his
representative specic to a proposed intervention without any coercion, undue inuence, fraud,
mistake or misrepresentation and such consent obtained after informing such individual or his
representative, as the case may be, such information, as specied in the guidelines, relating to
risks and benets of, and alternatives to, the proposed intervention in such language and in
such manner as understood by that individual or his representative, as the case may be.
The section mandates obtaining informed consent of such person or his representative for
a) undertaking or performing an HIV test;
b) performing any medical treatment, medical interventions or research.
The informed consent for HIV test includes pre-test and post-test counselling of the person
being tested or such person’s representative.
Section 6: Informed consent not required for conducting HIV tests in certain cases
The section provides certain instances where seeking informed consent for conducting an HIV
test is not required:
28
The HIV and AIDS (Prevention and Control) Act, 2017
a) where a court determines, by an order, that the carrying out of the HIV test of any person
either as part of a medical examination or otherwise is necessary for the determination of
issues in the matter before it;
b) for procuring, processing, distribution or use of a human body or any part thereof
including tissues, blood, semen or other body uids for use in medical research or therapy:
Provided that where the test results are requested by a donor prior to donation, the donor
shall be referred to counselling and testing centre and such donor shall not be entitled to
the results of the test unless he has received post-test counselling from such centre;
c) for epidemiological or surveillance purposes where the HIV test is anonymous and is not
for the purpose of determining the HIV status of a person: Provided that persons who are
subjects of such epidemiological or surveillance studies shall be informed of the purposes
of such studies; and
d) for screening purposes in any licensed blood bank.
Section 8: Disclosure of HIV status
a) The section states that no person can be compelled to disclose their HIV status except by
the order of the court that the disclosure of such information is necessary in the interest
of justice for the determination of the issues in the matter before it;
b) It further provides that no person shall disclose or be compelled to disclose the HIV status
or any other private information of other person imparted in condence or in a duciary
relationship, except with the informed consent of that person or a representative of such
other person.
Provided that, in case of a relationship of a duciary nature, informed consent shall be
recorded in writing.
The section also discusses certain exceptions to seeking informed consent for disclosure of HIV-
related information:
a) by a healthcare provider to another healthcare provider who is involved in the care,
treatment or counselling of such person, when such disclosure is necessary to provide care
or treatment to that person;
b) by an order of a court that the disclosure of such information is necessary in the interest
of justice for the determination of issues and in the matter before it;
c) suits or legal proceedings between persons, where the disclosure of such information is
necessary in ling suits or legal proceedings or for instructing their counsel;
d) disclosure of HIV-positive status to partner of HIV-positive person;
e) if it relates to statistical or other information of a person that could not reasonably be
expected to lead to the identication of that person; and
f) to the ofcers of the central government or the state government or state AIDS Control
Society of the concerned state government, as the case may be for the purposes of
monitoring, evaluation or supervision.
Section 9: Disclosure of HIV-positive status to partner of HIV-positive person
(1) No healthcare provider, except a physician or a counsellor, shall disclose the HIV-positive
status of a person to his or her partner.
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HANDBOOK FOR HIV & STI COUNSELLORS
(2) A healthcare provider, who is a physician or counsellor, may disclose the HIV-positive
status of a person under his direct care to his or her partner, if such healthcare provider
a) reasonably believes that the partner is at the signicant risk of transmission of HIV
from such person; and
b) such HIV-positive person has been counselled to inform such partner; and
c) is satised that the HIV-positive person will not inform such partner; and
d) has informed the HIV-positive person of the intention to disclose the HIV-positive
status to such partner:
Provided that disclosure under this sub-section to the partner shall be made in person
after counselling;
Provided further that such healthcare provider shall have no obligation to identify or
locate the partner of an HIV-positive person: Provided also that such healthcare provider
shall not inform the partner of a woman where there is a reasonable apprehension that
such information may result in violence, abandonment or actions which may have a
severe negative effect on the physical or mental health or safety of such woman, her
children, her relatives or someone who is close to her.
(3) The healthcare provider under sub-section (1) shall not be liable for any criminal or civil
action for any disclosure or non-disclosure of condential HIV-related information made
to a partner under this section.
Section 22: Strategies for reduction of risk
Any strategy or mechanism or technique adopted or implemented for reducing the risk of HIV
transmission, or any act pursuant thereto, as carried out by persons, establishments or
organizations in the manner as may be specied in the guidelines issued by the Central
Government shall not be restricted or prohibited in any manner, and shall not amount to a
criminal offence or attract civil liability.
‘Strategies for reducing risk of HIV transmission’ means promoting actions or practices that
minimize a person’s risk of exposure to HIV or mitigate the adverse impacts related to HIV or
AIDS including
(i) the provision of information, education and counselling services relating to prevention of
HIV and safe practices;
(ii) the provision and use of safer sex tools, including condoms;
(iii) drug substitution and drug maintenance; and
(iv) the provision of comprehensive injection safety requirements.
(ii) Provide free diagnostic facilities and ART to PLHIV
Section 14: Anti-retroviral Therapy and Opportunistic Infection Management by
Central Government and State Government
The Central Government and the State Government shall provide, as far as possible, diagnostic
facilities relating to HIV or AIDS, Anti-retroviral Therapy and Opportunistic Infection
Management to people living with HIV or AIDS.
Section 15: Welfare Measures by Central Government and State Government
The Central Government and the State Government shall take measures to facilitate better
access to welfare schemes to persons infected or affected by HIV or AIDS.
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The HIV and AIDS (Prevention and Control) Act, 2017
Section 19 and 20: Promote safe workplace in healthcare settings to prevent
occupational exposure.
Every establishment, engaged in the healthcare services and every such other establishment
where there is a signicant risk of occupational exposure to HIV, shall ensuring safe working
environment to provide in accordance with the guidelines and inform or educate all persons
working in the establishment of the availability of Universal Precautions and Post Exposure
Prophylaxis,
(a) Universal Precautions to all persons working in such establishment who may be
occupationally exposed to HIV; and
(b) training for the use of such Universal Precautions.
(c) Post Exposure Prophylaxis to all persons working in such establishment who may be
occupationally exposed to HIV or AIDS; and
This is applicable on healthcare establishments consisting of 20 or more persons.
Grievance redressal mechanism
Complaints Ofcer (Section 21): All establishments consisting of 100 or more persons (in
the case of healthcare establishments, consisting of 20 or more persons) shall designate a
Complaints Ofcer, whether as an employee or ofcer, member, director or trustee or
manager, every person, who is in charge of an establishment for the conduct of the activities
of such establishment, shall ensure compliance of the provisions of this Act.
Ombudsman (Section 23,24,25,26)
(a) Appointment of Ombudsman: Every state government shall appoint one more
Ombudsman possessing such qualication and experience as may be prescribed or
designate any of its ofcer not below such rank, as may be prescribed, by state
government.
(b) Powers of Ombudsman: The Ombudsman shall, upon a complaint made by any
person, inquire into the violations of the provisions of this Act, in relation to acts of
discrimination mentioned in section 3 and providing of healthcare services by any
person, in such manner as may be prescribed by the state government.
1) The ombudsman should carry all the processes as per the legal framework.
2) All records should be maintained as mentioned in the legal document.
3) All complaints shall be made to the Ombudsman in writing in accordance with the
form as specied in respective state rules. Provided that where a complaint cannot
be made in writing, the Ombudsman shall render all reasonable assistance to the
complainant to reduce the complaint in writing.
Orders of Ombudsman
4) The Ombudsman shall pass order within a period of 30 days of the receipt of the
complaint, and after giving an opportunity of being heard to the parties.
5) In cases of medical emergency of HIV positive persons, the Ombudsman shall pass
such order as soon as possible, preferably within 24 hours of the receipt of the
complaint.
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HANDBOOK FOR HIV & STI COUNSELLORS
Guardianship (section 32)
A person below the age of 18 but not below 12 years, who has sufcient maturity of
understanding and who is managing the affairs of his family affected by HIV and AIDS, shall
be competent to act as guardian of other sibling below the age of 18 years for admission to
educational establishments, care and protection, treatment, operating bank accounts,
managing property.
Condentiality and use of pseudonyms
The Complaints Ofcer shall, if requested by a protected person who is part of any complaint,
ensure the protection of the identity of the protected person.
Key Messages
It is important for the Counsellors to be familiar with the provisions of the HIV and AIDS
Prevention and Control Act (2017) which came into force with the purpose to control the
spread of HIV and to mitigate discrimination against PLHIV in work and social, medical
and nancial settings.
References:
The Human Immunodeciency Virus and Acquired Immune Deciency Syndrome (Prevention and
Control) Act, 2017 NO. 16 OF 2017 [20 April, 2017.]
The HIV & AIDS Policy for Establishments, 2022, NACO
Annexures - placed at the end of the handbook
Annexure 1 - HIV/AIDS Act English
Annexure 2 - HIV/AIDS Act Hindi
Annexure 3 - Gazette notication HIV/AIDS Act
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Introduction to Prevention Programme
5 under NACP
Targeted Intervention (TI) projects and Link Worker Schemes (LWS) are the major prevention
interventions under the National AIDS Control Programme (NACP). These interventions focus
primarily on providing services to the high-risk groups (HRGs) and bridge populations who are
at risk of acquiring HIV/STI infections. HRGs include female sex workers (FSW), men who
have sex with men (MSM), injecting drug users (IDU) and hijra/transgender (H/TG) people
whereas migrants and truckers are covered as a proxy of bridge population. The projects are
implemented in dened geographies through a peer-led, outreach-based service delivery model
in partnership with non-governmental organizations (NGOs) and community-based
organizations (CBOs) contracted through State AIDS Control Societies (SACS) under the social
contracting mechanism of NACP.
These programmes help the HRGs and the vulnerable population to reduce the harm
associated with their behaviours such as sex work and injecting drug use, improve the quality
of life, reach the overall goal of NACP and reduce the infections.
Table 5.1 - Groups covered by TI programmes
High-risk Groups Bridge Populations
Sex workers (Sws) Migrants
Men who have sex with men (MSM) Transport workers
Injecting drug users (IDUs) including female injecting Other vulnerable population
drug users (FIDUs)
Hijras and transgender people (H/TG)
Prison population*
* It may be noted that ‘Prison population’ consists of other groups of HRGs covered under NACP. The modalities of
service delivery for prison population are different from TI projects. Prison intervention is an SACS-owned activity
which is in close collaboration with state home department, prison authorities and the partners engaged under the
programme.
Importance of Counselling in Prevention Programmes
Prevention is the rst purpose of HIV counselling.
It decides whether the clients’ lifestyle puts them at higher risk and helps clients to
recognize and distinguish their high-risk behaviours.
It allows people to make informed choices about their future practices and behaviours.
It enhances their ability to reduce their risk of acquiring or transmitting the infection to
others.
It enhances behavioural change.
HIV counselling and testing service is a key entry point to prevention of HIV infection and
to treatment and care of people infected with HIV.
After the test, if a person is HIV negative, the counselling provides information and
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HANDBOOK FOR HIV & STI COUNSELLORS
material that can help them remain HIV negative.
It supports the HRGs and at-risk populations to access accurate information about HIV
prevention and care, thereby reducing the risk of acquiring the infection.
It provides information on spouse/sexual partner testing.
It helps with symptomatic screening for STIs/RTIs.
High-risk Groups
(i) Sex Workers
Sex worker is a gender-neutral term which covers adult men/women/hijra/transgender
people who are into sex work. For the purpose of TIs, an FSW is an adult woman who
engages in consensual sex for money or payment in kind as her principal means of
livelihood. In any given geography, sex workers are not a homogeneous group.
FSW can be categorized into various sub-categories based on where they work and more
specically where they recruit or solicit clients and not where they live or entertain the
clients.
The major typologies of FSW in India are street-based, brothel-based, lodge-based, dhaba-
based, home-based, highway-based and mobile/virtual space-based.
The higher risk faced by the SWs is reected in a substantially higher prevalence of HIV
among them than in the general population.
SWs have multiple sexual partners concurrently. Generally, full-time SWs have at least one
client per day, or at least 30 clients per month, and nearly 400 per year. Some SWs have
more clients than others, having several clients per day and 100 or more clients in a month.
As in Sankalak 2022, while the overall adult prevalence remains low (0.21% in 2021), HIV
prevalence among HRGs remains very high. HIV prevalence among Sex Workers (FSW) is
nine times of the overall adult prevalence.
Table 5.2- Sex Workers (SWs): Issues, Risk behaviours and Vulnerability factors
Specic Issues of SWs Risk Vulnerability Factors
Behaviours
A high number of Unprotected Lack of knowledge and poor risk
sexual partners sex: vaginal, perception
Unsafe sex and high anal and oral Exposure to violence from clients
rates of STIs Entertain clients in unknown locations
Regular partners, Lack of immediate support mechanisms
lovers, spouse and Chances of unwanted multiple partners
children during mobile/virtual-based sex
Alcohol or injecting Forced sex without condom use
drug use
Unwanted pregnancy
(ii) Men who have Sex with Men
The term ‘Men who have Sex with Men’ is used to denote all men who have sex with other
men as a matter of preference or practice, regardless of their sexual identity or sexual
orientation and irrespective of whether they also have sex with women or not.
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Introduction to Prevention Programme under NACP
As per the Sankalak report, 2022 (4th edition), around 3.20 lakh MSM (90% of the estimated
size) were covered under TI interventions in 2021–2022.
A total of 4.36 lakh HIV tests were done among MSM and seropositivity was 0.25%.
In 2020–2021, 93% of the HIV positives were linked to ART vis-a-vis 86% in 2021–2022.
Fluctuating HIV positivity among MSM has been an area of concern. However, ART linkage
has been constantly above 85% in the last three years, which will denitely contribute
towards the achievement of the third 95.
Table 5.3- MSM: Issues, Risk behaviours and Vulnerability factors
Specic Issues of MSM Risk Vulnerability Factors
Behaviours
Receptive or insertive anal sex Fear of exposure and therefore
Unprotected quick sexual encounters that
Multiple partners
anal and oral may be high risk
Unsafe sex and high rates of sex
Unavailability of condoms at
STIs
urinals, parks, railway
Alcohol or injecting drug use or stations, bus stands, etc. where
abuse these quick encounters take
place
Stigma and discrimination
Exposure to violence from
Pressure to marry a female by goons
the family
(iii) Injecting Drug Users (IDUs) including Female Injecting Drug Users (FIDUs)
HIV is highly transmissible among IDUs and FIDUs by sharing used needles and other
injecting equipment. HIV spreads very quickly due to the unsafe practice.
Some IDUs also engage in sex work, due to which the vulnerability increases of the IDUs
and FIDUs especially which can quickly link HIV transmission in the IDUs networks.
FIDUs face more challenges than their male counterparts. Many female drug users have
IDU partners, and many of them sell sex to nance their own and their partner’s drug use.
Apart from all the vulnerabilities that exist for IDUs, getting engaged in unsafe sex work
expose them to HIV and STI infections and violence too.
Table 5.4 - IDUs and FIDUs: Issues, Risk behaviours and Vulnerability factors
Specic Issues of IDUs and Risk Vulnerability
FIDUs Behaviours Factors
Unsafe injecting practices Sharing of Lack of nancial resources to
Sharing of needles and equipment needles/syring get new needles/syringes for
with peers es each encounter
FIDUs taking care of IDU Unprotected Drug-induced state leading to
partners/spouses sex: vaginal, high-risk sexual behaviours
Some FIDUs are sex workers anal and oral Stigma faced from society,
sex family members
Legal and ethical factors create
challenges
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HANDBOOK FOR HIV & STI COUNSELLORS
(iv) Hijra/Transgender Persons
Transgender is used as an umbrella term for persons whose gender identity or expression
(feminine, masculine, other) is different from their sex (male, female) at birth. It includes
transsexuals, cross dressers, intersex persons and other gender-variant persons.
Hijras: Individuals who voluntarily seek initiation into the hijra community, whose
traditional professions are badhai (giving blessings) and chhalla (seeking alms), but due to
the prevailing socio-economic and cultural conditions, a signicant proportion of them also
practise sex work for survival. These individuals live in accordance with the hijra
community norms, customs and rituals, which may vary from region to region.
The average age of sexual encounter by TGs was estimated as 15 years. More than one-
fourth of H/TG mapped were sexually active (IBBS, 2014–15), while another 30% were
active before turning 18 years. However, the HIV programmes reached TG women and
hijras after they turned 18 years of age.
HIV seropositivity was at 0.38% and 92% of the identied positives were linked to ART centre.
Efforts are being initiated to ensure reactive H/TG people for linkage of H/TG people with
ART, and adherence to viral load suppression.
Following are the issues, risk behaviours and vulnerability factors that make the
transgender people susceptible to HIV/STI:
Table 5.5- Hijra/ Transgender persons: Issues, Risk behaviours and Vulnerability factors
Specic Issues of Risk Vulnerability Factors
Hijra/Transgender People Behaviours
Receptive or insertive anal sex Unprotecte Fear of exposure and therefore
Multiple partners d anal and quick sexual encounters that
Unsafe sex and high rates of STIs oral sex may be high risk
Alcohol or injecting drug use or Unavailability of condoms at
abuse urinals, parks, railway
stations, bus stands, etc. where
Stigma and discrimination
these quick encounters take
Pressure to marry a female by the place
family
Exposure to violence from goons
Bridge Populations
The bridge population is dened as population that has potential exposure to HRG groups
(sexual and injecting) and has a propensity to transmit HIV/STI to the low-risk
population/general population. The bridge population is primarily identied as migrants,
transport workers and other vulnerable population including clients or partners of male and
female sex workers, trans-sex workers and MSM. Bridge and other vulnerable populations
(above 18 years of age) covered under the Targeted Intervention are dened as below:
(i) Migrants
India is characterized by widespread and uid migration and mobility. Hence an important
source of HIV-related vulnerability is mobility and migration. Due to change in language
and other difculties faced in other states, migrants get involved in sexual practices to
overcome their loneliness, which results in risk of HIV and STI. This reinforced by a lack of
HIV/AIDS awareness, information and social support networks at both source and
destination points, which cumulatively contribute to a migrant’s vulnerability.
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Introduction to Prevention Programme under NACP
Back home, spouses of migrants are also vulnerable to HIV if their husbands return on a
regular basis and have become infected with HIV. Some wives also have their own sexual
network during the absence of their husbands.
It is important to note that not all migrants are at equal risk of HIV. It is those men who are
part of sexual networks at their destinations – either with FSWs, MSM or transgender –
who are more prone to HIV infection. Similarly, those female migrants who take up
transactional sex at destination locations are at greater risk of HIV.
Issues specic to migrants:
Relative freedom in the new setting as well as peer pressure to experiment with new norms;
Distress migration driven by seasonal drought/disasters;
Loneliness, drudgery and long periods of separation from spouse/sexual partner;
Having disposable income, clubbed with limited choices for affordable entertainment and
recreation;
This usually means drinking and, sometimes, drugs as well as sex with SWs and other
casual sexual relationships.
Poverty (usually the reason for migrating in the rst place) makes women migrants more
vulnerable to being pushed into sex work at their destination to supplement their earnings.
Women migrants lack information and social support networks at both source and
destination points more than male migrants.
(ii) Transport Workers
Transport workers spend a considerable amount of time staying away from their home and
family members. Thus, they are more likely to engage in high-risk sexual behaviours than
short-distance truckers. They may have multiple sexual partners, including SWs, MSM and
transgender women on the highways, or have other xed partners enroute or at places where
they stop for rest or food. This results in a higher prevalence of STIs among truckers than
among the general population.
Issues specic to transport workers:
Transport workers sometimes get separated from their regular partners for extended
periods of time due to their occupation due to which they get engage with sexual networks to
full their sexual desire and long distance driving relief, consumption of alcohol/ substance
use leads to the vulnerability to HIV.
One can nd lots of highly active and easily accessible sexual networks operators along the
highways and at halt points / dhabas.
While the driver has money to access services of the sex workers, this can leave him or his
partner vulnerable to infection if his information about sexual health is minimal and they
engage in unprotected sex.
Senior truckers may use younger ones, especially cleaners, for sex. Power dynamics within
the community are such that the cleaner or younger trucker is largely helpless, and
ignorance about the risks of sex between men can lead to STIs or HIV infection.
(iii) Others vulnerable population
Any person, who is a part of sexual and injecting network of the HRG population will be
covered under the bridge population interventions. In order to reach out to this population, it is
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HANDBOOK FOR HIV & STI COUNSELLORS
important to reach out to the sexual network of HRGs in the intervention area. This includes
spouse and partners of PLHIV. Snow balling technique or social networking model is to be used
to reach out to these populations. Outreach micro plan should be prepared considering the
availability of the population to optimize access to services by them.
Prisoners
People living in prisons are particularly vulnerable to increased risk of HIV infection. Low
access to preventive and care services, overcrowding and poor prison conditions, neglect and
denial, gang violence and lack of protection for younger inmates signicantly increase the
vulnerability of prison inmates to HIV transmission. Prison conditions can enhance the spread
of TB due to overcrowding, poor ventilation, poor nutrition and inadequate or inaccessible
medical care, among others. Over-representation of key populations contributes to making the
settings a high-risk environment for HIV transmission.
The prevention packages provided to the prison population includes the following:
HIV testing and counselling
Care support treatment for PLHIV
Prevention, diagnosis and treatment for TB
Elimination of vertical transmission of HIV/Syphilis
Prevention and treatment of STIs
Drug dependence treatment including opioid substitution therapy (OST)
Referral or diagnosis of viral hepatitis
Raising awareness on HIV transmission through medical or dental services
Raising awareness on HIV transmission through tattooing, piercing and other forms of skin
penetration
Counselling/IPC (individual and group)
Issues specic to prison population:
Lifestyle of many inmates prior to incarceration includes unprotected sexual intercourse,
drug and alcohol abuse, poverty, homelessness, under-education and unemployment, all of
which are associated with risk of HIV/AIDS.
Drug users are often over-represented in prison populations, usually incarcerated for drug-
related crimes, and may continue to use drugs during their incarceration (United Nations
Ofce on Drugs and Crime; UNODC).
Frequent sharing of contaminated drug injection equipment is the predominant mode of
HIV transmission among prisoners.
HIV is also transmitted in prisons through unsafe sexual behaviour, sometimes associated
with sexual violence (UNODC).
High turnover of prison inmates fuels the spread of HIV and other infections such as TB.
After release, infected prisoners return to their social networks in the general community,
facilitating the spread of HIV and TB infection in the non-incarcerated community.
It may be noted that under the prison intervention, other incarcerated population who are in
other closed settings like Swadhar, Ujjala homes and other state-run homes are also covered
under the programme.
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Introduction to Prevention Programme under NACP
Key components of Tis
Behaviour change communication
Clinical services
Referrals & linkages
Provision of commodities
Enabling environment
Community mobilization
Table 5.6 - Key Components of TIs
Behaviour It includes development of context-specic strategies/activities to
change address the risk of infection through peer counselling and creating an
communication enabling environment to reinforce safer practices:
Interpersonal communication (IPC) by peer educators (PEs) and
outreach workers (ORWs)
Counselling for behavioural change
Field-level events/melas
Awareness generation workshops
Training on condom usage, negotiation skills and usage of needles
(IDUS only)
Multimedia advertisements
Use of social behaviour change communication (SBCC) materials
National toll-free helpline
Clinical Syndromic case management for STIs
services Regular medical check-ups
Community-based screening for HIV
Opioid substitution therapy (OST)
Abscess management
Referrals & Integrated counselling and testing centres (ICTCs)
linkages Anti-retroviral therapy (ART) centres
DSRC, Preferred Providers
TB centres
Screening and treatment for Hepatitis B/Hepatitis C
Other referrals as per the demand of the community
Provision of Free condom and lubricant distribution
commodities Social marketing of condoms
Clean needle/syringe exchange (IDUs only)
TIs ensure safer practices by providing choices and options of easy
accessibility, availability and acceptability
Enabling Creation of an environment that facilitates easier access to
environment information, services and commodities by the HRGs
Community Reach out to the community through ORWs and PEs
Mobilization Capacity building of communities to own the TI programme
Strengthening community systems
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HANDBOOK FOR HIV & STI COUNSELLORS
The Revamped TI strategy:
Table 5.7: Recommended strategy for core populations
Principal components Sub-components Purpose
Programmatic mapping To estimate the sizes of HRGs
and population size
estimation (p-MPSE)
Community outreach Strengthen outreach To increase coverage and cover HRGs by
activities reaching out to the sexual and social
networks of HRGs
Service delivery Differentiated To optimize human and nancial
prevention resources, decongest TIs and provide a
client-centred package of services
Navigation To improve linkages and adherence to
ART and ensure viral-load monitoring
Index testing To test spouses and sexual/injecting
partners of all PLHIV and biological
children
Community-based To test at-risk populations living in hard-
screening to-reach and unreached locations
Commodity distribution Secondary To improve access to needle and syringe
distribution of exchange
needles and syringes
Satellite OST centres To improve access and adherence to OST
Community-based To improve ART adherence through
ART dispensing decentralized care
Community systems Community To seek feedback from beneciary
strengthening scorecards communities to continuously improve the
quality of TI services
Other strategies
a) Reaching out to Female IDUs: Includes the single-window approach for providing
needles and syringes, condom, screening for HIV/Syphilis, OST, the collocation of ART
dispensation by TI, referrals and treatment of hepatitis B and C, TB etc. Strategies also
include formation of self-help/support groups, linkages to mental health services, social
protection schemes and provision of legal aid services. Their specic additional needs
should be recognized.
b) Spouses and female partners of IDUS: Active involvement of female spouses and
partners will enhance service uptake, regular clinical check-up, treatment adherence, etc.
among the IDUs.
c) Dera/gharana/jamath-based services: These services are for reaching the hard-to-
reach/unreachedtransgenders women where there is a strong network of dera/gharana/
jamath leaders.
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Introduction to Prevention Programme under NACP
d) Event-based services: This strategy is for identifying new transgender women/ hijras who
are not part of the existing TI. It proposes to recruit community mobilizers to mobilize
HRGs to avail HIV prevention services. Considering the geographical location of the
districts wherein the H/TG people are scattered, it establishes leadership, smart outreach,
community-based testing, mobilizing them through cultural events combined with different
outreach approaches, leaders’ messages etc.
Link Workers Scheme(LWS)
LWS is implemented to cover HRGs and other vulnerable populations (antenatal mothers,
spouses and partners of HRGs, migrants and truckers, youth, people with TB and PLHIV) in
rural areas. This scheme envisages the creation of demand for various HIV/AIDS-related
services, linking the target population to existing services, creation of an enabling and stigma-
free environment, increasing access to information and services by linking them to other
departments/programmes through ASHA volunteers, Anganwadi Workers, Panchayat heads,
etc. It may be noted that the scheme itself does not create any service delivery points.
The services provided to the beneciaries under LWS primarily considered three components:
Behavioural, biomedical and structural.
Major activities conducted are as follows:
Interventions at rural hotspots/congregation points;
Referral and linkages with services delivery points like ICTC /FICTC /DOTS / ART Centre/
DSRC etc.
Mid media/mass media activities;
Conducting health camps;
Promoting volunteers/ volunteerism;
Social marketing of condoms.
For more information on the LWS, please refer to the “Link Workers Scheme Operational
Guidelines”, TI Division, developed in April 2015.
Opioid Substitution Therapy (OST) for IDUs/ PWID/PWID
OST is provided as a key harm reduction strategy to prevent HIV infections among PWIDs
under NACP. The OST service involves treating opioid-dependent PWIDs with a long-acting
opioid agonist medication for an extended duration of time through the sublingual route, which
effectively minimizes craving and withdrawals, and thereby enables the PWIDs to stop
injecting drugs. NACP provides OST primarily as a ‘Directly Observed Treatment’ in a clinic-
based setting known as OST Centre under the supervision of a Medical Ofcer.
There is also a provision for take-home dosage for clinically stable clients satisfying all the
criteria provided. The OST programme is provided through three models: the collaborative
model at public health facilities, the NGO-based model provided at TI NGOs and the satellite
model which includes prison and closed settings.
Communication activities under NACP
Communication activities are directed towards enhancing awareness and knowledge levels
among general population to promote safe behaviour, generating demand for services,
motivating and sustaining behaviour change in a cross section of populations at risk and
strengthening enabling environment.
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HANDBOOK FOR HIV & STI COUNSELLORS
Following communication activities are conducted under NACP:
Mass Media
Television and radio campaign
Cinema theatre
Effective use of social media through Facebook, Twitter, Instagram, YouTube, etc.
Mid Media
Posters, hoardings, public displays, bus panels etc.
National folk media campaign
Special events on World AIDS Day, International Youth Day, NVD, WBDD, NVBD
On Ground Mobilization and Interpersonal Communication (Youth Interventions)
Adolescent Education Programme in more than 54,000 schools
Red Ribbon Clubs in more than 13,000 colleges
Out of school youth/college at state level
Flagship Initiatives
National Toll-Free AIDS Helpline1097
North East Campaign in all eight states
National Toll-Free AIDS Helpline1097
National Toll-Free AIDS Helpline 1097 was launched on
the occasion of World AIDS Day on 1 December 2014.
1097 is a 24x7 toll-free service run by NACO for use by
the general public and key populations. The short code
1097 can be dialled and reached from any
mobile/landline across India. The helpline currently
offers call support in 16 languages: Hindi, English,
Punjabi, Gujarati, Bengali, Assamese, Odia, Telugu,
Tamil, Kannada, Malayalam, Marathi, Mizo, Manipuri,
Khasi and Nagamese.
Services offered by 1097 helpline are information, counselling, referral and feedback/
grievances redressal.
Key Messages
I. Targeted Intervention (TI) is the prevention programme being implemented under
NACP. This is an approach where evidence-based systematic interventions are
implemented for specic target groups who are at high risk of HIV.
ii. The HRGs covered by TI are SW, MSM, PWID, Transgenders/Hijras s and prisoners. The
bridge population groups covered are truckers, migrants and other vulnerable
populations.
iii. The main principle for the revised and revamped TI strategy was a differentiated
approach to prevention that cautions against following a one-size-ts-all approach while
carefully segmenting the key populations to enhance an emphasis on risk and
vulnerability that would help mitigate the transmission of HIV with greater impact.
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Introduction to Prevention Programme under NACP
iv. Counselling is an essential part of prevention strategies. It helps people to get support
and allows them to make informed choices about their future practices and behaviours.
It enhances their ability to reduce their risk of acquiring or transmitting the infection to
others. It enhances behavioural change. It supports the HRGs and at-risk populations to
access accurate information about HIV prevention and care, thereby reducing the risk of
acquiring the infection. Following points should be considered while counselling:
a) Understand the marginalization: All HRGs face stigma and discrimination, even
violence, from the family and society. They are criminalized. Many are rejected by
family and community. They face many challenges in getting their fundamental
rights including healthcare.
b) Counsellors should use all basic counselling skills effectively while counselling HRGs:
Listen to their story. Do not just talk about HIV risk and infection. Make use of
empathy, reection and paraphrasing as much as possible. Express unconditional
acceptance. This is very important because they are facing rejection, and this will
help you to establish a rapport with them.
c) Understand the factors making them vulnerable: E.g., MSM hide their sexuality and
have sexual encounters at unsafe places like urinals; a new and young sex worker
may not have any say in demanding the use of condoms; a TG thrown out of the
house after their identity is disclosed.
d) Ensure support while making referrals. Personally talk with the stakeholders and
sensitize them.
e) Involve peer educators wherever possible. Get the support of the NGO.
f) Ensure condentiality, especially while making referrals.
g) Community-based and outreach services are important for the groups while
considering various challenges they face to access health services.
h) Make a list of the top priority issues of the HRGs and plan for the interventions.
Bridge population – Adapt same counselling strategies as above.
It is important to understand the feeling of loneliness among migrant workers and
the fatigue and stress of transport workers. The issues which make them
vulnerable should be addressed in counselling.
Support should be provided through counselling to address the barriers in
accessing the services.
Index testing is a highly recommended strategy to increase the reach and testing
coverage of sexual partners, spouses, social and injecting networks of the index
client
Community-based screening (CBS) is important for improving early diagnosis,
reaching rst-time testers and people who seldom use clinical services.
Link workers scheme LWS is implemented to cover HRGs and other vulnerable
population in rural areas. The services provided under the scheme primarily cover
behavioural, biomedical and structural components of the services being provided.
National Toll-Free AIDS Helpline1097 provides support in counselling, referral,
feedback or grievance redressal and any general information related to HIV/AIDS
in 16 Indian languages.
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HANDBOOK FOR HIV & STI COUNSELLORS
References
Strategy document titled National AIDS and STD Control Programme Phase-V (2021–2026).
Sankalak: Status of National AIDS Response (2022), NACO
Induction training module for Counsellors under National AIDS Control Programme, an Integrated
Training Module for ICTC, ART and STI counsellors, 2014
Revamped and Revised Elements of Targeted Intervention for HIV Prevention and Care Continuum
among Core Population, Strategy Document, NACO,2019
Operational Guidelines on HIV/STI/TB and Hepatitis Interventions in Prison and Other Closed
Settings, NACO, 2023
White paper on comprehensive health-related services for transgender persons, NACO, MoHFW, 2022
National AIDS Control Organisation (2020). Programmatic Mapping and Population Size Estimation
(p-MPSE) of High-Risk Groups: Operational Manual, New Delhi: NACO, Ministry of Health and
Family Welfare, Govt. of India.
Link Workers Scheme Operational Guidelines, TI Division, April 2015
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6 Substance Use in the Context of HIV/AIDS
Different denitions and terminologies have been used for categorizing the population of drug
users. The following terms are used universally to refer to the population of drug/substance
users.
Table 6.1 - Terms used to refer population of drug/ substance users
PWUD The term ‘people who use drugs’ is accepted to denote the population of drug
users who have used any psychoactive substance for non-medical or
recreational purpose through any route of intake.
PWID/IDU The term refers to people who inject drugs and injecting drugs users, which
are used interchangeably. Both refer to any person who has used any
psychoactive substance through the injecting route for non-medical purposes.
FIDU The term refers to female injecting drug users who have used any
psychoactive substance through the injecting route for non-medical purpose.
In general, the term PWID/IDU is inclusive of all injecting drug users
regardless of gender or sexual orientation and can also be used to denote all
injecting drug users.
The National AIDS Control Programme (NACP) denes a PWID as “People with injecting
drugs (PWID) are persons who have used any psychoactive substance through the
injecting route for non-medical purposes at least once in the last three months.” The
terms PWID and IDU are used interchangeably in many references and refer to the same
populations.
Basic Concepts in Understanding Substance Use
Drugs/Psychoactive substance: Any substance that when taken by a person modies
perception, mood, cognition, behaviour or motor functions. This denition includes legal and
illegal substances that can lead to dependence.
The majority of drugs/psychoactive substances can be broadly classied into eight categories as
alcohol, opioids, cannabis, sedative-hypnotics, cocaine and other stimulants, hallucinogens,
tobacco and volatile solvents.
Concepts in Substance Use/Addiction
Table 6.2 - Concepts used in substance use / addiction
Use The ingestion of alcohol or other drugs without the experience of any
negative consequences. E.g. If a student had drunk one beer at a party and
his parents had not found out, we could say he had USED alcohol.
Misuse When a person experiences negative consequence from the use of alcohol or
other drugs, it is clearly misuse. E.g. A 40-year-old man uses alcohol
occasionally; his boss throws a party, the man drinks more than usual and on
the way home he is arrested by police.
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HANDBOOK FOR HIV & STI COUNSELLORS
Abuse/ Maladaptive pattern of use resulting in physical, social, legal harm and
Harmful continued use in spite of negative consequences. E.g. The same 40-year-
Use old man continues drinking alcohol after the incident.
Dependence Dependence or addiction is said to have occurred when the following
symptoms are manifested. These criteria are important for determining
treatment goals and suitability to the different services such as opioid
substitution therapy or acute withdrawal management/detoxication.
Dependence criteria are as follows:
Drug taken in larger amounts or over a longer period;
Persistent desire or unsuccessful efforts to cut down;
A great deal of time is spent in obtaining the drug, using the drugand recovering from its
effects.
Important social, occupational or recreational activities given up or reduced;
Continued use despite harm;
Tolerance;
Withdrawal.
Common Progression Pattern of substance use
In general, the progression of substance use follows a common pattern from experimentation
with less dependence producing a more socially acceptable substance such as tobacco, alcohol
or cannabis to more dependence producing illicit and harmful forms of substances. The role of
the counsellor is to understand at what stage the patient is in and determine the appropriate
messages accordingly.
Drugs Commonly Injected by PWIDs in India
A vast majority of PWID in India use opioids and opioid derivatives from the poppy plant
(Papaver Somniferum) as their primary drug of choice. These opioids include heroin (pure, or
the impure smack or brown sugar) as well as pharmaceutical opioids such as buprenorphine,
pentazocine and dextropropoxyphene. The opioids may be injected either alone or in
combination with other substances including benzodiazepines such as diazepam, or
antihistamines such as chlorpheniramine1 or promethazine. The other substances are
combined with opioids to enhance the pleasure of opioids or due to some perceptions existing
among PWID regarding their positive effects.
Risk and VulnerabilitiesAssociated with Injecting Drug Use
A person who injects drugs faces multiple risks and vulnerabilities due to the cycle of daily
drug habit. The role of the counsellor is to help them understand the risks that they face, the
resultant harms and counsel them in reducing those risks.
The risks are encountered at multiple stages:
At the time of procuring of illicit drugs;
Obtaining money for procurement of drugs;
Drug intake through unsafe injecting practices;
During intoxication;
During withdrawals faced when the effect of the drug starts to wear out.
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Substance Use in the Context of HIV/AIDS
Table 6.3 - Risks and vulnerabilities associated with injecting drug use
Risk/Vulnerability Description
Injecting-related PWID are highly prone to sharing of used or infected needles,
risky behaviours syringes and other injecting paraphernalia such as cookers,
water, swabs etc. These behaviours lead to a number of clinical
complications including abscesses, blocked veins and
transmission of blood-borne viruses such as HIV and hepatitis B
and C.
An additional vulnerability among PWIDs is of ‘overdose’,which
is a potentially fatal, medical emergency.
PWID face injecting related risks due a number of reasons. The
reasons may vary from the injecting practices themselves or due
to the circumstances around injecting: peer inuence, injecting
in hazardous places, non-availability of injectable drugs, non-
availability of adequate needles/syringes and other injecting
paraphernalia andinjecting after a period of abstinence.
Sex-related risky PWID may occasionally engage in high-risk sexual behaviours
behaviours without condoms including sex with female sex workers and sex
with spouses or other sexual partners.
The FIDUs are also highly vulnerable to engage in unsafe sex in
exchange for drugs or money.
These behaviours put PWIDs at high risk of acquiring and
transmitting HIV, hepatitis B and C as well as other STIs.
Drug-related Aside from the physical complications discussed above, PWIDs
vulnerabilities also suffer from various psychological, legal, social and nancial
harms resulting from injecting drug use.
They might get into trouble with law enforcement agencies and
get arrested for possession of illicit drugs; they might commit
theft to pay for their drug habit and get arrested; they might
develop marital/family problems, become ostracised by their
family and society and be rendered homeless.
They might lose their employment and have nancial problems
as their daily life is now preoccupied with the drug habit.
Chronic abuse of drugs can affect their mental faculties.
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HANDBOOK FOR HIV & STI COUNSELLORS
Harms Associated with Injecting Drug Use
An injecting drug user faces multiple risks on a daily basis due to his drug habit leading to
various harms that manifest as physical, occupational or nancial harms, family or social
harms, psychological harms and legal harms as given in Table 6.1.
Table 6.4 - Harms associated with injecting drug use
Physical harms Infections; poor nutrition, debility, weight loss, overdose,
death
Occupational / Absenteeism from work, frequent changes of job, loss of job;
nancial harms losses suffered/debts incurred
Familial / Social harms Marital disharmony, separation/divorce; loss of reputation,
social outcast; stigma and discrimination
Psychological harms Guilt/Shame, lack of motivation, depression, anxiety, other
mental disorders
Legal harms Involvement in illegal activities leading to arrest or
imprisonment, drug dealing (NDPS Act)
Drug use is therefore associated with a wide variety of adverse consequences or harms across
multiple domains. These harms adversely affect not only the drug-using individual but also
their family, community, society and nation.
Drug Abuse Management Strategies
Design of policy and programmes to reduce demand, supply and reduce the harms from drug
use
Table 6.5 - Drug abuse management strategies
Approach Description
Demand reduction Primary prevention: Interventions aim at young individuals to
discourage initiation of drug use; includes awareness campaigns,
teaching life-coping skills and drug-refusal skills.
Treatment and rehabilitation: Identifying drug users, especially
those with abuse or dependence, and providing acute withdrawal
management/detoxication and psychosocial intervention and long-
term rehabilitation
Supply reduction Regulated supply of legal drugs: Along with certain regulations
of consuming alcohol, strategies like imposing duties/taxes should
be used to discourage alcohol consumption.
Total prohibition of illegal drugs: Declaring certain drugs
entirely illicit, making all related activities illegal (manufacturing,
trafcking, possession). Enforced through laws (e.g., Narcotic
Drugs and Psychotropic Substances Act 1985).
Harm reduction Policies and programmes to minimize or reduce harms resulting
from drug use without necessarily stopping drug use per se. This
strategy is based on the following universal truths:
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Substance Use in the Context of HIV/AIDS
a) While drug use cannot be eradicated completely, it is still
possible to reduce the harms arising from injecting drug use.
b) Reducing the harms is more important than stopping drug use
per se.
c) This is the most viable and pragmatic approach to drug use
based on a human rights approach.
d) This seeks to achieve realistic suboptimal objectives rather
than setting up to fail to reach utopian goals.
Harm Reduction Strategy under the National AIDS Control Program
As discussed in the previous section, to reduce the harms resulting from injecting drug use,
particularly HIV/AIDS and other blood-borne viruses, NACP has adopted the Harm Reduction
Strategy for designing and implementing the Targeted Intervention for People Who Inject
Drugs. As part of the commitment to end HIV/AIDS as a public health threat by 2030,
comprehensive harm reduction services for people who use drugs are provided under
NACP V.
Figure 6.1 - Comprehensive Harm reduction services for people who inject drugs
Needle syringe exchange programme (NSEP) including overdose
prevention and management
Opioid substitution therapy (OST)
HIV counselling, testing and ARV treatment
STI screening and treatment and condom promotion for
PWIDs and their sexual partners
Prevention, diagnosis and treatment for Tuberculosis (TB)
Vaccination, diagnosis and treatment for viral hepatitis B and C
Needle Syringe Exchange Programme
Under this programme, PWIDS are provided new/sterile needles and syringes to cover every
injecting episode in exchange for the return of the used needle syringe along with condoms as
per demand. In addition, the PWIDs are provided education on HIV, body to body virus (BBV)
and the risks of sharing injecting equipment, are taught safer injecting practices and are
counselled for HIV, HBV, HCV testing etc.
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HANDBOOK FOR HIV & STI COUNSELLORS
Goal: The goal of the needle syringe exchange programme is to ensure that every injecting act
is covered with a new needle/syringe to reduce transmission of HIV and BBVs.
Key objectives: The key objectives of the needle syringe exchange programme are as follows:
1. To facilitate safe injecting practices by
Providing sterile/new injecting equipment;
Practicing safe disposal option;
Removing contaminated needles/syringes from circulation.
2. To educate and inform PWIDs and injecting partners about safe injecting practices for
prevention of HIV transmission and other BBVs, thereby minimizing the hazardous
consequences of unsafe injection.
3. To build a rapport with the PWIDs for establishment of a line of communication that
ultimately links them with other services and assists in reduction of high-risk practices/
behaviour.
The Needle Syringe Exchange Programme (NSEP) is currently implemented at the TI NGO
facility under the NACP. The services are provided through both outreach using peer educators
from the PWID community and at the static TI drop-incentre. In general, the services under
the NSEP program include:
Table 6.6 - Services under NSEP
Information, education, Overdose prevention and management
communication HIV testing and treatment
Behaviour change communication STI screening and treatment
Commodity distribution of needle Referrals to ARTC, TB DOTs, NVHCP, NMHP
syringes and condoms facilities
Counselling Referrals to OST, detoxication and
Abscess management rehabilitation facilities
Opioid Substitution Therapy
Opioid Substitution Therapy (OST) is the second most integral component of harm reduction
services for PWIDs under the NACP. OST involves treatment of PWIDs who are dependent on
opioids with a substitution i.e., a long-acting opioid partial agonist medication administered
through the sublingual route for a prolonged duration of time under the direct supervision of a
trained medical ofcer and nurse. The philosophy of OST is to replace the illicit substance of
abuse with a safer, legal and long-acting alternative that effectively minimizes cravings and
withdrawals and enables the patient stop to injecting and lead a normal productive life.
Combined with extensive psycho-social intervention, the OST program is successful in reducing
drug-related harms including HIV/HCV transmission and in long-term treatment for opioid
dependency.
Benets of OST: The benets accrued from OST range from HIV/HBV/HCV prevention to
treatment of opioid dependence, and improvements in the well-being at the individual, family
and society levels. Some of the benets include the following:
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Substance Use in the Context of HIV/AIDS
a. Reduction in injecting behaviour (able to stop injecting);
b. Improved adherence to other treatments, especially treatment for HIV, TB and viral
hepatitis;
c. Reduction in illicit opioid use;
d. Reduced overdose-related deaths;
e. Reduction in criminality;
f. Reduction in domestic violence;
g. Improved childcare and family ties;
h. Improved productivity and gainful employment.
Models for OST dispensation under NACP
a) Collaborative model: In this model, the OST centre is located in a government healthcare
facility (medical college hospital, district hospital, sub-divisional hospital, CHC, etc.). It is a
full-edged stand-alone OST centre.
b) NGO model: In this model, The OST centre is located within an existing IDU TI project
offering the HIV prevention package such as NSEP and other clinical and outreach
services.
c) Satellite OST model: The satellite OST centre is not a stand-alone centre as the previous
two models but is basically a sub-centre (s) of the full-edged OST centres usually located
away and at a distance from the full-edged main/parent centre. The purpose of a satellite
OST centre is to (a) provide OST services to clients residing/congregating at remote
locations (more than 15–20 kms from the existing parent OST centre, clients having
difculty in access with a longer travel time, e.g., at least an hour or more) and (b) to
decongest existing OST centres having high daily client load of more than 200 so as to
ensure quality service delivery to each individual patient.
Counselling for People who Inject Drugs
This section deals with the type of assistance and counselling that can be provided at different
stages of drug use. As given in the previous sections, the counselling for people who inject
drugs is based on the principles of harm reduction, which state that complete eradication of
drug use is impossible and it is possible to systematically reduce and minimize the harms from
injecting drug use. Further, it is not necessary for the drug user to be abstinent before seeking
assistance and it is possible to offer help at each and every stage of drug use.
As shown in Fig.6.1, the counsellor can provide assistance to the drug user to reduce the risk
and harms of injecting drug use at every stage.
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HANDBOOK FOR HIV & STI COUNSELLORS
Figure 6.2 - Hierarchy of harm reduction strategy
Never start using drugs Preventive education to at-risk and
Even if using drugs, don’t inject general community
If injecting, assistance to stop Education to drug users on harms with
injecting drugs injection use including HIV, HBV, HCV,
abscess, etc.
If not able to stop injecting, don’t
share Opioid substitution therapy, medically
assisted treatment
If not in a position to stop sharing,
ensure clean equipment before Needle syringe exchange, education on
every use safe injecting practices, vein care,
abscess, overdose
Educate; provide cleaning materials,
disinfect with bleach as last resort
Figure 6.3-Risk Reduction for injecting and sexual risk behaviours
IDU Risk Reduction through Education Education on risky sexual behaviours
SAFER OPTIONS
No sex
Reduce
number
of shares One faithful partner
Continue injecting
with cleaned needles
Conditions injecting Minimum number
with sterile needles of partners
Substitution against medicines
Consistent
condom
Shift to illicit but non-injecting drugs use
Stop drug use
The counsellor is primarily and directly responsible for individual client well-being and
progress throughout the HIV prevention and treatment cascade. Behaviour change
communication is an important component in the counselling module for PWID. The role of the
counsellor is to ensure that PWID receive adequate information on HIV, BBVs and STIs, is
regularly accessing needle syringe exchange and condom services, regularly adheres to the HIV
and syphilis testing and repeat testing and maintains adherence and retention on ART if
PLHIV.
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Substance Use in the Context of HIV/AIDS
The counsellor has the following responsibilities:
Providing different forms of psychosocial counselling to NSEP clients and their
spouses/family members and their sexual partners;
Arranging referrals of clients to ICTC, ARTC, DSRC, OSTC, NTEP and NVHCP facilities;
Planning and implementation of strategies to reduce dropouts;
Making eld visits or visiting clients in the community and in the hotspots in the eld as
required.
The counsellor will be expected to cover the following topics as appropriate:
HIV and other blood-borne viruses such as viral hepatitis B and C
STIs and condom promotion
Risk reduction counselling
Safer injecting practices
Safer sex practices
Abscess prevention and management
Overdose prevention
Opioid substitution therapy
Detoxication and rehabilitation
NDPS Act Section 64, 64 A immunity
Pre- and post-test counselling
Crisis intervention and problem solving
Problem-solving skills
ART and co-morbidities
Risk Reduction Counselling for Safer Injecting
In conducting risk reduction counselling, the counsellor will explore current injecting practices
followed by the PWID client:
a. Understand the risky and safe practices;
b. Reinforce the safe practices followed;
c. Point out risky practices for modication;
d. Summarize the important practices at the end of assessment as feedback to the client.
(i) Counselling for before injecting:
a. Choose a safe place where you are not anxious as this helps in relaxing the muscles.
b. Do not inject alone; injecting in the presence of someone else will ensure availability of help.
c. Keep the immediate surroundings clean: use a clean newspaper or magazine to lay down
the injecting equipment.
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HANDBOOK FOR HIV & STI COUNSELLORS
d. Choose the smallest bore needle possible.
e. Use sterile water; if not, use cooled freshly boiled water.
f. Use an acidier such as vitamin C tablets or citric acid for dissolving brown sugar use
small doses of acidier, as large dose will injure the vein.
g. Do not heat the drug too much as doing so will cause injury to the tissue where the drug is
being injected.
h. Filters such as cotton swabs and cigarette butts are often used to lter out undissolved
particulate matters. Cigarette lter ends are preferable, as cotton swabs have loose bres
that may enter the injection.
i. Do not touch the cooker (metal cap, spoon used for mixing and heating) with needle tip, as
doing so will make the needle tip blunt.
(ii) Counselling for ‘during injecting’
a. Intravenous route is preferable to subcutaneous injection.
b. Clean the area where the drug is to be injected.
c. Best way is with plenty of soap and water.
d. If not possible, use alcohol swabs.
e. Ensure that alcohol dries off before injecting, otherwise the site will not be sterile.
f. Best area for injecting – cubital fossa (front of elbow)
g. Dangerous sites for injecting: Groin veins, neck veins, veins on the face, veins of the hand
and legs, breast veins and penile veins
h. Differentiating an artery from vein
i. Vein care techniques are tabulated below:
Table 6.7 - Vein care techniques
Rotate sites. Use the smallest size needle that you
Avoid missing the vein. can.
Avoid infections. Avoid ‘ushing’ after injecting.
Don’t inject in smaller veins. Don’t inject tablets/capsules.
Use smaller bore needle " larger bore Don’t make the tourniquet too tight.
needle will damage the vein. Hold the needle at 45-degree angle.
Tie a tourniquet that can be easily Once you hit a vein, stop further
released; do not tie the tourniquet tightly; puncture and draw some blood in vein
release tourniquet soon after the needle to conrm that it has hit the vein; the
enters the vein. blood should be dark red in colour.
Do not repeatedly push the blood back and Administer the drug slowly
forth.
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Substance Use in the Context of HIV/AIDS
(iii) Counselling after injecting
Slowly remove the needle from vein.
Immediately apply pressure on the injected site with a dry cotton swab. DO NOT use alcohol
swabs.
Apply pressure for at least one minute.
Allow time for injected vein to heal.
Use another site to inject rotate veins.
Opioid overdose
Overdose on drugs, particularly opioid overdose, is very common and can often be fatal. The
counsellor should explain the risk factors for overdose, the early warning symptoms and what
to do in case of overdose such as the administration of naloxone. Teaching the patient rst aid
for an overdose may also lead to the client helping their friends out during an overdose episode.
Refer to the handout for details of overdose management.
Table 6.8- Overdose: Symptoms, Emergency aid and Prevention counselling
Symptoms of overdose: Seemingly awake, but no response elicited on giving any stimulus
(such as calling out name), skin becomes pale in colour, body goes limp, slow pulse/no pulse,
bluish coloration of ngernails, vomiting, choking noise, shallow breathing.
Emergency aid for overdose: Emergency/rst aid should be given before medical help
arrives.
1. Shout the name and shake the person. And press the breastbone with your knuckles.
2. If the person does not respond to noise, call the emergency helpline and/or ambulance.
Put the client in recovery position. Do not leave the person alone.
3. Make sure nothing is blocking their airway, and there is nothing in the mouth. If
necessary, use your nger to get the stuff out.
4. Rescue breathing if no or slow breathing: mouth-to-mouth resuscitation
Explain to the participants that the following points need to be kept in mind during overdose
management:
Don’t leave someone who is overdosing alone, except if you absolutely must leave the area
to call for help. The person could stop breathing and die.
Don’t put the person in the bath, this could result in death.
Don’t give the person anything to drink or to induce vomiting, this could cause choking.
Do not make the person drink salt water or put salt in their mouth. This could cause
choking too.
Do not inject salt water as this is dangerous and can cause sudden death.
Counselling for preventing overdose
The client should be educatedon what the risk factors are for overdose. The client should
be made aware that reusing just after a period of abstinence of more than three days
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HANDBOOK FOR HIV & STI COUNSELLORS
would put them at the greatest risk for overdose. During abstinence, the client has lost
the tolerance to drugs, and using the same dose as before would place them at risk of an
overdose.
The client should be warned that though they are buying the heroin from the same dealer,
the purity of the sample may not be the same. This may lead to overdose.
The client should be told to take a small dose rst before taking the full dose to test
purity.
The client should be told to take injections in the presence of someone else, so that help is
readily available if something goes wrong.
The client should be educated that mixing drugs, especially other brain-depressing drugs
such as alcohol, sedatives/hypnotics, along with heroin or other opioids would place them
at a greater risk for overdose.
The client should also be educated about some myths associated with treating overdose
that would not help: inducing vomiting, drinking water, drinking coffee/tea, taking cold
showers.
The clients and their friends should be educated on the recovery position as part of rst
aid and on administration of naloxone for opioid overdose.
Counselling for Opioid Substitution Therapy
At the OST centre, the counsellor is primarily and directly responsible for individual clients’
treatment and adherence, retention and overall progress in therapy and has the following
responsibilities:
Assisting the doctor in assessment and induction of new OST clients as well as follow-
up;this includes taking case history of the new client and determining eligibility for OST.
Providing different forms of psychosocial counselling to OST clients and their spouses/family
members;
Arranging referrals of clients to ICTC, ARTC, DSRC, NTEP and NVHCP facilities;
Planning and implementation of strategies to reduce loss to follow-up in coordination with
link IDU TI;
Making home visits or visiting clients in the community and in the eld as required.
The counsellor at the OST centre will be expected to be familiar with the following topics and
techniques besides having adequate knowledge and comprehension of the technical aspects of
agonist maintenance therapy using buprenorphine and buprenorphine-naloxone. Different
techniques such as role play and simulation exercises will be used. The NACO OST Training
Manual 2021 will be used as a reference for the relevant training materials.
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Substance Use in the Context of HIV/AIDS
Table 6.9 - Techniques for counsellors for OST clients
Motivation enhancement Decision balancing, adherence counselling, supporting self-
efcacy and feedback
Psychological education Treatment modality, treatment duration and need for active
participation in treatment
Relapse prevention High-risk situations, warning signs of relapse and coping
strategies
Support/Self-Help groups Handling dropouts, benets of OST and spouse/family
counselling
Co-morbidities HIV/HBV/HCV/TB testing and treatment
Legal Provisions under Narcotic Drugs and Psychotropic Substances (NDPS)
Act, 1985
The counsellor should be familiar with certain provisions under the NDPS Act, 1985 and
provide basic information on the rights available to PWIDs in case of arrest or detention:
Table 6.10 - NDPS Act 1985
Section 4 of NDPS Act: Central Government can take measures with respect to
identication, treatment, education, after care, rehabilitation and social re-integration of
addicts.
Section 71 of NDPS Act: Gives the government power to establish centres for the
purpose outlined in Section 4 AND the power to provide narcotic drugs and psychotropic
substances to addicts registered with it. Government-funded OST centres operate within
Section 71 of NDPS Act.
PWIDs rights on arrest and detention: Right to know reason for arrest;right to inform
one person - friend, relative of your arrest;right to be taken to magistrate within 24 hours
Immunity from prosecution: If an addict is arrested with small quantity (e.g.up to
5gmsheroin or up to 100gmscharas), they can avoid prosecution if they volunteer for drug
dependence treatment at government-recognized centre. (Section 64A; added in 2001).
Have to complete treatment: If treatment is left incomplete, then sent back to court.
Key Messages
NACO denes PWID as people who have used any psychoactive substance through the
injecting route for non-medical purposes at least once in the last three months.
People inject drugs for various reasons:e.g. to enjoy the sense of detachment or euphoria,
peer pressure, family environmentor to avoid withdrawal symptoms.
Opioid dependence syndrome (ODS) is a pattern of opioid drug use in which an individual
uses opioid on a daily/almost daily basis and fulls the criteria for dependence on opioid
drugs.
Drug use problems are addressed with approaches such as supply reduction, demand
reduction and harm reduction.
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HANDBOOK FOR HIV & STI COUNSELLORS
Counsellors’ Role
Detailed risk assessment should be done. Clients may not directly inform counsellors that
they use drugs. Counsellors will have to elicit the information. Start the conversation and
use the counselling skills discussed in the previous chapters. Rapport establishment is
very important. Assure condentiality.
The funnelling approach of questioning (beginning with a broad question, then specic
question) is useful to elicit information on drug use. E.g.
“Have you ever smoked?
What have you smoked?
Have you ever sniffed any substance?
What have you sniffed?”
You may ask the following questions:
a) “Some people like to smoke, some people like to inhale substances. They may use
tobacco or sniff glue or use medical drugs in a combination form. Have you ever done
anything like this?”
b) “We know that one route for the spread of HIV is through the sharing of needles. Have
you ever had any instance where you have had to use a syringe/ needle?”
c) If the client responds “Yes”, follow up with an open-ended question: “Could you tell me
more about that please?”
Show a chart with pictures of different substances and ask clients to point to the
substances they may have tried out in their lives.
A comprehensive risk assessment will cover the following:
- Basic details: age, sex, marital status, education
- Details of drug use: type of drug, frequency and amount, mode of use, time of last
dose
- Complications with drug use: physical, legal, occupational, nancial, marital/familial,
social, psychological
- High-risk behaviour
- HIV-related knowledge and belief
- History of medical and mental illness
- Current living status
- Motivation leve
lUnderstand the factors making the PWID vulnerable:
- Stigma and discrimination, rejection from the family, society
- Criminalization
- Lack of access to support services
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Substance Use in the Context of HIV/AIDS
- Unsafe sex and needle exchange
Counsellor should assess if there is any harmful use or dependence and refer the client to
the clinician for further management. Counsellor can continue with the counselling for
behaviour change.Counselling should be provided even to the individuals who might have
just used injecting drugsonce in a while.
PWID face injecting risk due to lack of knowledge, lack of adequate time for injecting,
injecting in hazardous places, non-availability of injecting drugs, non-availability of
needles and syringes and reuse of needles and syringes. Understand these factors.
Other than acquiring HIV, faulty injecting practices increase the risk of other blood-borne
infections (Hepatitis B&C, syphilis), local skin infections, sclerosis of veins, scarring of
tissue, septicaemia, infection of internal organs and risk of injection into the artery.
Explain substance use disorders to the clients
- Make your clients aware about the harms, risks and vulnerabilities associated with
drug use.
- PWID have greater risks of acquiring HIV not only because of injecting drugs but also
having more sexual partners.
- Allow PWID to select the options available to reduce the harm and its related risks.
- Talk to the clients about the OST centres available in their area.
- Inform them that overdosing from opioid drugs is common and can be fatal.
- Explain the symptoms and management of overdose.
- Explain how drugs not only cause deterioration of health, but also create other
challenges for the family and society.
Give the information on overdose and its effects. Counsel for managing overdose.
The rst thing to do in the case of overdose management is to call the ambulance and
take the client to the emergency ward of a hospital. Naloxone is administered
immediately in cases of opioid overdose.
NSEP is provided for injecting drug users to ensure that every injecting act is covered by
a new/sterile needle-syringe and to stop any further transmission of HIV or other BBVs
by reducing sharing of used infected needle syringes.
The counsellor should accept and internalize the following facts related to injecting drug
use:
- It is not possible in a practical world to eradicate drug/intoxicant use.
- It is not required for the drug user to be abstinent before getting help.
- Not every drug user responds to counselling in the same manner and degree.
- It is possible to offer help at each and every stage of drug use as mentioned below.
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HANDBOOK FOR HIV & STI COUNSELLORS
Table 6.11- Suggestions for different scenarios related to IDUs
Client is not able to A PWID may not be able to access clean needles and syringes
stop sharing every time they want to inject. So,ask the client to be
prepared for such an eventuality and carry one set of new
needles and syringes all the time.
Client is not able to For various reasons, the client may not be in a position to
stop injecting, but is stop injecting drugs. Educate the client about the risks of
in a position to avoid sharing and reusing syringes, inform about NSEP, educate
sharing how to inject safely, explain overdose prevention and
management and offer OST if needed. Enhancement therapy
may be given to enhance the motivation of the client.
Client has stopped Clients should be motivated to remain away from injecting
injecting drug use; relapse prevention should be taught.
Counselling for Educateon risk factors of overdose.
preventing overdose
References:
NACO (2021) Clinical Practice Guidelines (Third Edition): National AIDS Control Programme,
Ministry of Health and Family Welfare, Government of India
NACO (2021) A Training Manual for Service Providers (Third Edition): Buprenorphine based Opioid
Substitution Therapy under National AIDS Control Program Third Edition Ministry of health and
Family Welfare, Government of India
NACO (2021) Standard Operating Procedure (Third Edition): Buprenorphine based Opioid
Substitution Therapy under National AIDS Control Program, Ministry of health and Family Welfare,
Government of India
NACO (2023) Guidance document on Integrated Package of Services for People who use drugs: A joint
approach of MoSJE and MoHFW, Government of India
NACO. (2011). Refresher Training Programme for ICTC Counsellors (Second Edition), Trainee's
Handouts. New Delhi, India: National AIDS Control Organization, Ministry of Health and Family
Welfare, Govt. of India.
NIDA. (2012). Drug abuse and HIV: Research Report Series. USA: National Institute on Drug Abuse,
Department of Health and Human Services, National Institute of Health.
UNODC (2011). Needle Syringe Exchange Program among injecting drug users: United Nation Ofce
on Drugs and Crime, Regional Ofce for South Asia
UNODC (2011). Counselling in Targeted Intervention for Injecting Drug Users – A facilitators manual.
United Nation Ofce on Drugs and Crime, Regional Ofce for South Asia
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7 Counselling and Testing for HIV
Knowing HIV status enables people to make informed decisions about their life in a timely
manner and adopt healthy behaviour. People who have been engaged in high-risk behaviour for
HIV or have been exposed to HIV infection should receive necessary information about
HIV/AIDS through adequate and correct counselling sessions. HIV counselling and testing
services (HCTS) provide a vital gateway to early diagnosis and linking of the clients with
preventive treatment, care and a cascade of other support services.
The benets of knowing your HIV status are listed below:
Staying HIV free: A negative HIV test result opens the door to accessing information about
the range of HIV prevention options available depending on the various risk factors to keep
the client HIV free.
Knowing the HIV-positive status earlier, starting treatment earlier: The earlier that
someone is diagnosed as living with HIV, the earlier life-saving treatment can be initiated.
The earlier HIV treatment is initiated after detection, the better the outcome.
Looking after loved ones: Early initiation of HIV treatment reduces the load of HIV virus
in a person’s blood to undetectable levels. The undetectable viral load levels in the blood
have near to zero chances of HIV transmission.
Stopping transmission to babies: A pregnant or lactating woman diagnosed with HIV
can access a range of options that ensures her and her babies’ health to prevent vertical
transmission of the infection.
Claiming the right to health: By deciding to know their HIV status, people are
empowered to make choices about their right to health.
Staying alive and well: Taking a HIV test can also provide an opportunity to screen and
test for other illnesses, such as TB, STIs, hepatitis, high blood pressure, diabetes and other
communicable and non-communicable diseases.
HIV Counselling and Testing Services (HCTS)
HIV Counselling and Testing Services HCTS continues to envisage the provision of
comprehensive services in an integrated manner, not limited to HIV testing. HCTS comprises
of the following:
Counselling (pre-test counselling, informed consent and post-test counselling);
Testing and prompt delivery of test results with embedded quality assurance;
Ensuring audio-visual privacy and condentiality;
Linkages to appropriate HIV prevention, care, support and treatment services.
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HANDBOOK FOR HIV & STI COUNSELLORS
Five Cs for HIV Testing:
Consent, which is obtained in verbal form from people undergoing testing in order to access
testing and counselling services.
Condentiality refers to the non-disclosure of discussions between the healthcare provider
and the receiver until the receiver has their own will.
Counselling is a condential dialogue between an individual and a counsellor. Its aim is to
educate people about HIV/AIDS and allows the individual to make an informed decision about
HIV testing and to comprehend the implications of the test results.
Correct diagnosis and test result: HIV testing providers should strive to provide high-quality
testing services and quality assurance mechanisms for correct diagnosis.
Connection to prevention, treatment and care services should include effective and
appropriate follow-up, including long-term prevention and treatment support.
HIV Testing
HIV infection is diagnosed largely under the programme by the detection of antibodies against
HIV in the blood of infected patients. HIV infection in any individual can be detected by
laboratory tests that demonstrate either the virus or viral products, or antibodies to the virus
in blood/serum/plasma. In children below 18 months of age, due to persistence of maternal
antibodies, diagnosis of HIV is made by PCR tests that detect HIV total nucleic acid (NACO,
2016).
What are antibodies?
The human body produces certain specic type of proteins in response to detecting some
foreign antigens (i.e., infections). These proteins are called antibodies. After HIV enters the
body, it infects CD4 type of T cells and is recognized by our immune system as ‘foreign’. In
response to this foreign invasion, our body produces antibodies. After the window period, these
antibodies are detectable through laboratory tests in our blood. When these antibodies can be
detected in someone’s blood, it is regarded as a ‘Positive HIV Test’.
What is the window period?
Window period represents the period between infection with HIV and the time when HIV
antibodies can be detected in the blood (6–12 weeks). A blood test performed during the window
period may yield a negative test result for HIV antibodies. These cases may require repeat
testing after 12 weeks (HCTS Guidelines, 2016). Therefore, it is important to know that the
person under window period remains infective and can transmit the infection to others. The
history of window period should be elicited in such patients through proper counselling and
assessing the duration of exposure. The patient in window period should be counselled about
the negative HIV test result,motivated and followed up for repeat testing after 12 weeks.
HIV tests strategies and algorithm
All testing facilities should ensure reliable, accurate and reproducible results using well-
dened strategies and diagnostic algorithms in view of the varying prevalence of HIV
infection in different populations and the availability of a variety of different diagnostick its
in the market.
HIV testing strategies should involve a logical sequence of performing two or more tests, one
after the other (serial) or simultaneously (parallel) to arrive at a conclusion on the HIV
status of a person being tested.
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Counselling and Testing for HIV
A testing algorithm with combination and sequence of specic tests that are used to full
the testing strategy should be followed.
The three principles of the HIV testing as per the programme are as follows:
- Enzyme immune assay (dot-blot), immunoltration and immunoconcentration are the
three principles for HIV testing.
- As per the recommendation of the TRG, any of the testing principles can be utilized in
sequence for conrmation of the diagnosis of HIV.
- ELISA can be used to replace the enzyme immunoassay when there is shortage or non-
availability of three rapid tests.
HIV Testing Strategies
The following strategies are to be used for HIV testing in adults and children above the age of
18 months:
Strategy 1: Blood Banks & HCTS Screening Facilities
Single Test (enzyme-linked immunosorbent assay [ELISA] or rapid)
Mandatory for screening donated blood; if found reactive, the donated blood should not be used
for transfusion/transplantation. After informed consent, the donor should be promptly referred
for conrmation of the HIV diagnosis at the nearest SA-ICTC for further conrmation and
linkage to the cascade of treatment and care services.
Strategy 2 (A): HIV Sentinel Surveillance
Two rRapidt Tests done by using two test kits
Mainly used in case of HIV sentinel surveillance where two test kits are being used. The
patient is declared HIV-negative if the rst test is non-reactive and as HIV-positive when both
tests show reactive results. When there is discordance between the two tests (rst reactive and
the second non-reactive), it is interpreted and reported as negative.
Strategy 2 (B): Clinically Symptomatic and Suspected Individuals
A patient who is clinically symptomatic and suspected to have an AIDS indicator
condition/disease should be tested at SA-ICTC twice using kits with either different
antigens or principles
The patient is declared HIV-negative if the rst test is non- reactive.
The patient is declared HIV-positive when both tests show reactive results.
When there is discordance between the rst two tests (rst reactive and the second non-
reactive), a third test is to be done. When the third test is also negative, it is reported as
negative.
When the third test is reactive, it is to be reported as indeterminate and the individual is
retested after 14–28 days.
Strategy 3: Diagnosis of Clinically Asymptomatic Individuals
Screening is done at F-ICTC/CBS/VHSND using a single rapid test kit.
If the test is found non-reactive, the individual is to be considered HIV-negative and needs
to be followed up if the patient is high risk.
If the test result is found reactive, the individual should be promptly referred for
conrmation of the diagnosis at the linked SA-ICTC and further cascade of services.
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HANDBOOK FOR HIV & STI COUNSELLORS
The type of strategy to be adopted would depend on the ultimate purpose for which HIV testing
is being carried out. One of the essential prerequisites for the use of this algorithm is that the
rst, second and third tests (A1, A2 and A3) employed are based on different serological
principles and/or use of different HIV antigens in the assay. Samples within determinate
results are to be sent to higher laboratories for conrmation.
An HIV positive person should be encouraged through counselling to share the positive test
result with his or her spouse, sexual or needle sharing partner(s) and bring the spouse or
partner for testing.
Universal precautions should be followed while handling blood and body uids – including all
secretions and excretions (serum, semen, vaginal secretions) – by all healthcare providers at all
times. The facilities should have provision of providing post-exposure prophylaxis (PEP) in case
of accidental exposure in the form of needle stick injury or spill of infected specimen.
Conrmation
In asymptomatic individuals, conrmation should be done using three rapid tests of three
different antigens or principles. The individual is considered HIV-negative if the rst test is
non- reactive and as HIV-positivewhenall three tests show reactive results.
Early Diagnosis in Children below 18 Months
HIV-1 qualitative virological assay should be used for testing at 6 weeks of age or at the
earliest opportunity there after. The testing algorithm as dened needs to be followed for
children after 6 months of age up to 18 months. Parallel antibody testing needs to be performed
followed by qualitative PCR if any of the antibody tests is positive to understand the HIV
status.
HIV Counselling and Testing Services
NACO has made signicant advances in terms of how HCTS will be offered across the country.
Facilities for HIV Counselling Testing Services
Facility-based HCTS: Facility-based HCTS (screening or conrmation) are offered to
individuals accessing healthcare facilities functioning of the institution where the HCTS
facility is located.
Community-based HCTS: Community-based screening (CBS) is an important approach
for improving early diagnosis, reaching rst-time testers and people who seldom use clinical
services, including men and adolescents in high-prevalence settings and HRG populations.
To improve HCTS access and coverage, community-based HIV screening is carried out
through various approaches such as the following:
Mobile HCTS
The main functions of this mobile SA-ICTC are to mobilize pregnant women and vulnerable
populations in the community. The mobile ICTC can also be leveraged for the promotion of IEC
for HIV/AIDS, condom and other commodity distribution, dispensation of ARV in remote areas
and OST dispensation to the peripheral areas. The mobile ICTC can be combined with the
general heath camp to provide the range of services to the people who are residing in far-ung
areas.
There are two types of mobile HCTS:
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Counselling and Testing for HIV
a) Mobile HCTS for HIV conrmatory test: A mobile SA-ICTC is a vehicle (van, boat, etc.)
with facilities to conduct HCTS and regular medical and ANC check-up.
b) Mobile HCTS for HIV screening test: As per the MoHFW/GoI decision, the existing
mobile medical units (MMU) serving hard-to-reach areas under the NHM should be
leveraged as mobile F-ICTCs, as per the prescribed norms, for conducting HIV screening
services (pre-test counselling, informed consent, HIV screening test and post-test
counselling) in addition to routine activities.
Screening by ancillary healthcare providers
To enhance the outreach and coverage of priority populations for HIV testing, the following
nursing and paramedical functionaries have been identied to be trained to conduct HIV
screening (Ref: National HIV and Counselling Testing services, guideline of 2016):
Public health nurse (PHN)
Lady health visitor (LHV)
Auxiliary nurse midwife (ANM)
Counsellor
Pharmacist
Multipurpose worker (MPW)-male
Peer educator (PE)
Outreach worker (ORW)
Other trained ancillary health cadre.
Screening for HIV by Targeted Intervention
To increase the HIV testing coverage among HRGs, screening for HIV by TI should be
implemented to ensure that HCTS are easily available and accessible to high-risk (core and
bridge) groups and priority populations. This HIV screening is undertaken by TI in the
community setting or in the TI setting with the help of staff present in the TIs.
External Quality Assurance System (EQAS)
Quality is an absolute requirement for any testing laboratory. A false-positive or false-negative
result from an HIV testing laboratory is associated with social, ethical, medical and legal
implications. The National External Quality Assurance System (EQAS) ensures quality in HIV
testing by implementing SOPs and hierarchical laboratory networks. Each SA-ICTC is linked
to an SRL, conducting retesting and panel testing for quality assurance.
Each SA-ICTC is linked to an SRL, which is responsible for mentoring and monitoring quality
at the SA-ICTC. Additionally, once in 6 months, as part of a periodic assessment of quality of
testing at the SA-ICTC, a panel of four blinded samples is sent by the linked SRL to the SA-
ICTC for testing. The SA-ICTC reports back the panel testing report to the linked SRL. In
turn, the SRL provides feedback to the SA-ICTC.
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HANDBOOK FOR HIV & STI COUNSELLORS
Key Messages
a) Knowing their HIV status enables people to make informed decisions about their
future. If the status is known, all required care can be taken. E.g. if the report is positive,
ART can be initiated. It enhances the quality of life of the client. Not doing the test
leads to many complications. If the test report is negative, precautions can be taken to
stay negative. So, counsellors should discuss the importance of HIV testing with the
clients (especially those who are reluctant to test).
b) HIV infection is diagnosed largely by the detection of antibodies against HIV in the
blood of infected people.
c) A person in the window period remains infective and can transmit the infection to
others. This is a very important point during counselling. Explain to clients that the
infection might be there but the antibodies are not found in the blood. So the test
report is negative but the person is infected. Therefore, safe sex practices should be
always followed.
d) It is recommended that HIV testing should be done using highly sensitive and specific
rapid tests in HCTS, which provide reliable and accurate results. This point also should
be explained during counselling. This will help the clients to trust the test results.
Inform the clients that three tests with different principles are done for the most
accurate results.
e) ‘Five Cs’ of HIV testing mean consent, confidentiality, counselling, correct test results
and connection (linkage to prevention, care and treatment services) – these apply to
all HIV testing services.
Consent: Informed consent must be obtained from individuals undergoing testing to
access testing and counselling services.
Confidentiality: Discussions between the healthcare provider and receiver remain
undisclosed until the receiver makes their own choice.
Counselling: Confidential dialogue between individual and counsellor to educate about
HIV/AIDS and contribute to behaviour change.
Correct test results: Striving for high-quality testing services, ensuring correct
diagnosis and test results through quality assurance
Connection to services: Linking individuals to prevention, treatment and care services,
including effective follow-up and support
f) Counsellors have a greater role in the group/individual counselling, especially at the
community-based HCTS.
g) It is important to follow the EQAS guidelines to ensure the quality of testing.
Counsellors should ensure that samples are sent for EQAS.
h) Some clients do not trust the test results because they cannot accept the fact that
they are HIV positive. The quality of the testing process should be explained to the
clients. In addition to this, emotional support should be extended.
i) In the pre-test counselling, all clients should be informed that the test quality is very
good at the HCTC.
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Counselling and Testing for HIV
References
Guidance note from the National Guidelines for HIV Testing, 2015
National HIV Counselling and Testing Services Guideline, Chapter 3 – Counselling for HIV Testing
National Operational Guideline for ART Services, NACO, 2021
National Guidelines for HIV Care and Treatment, NACO, 2021
Integrated training module for ICTC, ART, and STI Counsellors, NACO, Nov 2014
Statutory Orders and Notications Issued by the Ministries of the Government of India (Other than the
Ministry of Defence), The Gazette of India, July 9, 2022/ASADHA 18, 1944
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HANDBOOK FOR HIV & STI COUNSELLORS
8 Basic Counselling Skills
Counselling is a professional relationship between a client and a counsellor to empower the
client in dealing with issues in life and choosing the most suitable option from the available
alternatives. The counsellor facilitates the process in such a way that empowers clients to
make constructive decisions for their lives and become resilient and well-functioning
individuals. The goal of counselling is to lead the clients in making constructive changes in
beliefs, behaviour and emotional distress.
Counselling is not advice-giving. Counselling also is not Health Education.
“Counselling is a condential dialogue between an individual and a counsellor. It aims to
provide information on HIV/AIDS and bring about behaviour change in the individual. It also
enables the individual to take a decision regarding HIV testing and to understand the
implications of the test results”. (National HIV Counselling and Testing Services Guideline,
Chapter 3 – Counselling for HIV Testing).
The Basic Principles of Counselling
Table 8.1 - Counselling Principles
Principle of A counsellor accepts the client as they are and with all their
Acceptance limitations. They believe that acceptance is the crux for all help. They
do not condemn or feel hostile towards the client just because their
behaviour differs from the approved one.
Principle of No two persons are alike in all qualities and traits. Their problems
individualization may be the same but the cause of the problem, the perception towards
the problem and ego strength differs in every individual. Therefore,
each individual client should be treated as a separate entity and
complete information is required to establish close relations in order
to solve their problem from the roots.
Principle of non- The counsellor should avoid making assumptions or judgements
judgmental about the client from their appearance, profession, age or the purpose
attitude of seeking help. E.g., a client in her 60s may approach you to get
information on HIV, STI and safe sex or a healthcare professional
may approach you for help in getting rid of drug use. So, you cannot
judge them on the basis of age or profession and the reason for
seeking help. Always remember that people have the right to make
their own choices.
Principle of The counsellor should not reveal any information gathered from the
condentiality client without the client’s permission. It is important to maintain
condentiality and trust in a counselling relationship. In addition, the
counsellor should communicate clearly to the client that
condentiality/secrecy will be maintained. At all times, respect the
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Basic Counselling Skills
condentiality of what is disclosed to you. Do not fall into the trap of
gossip, which is unprofessional conduct.
Principle of The counsellor places themselves in the client’s shoes and tries to feel
empathy what they are feeling. Empathy is known to increase prosocial
(helping) behaviours.
Principle of The counsellor tries to understand the client’s feelings and emotions
controlled but does not get involved emotionally in the client’s problems. The
emotional counsellor’s over involvement will not help the client. On the
involvement contrary, if you are stable, you will be in a better position to help
them. Over-involvement is one of the causes of burnout. It is
important that you care for your own mental health.
Principle of It is the road to the identication of the client’s problem. The function
communication of the counsellor is to create an environment in which the client will
feel comfortable in expression of their feelings. Use simple language.
Do not use jargon. Use local terms.
Principle of Safe environment for the expression of feelings is the recognition that
expression of you understand them. Clients have the need to express their feelings
feelings freely without being judged, especially their negative feelings. Allow
clients to express feelings freely. Say that it is okay to cry, to feel
disappointed or angry. Never say,“Don’t cry. Things will be ne/There
is nothing so scary.”
Principle of self- Counsellors should know their own strengths and limitations. If they
awareness feel that the problems of the client are beyond their capacity, the
client should be referred to the appropriate authority. Counsellors
also should be aware of their own values, attitudes and psychological
state. They should ensure that this does not interfere in the
counselling process.
Importance of counselling in the context of HIV
Most of the HIV infections in India are through sexual transmission. Discussion on sexual
issues is considered a taboo. So, clients need a safe environment to discuss the issues.
Counselling PLHIV is important because HIV infection is lifelong.
Prevention of HIV transmission and supporting those affected directly or indirectly by HIV
are the dual aims of HIV counselling because changes in behaviour can prevent the spread
of HIV.
Through counselling, the counsellor creates awareness and prepares a person for both the
seropositive and seronegative status.
HIV/AIDS is associated with stigma and discrimination, which leads to mental health issues
of anxiety, depressed feelings, denial, anger and guilt, which a person is likely to go through
on knowing their seropositive status.
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HANDBOOK FOR HIV & STI COUNSELLORS
Table 8.1 - Qualities of a counsellor
Knowledgeable Skilful Observant Communication
Should have Should be well Should be a keen skills
knowledge of the equipped with skills observer of the Should communicate
eld and should be required for the role client’s verbal and clearly without
updated with latest to perform. Here non-verbal barriers. Use simple
information training, practice behaviours. language and terms
and feedback on the E.g.,even if the that the clients will
skills play an client is not understand. Keep
important role. speaking, can guess silence when the
their state of mind client is not
by observing. speaking anything.
However, it always It may help the
advisable to cross client to contain the
check this feelings. Non-verbal
understanding communication also
before coming to is important in
conclusions. counselling.
Ethics and values Personal integrity Organized Flexible
Should know the Should have a high Should be good at Should accept any
ethical code of degree of personal time management, new challenging
conduct of the integrity and well equipped with behaviours from the
community they credibility. Honest the skills required clients and mould
serve. Should be with self and clients. for optimal executive the session structure
aware of the values They know their functioning, record according to the
in counselling like limitations and will maintenance of needs of the client. A
condentiality, not mislead clients. cases and keeping a good counsellor does
freedom of the E.g., they refer the focus on which client not rigidly assume
individual, not clients to medical to get shifted to the diagnosis in the
imposing your own ofcers or another follow-up sessions rst few sessions.
values on the client counsellor if they do and which client’s
etc. Other important not know anything. case needs to be
values are closed.
considering the well-
being of the client
and not asking for
any information to
satisfy own
curiosity.
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Basic Counselling Skills
Open-Minded Patience Active listening Unconditional
Should have Counsellor has to They provide a positive regard
acceptance for all practice tolerance listening ear to the and non-
types of clients, because clients come client. They even judgmental
acknowledge both with various issues, read the non-verbal attitude
negative and they express various cues of the clients. Accepting all clients
positive feelings feelings even and not being biased
aggression, negative towards any specic
attitude. Still, caste, religion,
counsellors work community or clients
with them. with specic
behaviour, which is
different from social
norms.
Reection of Paraphrasing Interpretation Repeating and
feeling and The counsellor (Giving back to the summarizing
questioning attempts to give client the core issue Should help clients
Should recognize ‘feedback’ to the that they are understand
client’s feelings and client by stating the struggling with.) everything they are
let them know you essence or content of The counsellor helps told, highlighting
have understood what the client has to establish what is decisions which have
their feelings; ask just said. relevant, been made and need
open-ended emphasizing the to be acted on,
questions that allow important points. providing guidance
for more explaining. When people avoid and direction to
Help the client to go focusing on the real both, counsellor and
deeper into their problem and talk client.
problems and gain around the issue,
insight. this skill should be
used. Interpretation
goes beyond what is
explicitly expressed.
Empathy Condentiality
Counsellors try to understand the client’s Client should be informed before the start
feelings and the situation from the client’s of counselling about their right to
point of view. Being empathetic never condentiality. A counsellor guides the
means that the counsellor agrees with the client so that whatever information is
perspective of the client. It means that the shared in the session will remain
counsellor puts self in the shoes of the condential. The information shall not be
client to learn about the scenario from the shared with anyone unless there is a risk
client’s perspective. to the life of the client.
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HANDBOOK FOR HIV & STI COUNSELLORS
Points to consider while counselling high-risk groups:
Table 8.3 - Counselling high-risk groups: Points for consideration
Counselling Sex Workers Counselling PWID
Stigma and discrimination Stigma and discrimination
High number of sexual partners Unsafe injecting practices
Unsafe sex and high rates of STIs Sharing of needles and equipment with
Regular partners, lovers, spouse and peers
children Care for partners/spouses of PWID
Alcohol or injecting drug use or abuse Some female PWID are sex workers.
Unwanted pregnancy and EVTHS Legal and ethical factors create challenges
services may be needed to enabling environment
Counselling MSM and Counselling clients during the
Hijra/transgender people index testing
Stigma and discrimination Index testing is voluntary service to all
Pressure of marriage from family clients who are HIV-positive.
Receptive or insertive anal sex With consent, tests for their sex and
Multiple partners needle-sharing partners and biological
children <19 with unknown HIV status
Unsafe sex and high rates of STIs
Approaches for partner referral i.e., client
Alcohol or injecting drug use or abuse
referral and provider-assisted referral.
Preferred method of partner notication or
child testing for each named partner/
child.
Intimate partner violence (IPV) risks
Appropriate service for partner(s) and
children based on HIV status
Counselling sero-positive Counselling PLHIV
pregnant woman
Partner/spouse testing Insight about the diagnosis (denial/ partial
Term of pregnancy insight/acceptance)
Treatment (ARV) history of PW Partner/spouse testing
Linkage with ART services Screening of OIs e.g., 4S screening for TB
EVTHS services including VL testing Education about HIV/AIDS including
at 32–36 weeks of pregnancy prevention and treatment
Infant feeding guidelines Identify barriers to treatment
Nutrition Treatment (ARV/Prophylactic) -
Treatment adherence counselling including side effects
Adherence/Follow-up counselling
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Basic Counselling Skills
Stigma and discrimination as well as alcohol and injecting drug use or abuse make a person
vulnerable to HIV infection. This point should be considered while doing the risk assessment of
all HRGs especially – Sex Workers, PWID, MSM and H/TG.
Counselling Room
HIV counselling is a condential dialogue between a client and a counsellor. The counselling
process includes evaluating the personal risk of HIV transmission and discussing how to
prevent infection. During the counselling process, the clients may want to discuss their
personal lives and problems, so it is important for the counsellors to create a comfortable
counselling environment where clients can relax, trust, feel at ease and open up about thoughts
or emotions.
List of Referral Services
A counsellor’s role does not end with the end of counselling session; counsellor should have a
holistic approach encompassing health, family life, social life and empowerment of the client.
Counsellor should be able to provide possible solutions to client’s worries and concerns. Client
concerns may not always be related to health, HIV or treatment.
A counsellor should be able to link clients up with appropriate service provider, government
schemes and try to resolve their problem and empower them. This is the way to demonstrate
empathy. To be able to do so, a counsellor should be knowledgeable about government
programmes, NGO schemes and new policies. He/she should be able to establish linkages with
such service providers. A list of these referral services can help the counsellor to providethe
best possible service to clients.
Key Messages
HIV counselling informs and guides behavioural change, aiding decisions on testing,
understanding results, initiating treatment and ensuring adherence.
Counselling is a private, empowering dialogue fostering self-made decisions in life, not
advice-giving. Its goal is constructive changes in beliefs, behaviour and emotional well-
being.
Counsellors focus on the client as a whole, considering their background, struggles and
vulnerabilities beyond the infection. Personalised support is vital for understanding
unique life contexts.
Every client is unique; personalized, respectful care is essential. Complete client
information is crucial, respecting their personality, choices and right to live
autonomously.
Effective counselling builds trust through acceptance and understanding. This alliance is
maintained throughout the counselling process, ensuring continuous support.
Basic counselling principles –
Accepting and Non-Judgmental:
- Encourage openness: "Feel free to share; no judgment here."
- Reassure condentiality: "Your privacy is ensured; relax and talk freely."
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HANDBOOK FOR HIV & STI COUNSELLORS
Empathy and Clear Communication:
- Show understanding: "I understand your situation and concerns."
- Use simple language: "Explain clearly; use local terms for better comprehension."
Expression of Feelings:
- Allow emotional expression: "Express fears and feelings openly; it's a safe space."
Self-awareness and Sensitivity:
- Be mindful: "Stay aware of your attitudes; ensure they don't affect counselling."
Aims of HIV Counselling:
- Raise awareness: "Our goal is HIV prevention and support for all affected."
Basic counselling skills (qualities of a counsellor) -
Active Listening: Pay attention, nod, show interest, and notice nonverbal cues.
Effective Questioning: Use open-ended questions for clients to express themselves
fully.
Empathy: Show understanding and acknowledgment.
Paraphrasing and Reection: Repeat client's thoughts for validation and deeper
understanding.
Knowledge and Awareness: Stay informed about government programs, NGO
schemes, and policies.
Targeted Intervention Sensitivity: Conduct thorough risk assessments and
address stigma, discrimination, and vulnerability issues during sessions.
Counselling Room: It is important for the counsellors to create a comfortable counselling
environment where clients can relax, trust, make patients feel at ease and create an
environment where it is possible to open up about thoughts or emotions.
List of Referral Services: The counsellor should be able to link the clients with
appropriate service providers and government schemes.
References:
National HIV Counselling and Testing Services Guideline, Chapter 3 – Counselling for HIV Testing
National Operational Guideline for ART Services, NACO, 2021
National Guidelines for HIV Care and Treatment, NACO, 2021
Integrated training module for ICTC, ART, and STI Counsellors, NACO, Nov 2014
Annexure: Ambience of the Counselling Room
HIV counselling is a condential dialogue between a client and a counsellor aimed at enabling
the client to cope with stress and take personal decisions related to HIV/AIDS. The counselling
process includes evaluating the personal risk of HIV transmission and discussing how to
prevent infection. During the counselling process, the clients may want to discuss their
personal lives and problems, so it is important for the counsellors to create a comfortable
counselling environment where clients can relax, trust, make patients feel at ease and open up
about thoughts or emotions.
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Basic Counselling Skills
Suitable environment for counselling is as follows:
A direction sign board and a name board in local language to make it easier for clients to
nd the counselling room;
The counselling room should have a calm and quiet environment where the client can feel
secure and protected. At the same time, he/she should feel condent about condentiality.
Privacy should be demonstrated to the client.
The room should be free from any kind of disturbance like outside noise, ringing telephones,
people disturbing in between.
A suitable environment for counselling will feel like neutral ground to both the counsellors
and the clients. If you display too many personal items, it could make the patient feel as if
they are visitors in someone else’s home. You can avoid this by not keeping personal items.
Keep your space clean and organized. This type of environment is better for counselling
sessions for several reasons. First, it sends the message that you care about your work and
pay attention to detail. Second, while a messy ofce can generate feelings of anxiety, a clean
and organized space will have a calming effect on your patients. Third, it can help keep your
clients from feeling distracted when their eyes are wandering around all over your ofce.
You want them focused on what you are saying, not on all of the clutter.
Using natural elements in your ofce can also help create an environment that is suitable
for counselling. You could start by adding some natural elements like plants, scenic photos,
or painted landscapes. They help patients feel less stressed, which makes counselling
sessions ow more smoothly.
Have adequate lights in the counselling room.
Total privacy should be observed at the time of counselling.
The chairs and tables should be arranged in a way that ensures adequate space and an
environment for the clients to feel secure.
IEC materials should be available at all HCT sites to provide education to waiting clients.
Make the counselling centre child friendly. While a separate room for counselling of children is
ideal, this is not always possible in a crowded hospital. Alternatively, you could plan a child-
friendly corner with the following:
A small blackboard at the child’s level;
Drawing paper and other art material;
Inexpensive games and toys for children;
Noticeboard with paintings by children such as calendars with complete adherence marked
by children, or pictures drawn by them. (Here, remember to use rst names only to protect
their identity.)
Storybooks
Some festival decorations;
Coloured pictures from magazines/newspapers of popular sports persons or animals.
You can mobilize these resources from places such as toy shops, publishers/distributors of
children’s magazines, service organizations/clubs like Rotary Club and Lion’s Club, local
philanthropists and NGOs/CBOs/Networks.
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HANDBOOK FOR HIV & STI COUNSELLORS
Risk Assessment, Pre-and Post-test
9 Counselling and Index Testing
Risk assessment
The client ow at HCTS conrmatory facilities has been revised to enhance focus on priority
clients. The clients are prioritized on the basis of referrals. All direct referrals are prioritized
and assessed for risk of HIV, while all provider referral clients are fast tracked. However,
counsellors may administer risk assessment to provider referral clients at the time of pre-test
or post-test, if they feel the need, based on their interaction with client. The risk assessment is
documented in SOCH.
“At risk” populations/priority population:
Self-initiated clients at ICTC with risky behaviour;
Social and sexual networks of self-initiated clients/individuals;
Clients motivated from helpline 1097/IEC material;
Youth and adolescents at risk;
Individuals having casual sexual relations with regular/non-regular partner/s;
STI/RTI clients visiting DSRC/STI Clinics with STI complaints;
HIV-negative but at-risk clients identied through virtual outreach, NACO Helpline 1097
etc.
Regular and non-regular partner/s/spouse of HRG (FSW, MSM, TG/TS) who are not
associated/covered with TIs, LWS & OSC;
Needle/Syringe-sharing partners (IDU/FIDU) and their sexual partners (who are not
associated with TIs/ LWS/OSC);
HIV-negative partners of discordant couples;
Screened reactive referrals for conrmatory test and screened reactive from blood banks (BB);
Pregnant women;
Exposed babies.
The priority clients will be assessed for risk of HIV based on seven risk assessment questions
listed below:
Q.1 : Do you have the habit of using/sharing injecting drugs? (Response: Used/ Shared/
Refusal to answer)
Q.2 : What kind of sexual partner(s) do you have? (Response: Male/ Female/ TG/ No sexual
partner/ Refuse to answer)
Q.3 : Do you have any sexual relationship beyond your spouse/partner? (Response: Yes/ No/
Refusal to answer)
Q.4 : Have you bought sex in the past from a man, woman or TG using money, goods, favours
or benets? (Response: Yes/ No/ Refusal to answer)
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Risk Assessment, Pre-and Post-test Counselling and Index Testing
Q.5 : Have you provided sex in the past in exchange for money, goods, favours or benets?
(Response: Yes/ No/ Refusal to answer)
Q.6 : Any STI symptoms in the last three months? (Response: Yes/ No/ Refusal to answer)
Q.7 : Is your spouse or partner a PLHIV? (Response: Yes/ No/ Refusal to answer).
It should be emphasized that HIV risk assessment should be undertaken in a sensitive and
non-judgmental manner, so that clients are encouraged to openly discuss their concerns. In
addition, sensitive information is condential and the HIV risk behaviour or infection status
should not result in any discriminatory treatment to the client.
All the clients identied as ‘at-risk’on the basis of risk-assessment and whose HIV test result is
negative will be linked to the comprehensive prevention services under SSK. In case the clients
cannot be linked to SSK for any reason, they will be followed up at the existing conrmatory
facility for prevention services.
At SSK, additional details related to client history and demographics will be recorded to better
understand client prole and requirements. The details of their social/sexual/injecting partners
will also be elicited to generate awareness around HIV and STIs and encourage their partners
to access NACP services. The needs (health and non-health) and risk categories of clients (basis
risk-assessment) will be assessed by the SSK staff, and a holistic package of services will
accordingly be provided to clients in line with SSS Operational Guidelines and States’
Implementation Plan (Sampoorna Suraksha Strategy, Operational Guidelines (2nd Cut), 2023).
Table 9.1 - Risk categorization at SSK
Questions Interpretation basis on response
Q1 If “Used and Shared” or “Shared”>>High risk
If “Used”>> Moderate risk
If “Refuse to answer”>> Low risk
If “No”>> Not at risk
Q2 If Client is Male and Sexual Partner is Male>> High risk
If Client is Male and Sexual Partner is TG>> High risk
If Client is TG and Sexual Partner is Male>> High risk
If Client is TG and Sexual Partner is TG>> High risk
For other scenarios >> Not at risk
Q3 If “Yes”>> High risk
Q4 If “Refuse to answer”>> Low risk
Q5 If “No” >>Not at risk
Q6 If “Yes”>> Moderate risk
If “Refuse to answer”>> Low risk
If “No” >>Not at risk
Q7 If “Yes”>> High risk
If “Refuse to answer”>> Moderate risk
If “No” >>Not at risk
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HANDBOOK FOR HIV & STI COUNSELLORS
A) Pre-test Counselling:
Pre-test counselling is provided to the individual before HIV testing using posters, ip
charts, brochures and short video clips so as to prepare him/her for the HIV test and to
address myths and misconceptions regarding HIV/AIDS.
This can be done in two ways: (a) one-on-one counselling and (b) group counselling. One-on-
one counselling should be done for all individuals accessing HCTS services where risk has
been elicited. Group counselling can be done when the counsellor is addressing a group such
as pregnant women at ANC clinics.
At screening facilities, any paramedical staff designated for HIV screening (PHN/
LHV/ANM/MPW male/pharmacist/LT) in the health facility should provide the pre-test
counselling.
At screening and conrmatory facilities, prescribing physician or any paramedical staff
designated for HIV screening shall provide pre-test counselling for all provider referral
clients. However, for all priority clients, pre-test counselling shall be provided by the
counsellor after administering risk assessment.
Table 9.2 - Content of pre-test counselling
a. Provide information on HIV and AIDS: What is HIV, what is AIDS, window period,
route of transmission, prevention message, care, support and treatment services.
b. Explain the benets of HIV testing and risk assessment.
c. Assure condentiality.
d. Explain that the individual has the right to opt out of HIV testing.
e. Explain the implication of a positive test result, including availability of treatment.
f. Explain the implications of a negative test result including preventive services.
g. Disclosure if positive and avail Index Testing Services.
h. Provide information on genital, menstrual and sexual hygiene.
i. Demonstrate the use of a condom using a model.
j. Provide information on spouse/sexual partner testing.
k. Extend the opportunity to the individual to ask and clarify doubts.
l. In addition, explain to all pregnant/breastfeeding women regarding EVTHS.
m. Additional counselling for patient who has declined the test:
they can return at any time for further information and or testing;
information on other health facilities that can offer HIV counselling and testing
services;
information that can be used in prevention and risk reduction for that individual;
that declining the test does not affect any other health service provision.
n. Informed consent: After pre-test counselling, informed consent of the client must be
taken for the HIV test. Informed consent remains one of the essential ve Cs.
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Risk Assessment, Pre-and Post-test Counselling and Index Testing
Table 9.3 - Informed Consent
Informed It should always be obtained individually and in private. Even if pre-
consent by an test counselling is provided in a group setting, everyone should give
adult at HCTC informed consent for testing with an opt-out option.
Consent for Informed consent has to be obtained from the parents/guardians/
individuals caretaking institutions or NGO concerned. In case there is a difference
below the age of of opinion on consent for testing between the parents/guardians and
18 years the individual below 18 years of age, the counsellor may further
counsel the individual/parent/guardian to prepare for testing. In case
such individuals are unwilling to involve parents/guardians in their
HIV testing process, they should be counselled again. If there is no
parent/guardian, then the local legal authorities may grant permission
for testing.
Consent for The blood sample of such a patient should be sent to the nearest HCTS
non-ambulatory facility and the healthcare provider should sign the register in lieu of
individuals the patient, after obtaining verbal informed consent.
Informed consent has to be obtained from their family/ parents/
guardians/ caretaking institution, or NGO. If there is no parent/
Consent for
guardian, then the local legal authorities may grant permission for
patients in
testing. The relevant person/organization providing consent will also
coma
be responsible for signing the counselling register. In certain
circumstances where HIV testing is warranted, the decision to test lies
with the concerned medical healthcare provider.
B) Post-test Counselling:
All efforts must be made to provide same-day test results and post-test counselling to all
those accessing HIV services at the HCTS facilities.
Individual post-test counselling must be conducted for all HIV reactive/indeterminate/
positive at conrmatory facilities and wherever risk has been elicited, irrespective of
whether the result is HIV non-reactive/reactive at the screening facility.
At screening facilities, any paramedical staff designated for HIV screening (public health
nurse/lady health visitor/auxiliary nurse midwife/Multipurpose worker male/pharmacist/
laboratorytechnician) in the health facility should provide post-test counselling.
At conrmatory facilities, post-test counselling shall be provided by the counsellor.
However, the post-test counselling and the follow-up counselling sessions shall be
customized to the patients being tested, such as pregnant women, adolescents, at-risk, HRG
etc
Content of the post-test counselling is detailed in Table 9.3.
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HANDBOOK FOR HIV & STI COUNSELLORS
Table 9.4 - Content of the post-test counselling
HIV result Content of post-test counselling
All results An explanation of the test result;
(screening as well Risk education counselling, condom demonstration and provision
as conrmatory of condoms;
sites) including Emphasis on the importance of disclosure and partner testing;
negative/non- Information about the availability of partners’/couples’ testing and
reactive counselling services;
Information on genital, menstrual and sexual hygiene;
Linkages to TB/STI/ANC services, TI programmes, etc.
An opportunity for additional counselling of the individual,
clarication on myths and misconceptions.
Additional counselling messages based on test result:
Negative Importance of safe practices and preventive measures;
(conrmatory site Importance of follow-up services and retesting at prescribed
and at-risk clients) intervals;
Reactive (screening This is only a screening test for HIV. With this result, it is not
site) possible to conrm the HIV status.
Explain the need for conrmation of HIV diagnosis at an SA-ICTC
and the process followed.
Fill the linkage form and provide directions for reaching the
nearest SA-ICTC.
Positive Explain the test results and diagnosis.
(conrmatory site) Avoid information overload.
Listen and respond to needs (the patient may be overwhelmed and
hear little after being told the positive result).
Discuss the immediate implications and treatment options if the
patient is in the condition to receive further information.
Review immediate plans and support.
Assess and address concerns, denial, fear, risk of suicide,
depression and other mental health consequences of diagnosis of
HIV infection.
Provide clear information on free ART (where it is offered, when
ART will start, for how long it has to be taken, how many times it
has to be taken, who will provide ART, what tests are required for
starting ART, etc.) and reducing the risk of HIV transmission.
Discuss possible disclosure of the result and encourage index
testing.
Assess the risk of violence by partner/spouse and discuss existing
support system to help such individuals, particularly women, who
are diagnosed HIV positive.
An HIV-positive diagnosis is a life-changing event. Post-
test counselling should always be responsive and tailored
to the unique situation of each individual or couple.
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Risk Assessment, Pre-and Post-test Counselling and Index Testing
Link to District Level Network (DLN)/peer support groups
Indeterminate All individuals with an indeterminate test result should be
(conrmatory site) encouraged to undergo follow-up testing in two weeks to conrm
their HIV status. Emphasize the need for and ensure follow-up
testing.
Discuss immediate concerns and help the individual.
Assess the risk of suicide, depression and other mental health
consequences of a diagnosis of HIV infection.
Pregnant WLHIV Potential risk of transmitting HIV to the infant
Benets of early HIV diagnosis and treatment for mother and
infant
Infant-feeding practices
Victims of sexual Counselling on the need for baseline HIV, other STI and
assault pregnancy testing;
Post-exposure prophylaxis (PEP) for HIV and STI and counselling
for its adherence;
Follow-up HIV counselling and testing after 3 months and 6
months (as applicable);
High-risk group Address stigma and discrimination-related issues.
(HRG)/bridge An individual may have more than one type of risk behaviour.
population Explore and address it.
Need for follow-up counselling (if applicable);
Connect with social protection schemes and services from support
structures as applicable: e.g., crisis response team, legal support,
etc., when needed;
Linkages to Targeted Interventions or LWS.
C) Follow-up Counselling:
Follow-up counselling is required in the management of a person who has tested positive, or in
the situation where a person who tested negative is continuing to participate in high-risk
behaviours for HIV. Follow-up counselling is recommended for the following individuals:
Individuals who have not accepted their HIV-positive report;
Individuals who have not been linked to care, support and treatment services;
Individuals in need of services from support structures such as legal, socio-economic welfare,
etc.
For further details, please refer the following NACO guidelines:
For at-risk negative clients: Please refer page nos. 24–25 (Sampoorna Suraksha
Strategy, Operational Guidelines (2nd Cut), 2023)
For newly identied PLHIV: Please refer page nos. 57–59 (National Guidelines for
HIV care and treatment, 2021)
For repeat HIV testing: Please refer page no. 59 (HIV Counseling and Testing Services,
2016)
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HANDBOOK FOR HIV & STI COUNSELLORS
Index Testing Services (Partner notiofication services/Contact tracing
services)
(Refer Index Testing Services SOP, 2020)
Index testing services (ITS), or partner notication services, is a voluntary case-nding
approach where trained providers, with the consent of the HIV-positive client, focus on the
elicitation of the sexual and/or needle-sharing partners and biological children and offer them
HIV Counselling and Testing Services (HCTS).
Implemented appropriately and safely, index testing can link HIV-positive individuals to life-
saving treatment, break the chain of transmission and link HIV-negative people to other
appropriate prevention services (e.g., SSK, TI, OST etc.)
Index client: All PLHIV (newly diagnosed and known HIV positive person who have had
an interruption in treatment or who are identied as having high viral load), including high-
risk groups (FSW, MSM, TG and IDU), adults, adolescents, children and bridge population
(Truckers and Migrants)
Contact:
- Sexual contacts should include ALL persons they have had sex with (even if it was just a
single encounter and even if they always use condoms with this partner).
- Needle-sharing contacts including ALL persons they have shared needles or injection
equipment (even if it was just one time and even if they cleaned the needle before
sharing);
- All biological children who are less than 19 years of age:
In case of woman newly diagnosed with HIV
In case of a male index case, if the wife is HIV positive, deceased, or her status is
unknown
For Index Case who are children (<19 years), the contacts will include:
Biological mother
Biological father, if the child’s mother is HIV positive, deceased, or her status is unknown.
Biological sibling/s
Sexual and needle sharing partners if elicited in the history taking
Approaches to index testing services
Index testing can be delivered by many approaches, including client (or patient) referral and
provider-assisted referral. Client-centred counselling should be used to assist the index client
to determine which approach is best for each named partner. Clients may choose different
approaches for different partners. Ensuring client consent, condentiality and safety are
critical. According to WHO terminology and denitions:
In Client referral (also called passive referral), a trained provider encourages HIV-positive
clients to voluntarily disclose their status to their sexual and/or drug-injecting partners and
encourages their partner to get tested. HIV-positive clients may also inform their partner(s)
through anonymous means, such as web-based messaging services (emails, web-based
applications, etc.), if they do not want to disclose their identity.
Provider-assisted referral consists of three sub types:
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Risk Assessment, Pre-and Post-test Counselling and Index Testing
- Provider referral: Counsellor or other healthcare provider calls or visits the index
client’s partner(s) and recommends that they test for HIV.
- Contract referral: Index client and counsellor work together to refer index client’s
partner(s). They agree on a time (e.g., within 14 days) in which the client will tell
partner(s). If client does not tell within agreed time, counsellor contacts partner(s).
- Dual referral: Counsellor/provider sits with index client and partner(s) to support
index client in telling partner(s) about HIV status (if they choose to disclose); or
provides a safe space for testing together.
Implementing quality and ethical index testing services
The following section provides detailed information about the where, who, to whom, how and
what of ITS.
Table 9.5 - Summary of index testing services
Where should To whom should ITS be offered Who can
ITS be offered offer ITS
HCTC All newly diagnosed HIV-positive individuals HCTS
conrmatory sites) including children <19 years counsellor
ART/Link ART All ART clients (including children <19 Counsellor, staff
Centre years) who have not been offered ITS at nurse, care
the ICTC coordinator
All ART clients (including children <19
years) with an unsuppressed viral load
All ART clients reporting a change in
relationship
All ART clients returning to care after
treatment interruption (LTFU)
All ART clients with an incomplete ‘family
tree’ status documentation
For PLHIV with an unsuppressed viral
load
At least bi-annually as a part of HIV
treatment services for discordant couple
Care and Support All PLHIV registered at CSC who have never Peer counsellor or
Centre (CSC) undergone index testing outreach worker
Sampooran All PLHIV registered in the SSK who have Master counsellor,
Suraksha Kendra never undergone index testing peer counsellor, SSK
(SSK) All at-risk negative clients who turned out manager or outreach
positive on subsequent visit worker, as applicable
One Stop Centre All active HRG PLHIV registered in the OSC Master counsellor,
(OSC) who have never undergone index testing peer counsellor or
outreach worker, as
applicable
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HANDBOOK FOR HIV & STI COUNSELLORS Risk Assessment, Pre-and Post-test Counselling and Index Testing
Targeted All active HRG PLHIVs registered in the TIs Counsellor, outreach
Intervention who have never undergone index testing worker, peer
educator/peer
navigator as
applicable
OST/satellite OST All HIV-positive PWIDs, not offered ITS at Counsellor, nurse,
Centre any of the other facilities outreach worker,
peer educator/peer
navigator as
applicable
Mobile Outreach All PLHIV from hard-to-reach areas or who Outreach worker or
could not reach any of the above facilities (not peer educator/peer
offered or not opted for ITS at any facility). navigator
Notes:
i. Children without an ongoing or new HIV exposure do not need re-testing if status is known.
ii. To avoid duplication, all the KP PLHIVs registered with TI/OST/SSK/OSC programme may be referred to the
concerned facility to avail ITS.
Core Principles of Index Testing Services
The WHO 5 Cs (Consent, Condentiality, Counselling, Correct test result and Connection to
treatment services) are principles that apply to all HCTS including ITS.
Consent: Clients must provide their informed consent before HIV testing; coerced testing is
never appropriate, regardless of where the coercion comes from. If found HIV positive, a
second informed consent is to be obtained for participation in Index Testing services before
moving ahead. No pressure should ever be placed on anyone being tested for HIV to disclose
their partners if they choose not to. Clients may opt out of Index Testing services for any
reason, and for no reason at all, at any time and not limited to fear of Intimate Partner
Violence (IPV) with no impact to their receipt of HIV prevention, care and treatment
services.
Condentiality: Index testing services must be condential; the name of the index client
should never be shared with the partner and the partner’s HIV status should never be
shared with the index client (unless consent is obtained from both parties). Programmes
should have standard operating procedures (SOPs) such as protection of personally
identiable data, access to data and secure storage space in place to protect the
condentiality of both the index clients and their partner(s) and children. Condentiality of
index client and all named partners and children must be maintained at all times.
Counselling: Index testing services must include appropriate and high-quality pre-test
information and post-test counselling. These counselling messages should include discussion
on the benets and risks of ensuring that all partners and biological children of HIV-positive
individuals receive an HIV test.
Correct test results: Index testing must be performed according to National Counselling
and Testing guidelines, testing strategies, norms, and standards including communication of
the correct result.
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Risk Assessment, Pre-and Post-test Counselling and Index Testing
Connection: Connection or referral to treatment services for newly diagnosed HIV-positive
partner(s) and children and to HIV prevention services for HIV-negative partner(s) and
children must be supported by index testing programme through concrete and well-
resourced patient referral, support, and/or tracking systems.
All index testing services must be client-centred and focused, condential, voluntary and non-
coercive, free of cost, non-judgemental, culturally/linguistically appropriate, accessible,
available to all and comprehensive and integrative.
How to provide Index Testing Services ?
Figure 9.1 - 10 Steps of Index Testing Services
The 10 Steps of Index Testing Services
1. Introduce the concept of Index Testing Services during pre-test counselling.
2. Offer Index Testing as a voluntary service to all clients testing HIV positive or with a high viral load.
3. If client accepts participation, obtain consent to inquire about their partner(s) and biological child(ren).
4. Obtain a list of sex - and needle-sharing partners and biological children <19 with unknown HIV status.
5. Conduct an Intimate Partner Violence (IPV) risk assessment for each named partner.
6. Determine the preferred method of partner notication or child testing for each named partner/child.
7. Conduct all named partners and biological children <19 with unknown status using preferred approach.
8. Record outcomes of partner notication and biological children.
9. Provide appropriate services for partner(s) and children based on HIV status.
10. Follow up with client to assess for any adverse events associated with index testing services.
Intimate Partner Violence (IPV) risk assessment is done to ensure no harm comes to the
index client, their partner (s) or family members as a result of participating in ITS. IPV
assessment should rule out any form of physical, emotional or sexual violence by the partner.
If client discloses violence:
Index testing should not be carried out if the client has high risk of IPV or does not feel
comfortable with any of the notication approaches. All decisions about partner notication
should ultimately be up to the client. At the same time as rst line of response the client
could be informed about how they could protect themselves from potential violence. The
WHO dened “rst-line support” using the acronym “LIVES” should be followed wherever
possible (Listen, Inquire, Validate, Enhance Safety and Support Through Referrals).
The repeat Index Testing Services may be offered to the Index Case after certain time period
which is mutually agreed upon and noted for follow up.
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HANDBOOK FOR HIV & STI COUNSELLORS
Key Messages
Risk assessment: Ask explicit questions about sexual practices, drug-using practices,
occupational practices, receipt of blood products, organs or donor semen. It is very
important how counsellors ask the questions. Preferably open-ended questions should be
asked rst, followed by specic questions. E.g.“What made you come to us today?” Then
after listening to the narration, ask “How long have you had this symptom/
problem?”Again if you need details, ask “Can you please tell me more about this?”.
Preferably, the pattern of asking questions should be as follows:
- Introduce topic: “The symptoms you mention are often related to sexual behaviour. So I
will now ask you some questions about this. I request you to be truthful so that I can
help you. What you say to me is only known to me and the doctor.”
- Broad and specic question:“Have you ever had anal sex?”
- More specic but open-ended question: “Please tell me when and with whom.”
- Some clients tells too many things that may not be relevant for risk assessment but you
may get important information through it. E.g. Who are all staying with the client?
What is his/her support system? Note down all such important details which may be
useful later.
It is also a skill of the counsellor to bring back the client to the topic if they are sharing
too many details.
Refer to the questions in the risk assessment tool and ensure that all information is
collected. Counsellors will have to ask multiple sub questions to get the answers for the
questions in the risk assessment tool. Clients may not disclose everything in the rst
session. Continue to maintain rapport so that they may disclose it in a while or perhaps in
the next session. So, counsellors will have to keep on updating the client’s details.
Remember, following persons are at high risk:
- Multiple partners/more than one partner;
- High-risk sexual behaviour – high frequency of unprotected sexual intercourse, anal
sex;
- Women, all groups covered under TI;
- Girls, if they have started their sexual activity early i.e., before 18 years of age.
Pre-test counselling is the rst contact of the client with the counsellor. So, establish
rapport and trust. Assure condentiality. Remember to use counselling skills while
talking with the client. Only then the clients may feel like disclosing personal
information. Listen to the story of the client. This may help counsellors to know the
reasons for HIV infection and the vulnerability factors of the client.
One of the objectives of pre-test counselling is to prepare the client for the possible test
report.
Post-test counselling is provided after HIV testing to help the individual understand the
diagnosis and implications of the result. It also helps the individual cope with the HIV
test result. The counsellor assesses the mental health of the client and supports the client
until they understand and accept the result. Managing emotional responses after
disclosure is important.
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Risk Assessment, Pre-and Post-test Counselling and Index Testing
Partner disclosure and testing: Assess whether the client is stable. If yes, talk about
disclosure. Offer support. Discuss the challenges. If the client nds it difcult, rehearse
on doing it. If the client still needs support, ask him/her to come with the partner. Then
counsellor can disclose it in front of the client. Manage the emotions and reactions of
partners too. Then advise for partner testing when you feel that they are ready. This
readiness assessment is important at various stages of pre- and post-test counselling.
Index testing is a very sensitive issue. A client may not be ready due to several reasons
like fear of disclosure, rejection from the partner and possible violence from the partner.
Counsellors need to understand the client’s perception of this. They might be thinking
that their life has become complicated after HIV diagnosis. It is quite stressful and
burdensome. By doing partner testing, they may not want to complicate it further. So,
counsellors should play an important role in addressing these issues. Explain how testing
will help the client in the life ahead.
Strict adherence to 5Cs (Consent, Condentiality, Counselling, Correct test results and
Connection to prevention/treatment).
References
HIV Counseling and Testing Services, (2016), NACO
Index Testing Services SOP, (2020), NACO
National Guidelines for HIV care and treatment, (2021)
Sampoorna Suraksha Strategy, Operational Guidelines (2nd Cut), (2023), NACO
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10 Condom Use
A condom is a widely used prevention tool in sexual health. It is a type of barrier contraceptive
that helps reduce the risk of HIV, sexually transmitted infections (STIs) and unintended
pregnancies. It gives protection to both the partners .
Figure 10.1 - Condom as prevention tool
CONDOM AS A PREVENTION TOOL
STI Prevention Pregnancy Prevention Ease of Use
Provides a protective barrier Highly effective at preventing Convenient prevention tool
against Infections such as unintended pregnancies when since they are easily accessible,
HIV/AIDS, gonorrhea, used correctly and consistently affordable, and require no
chlamydia, syphilis, and herpes prescription.
A B C D E
Protection for Both Partners Safe Sex Promotion
Offer dual benet of Promotes safe sex practices and
safeguarding both parties from helps to protect themselves and
potential STIs and unwanted their sexual partners from the
pregnancies. transmission of STIs.
Note: It is important to note that while condoms are highly effective, they are not 100% fool-proof. They can break or
slip if not used correctly or if they are past their expiration date. However, when used consistently and properly,
condoms are considered one of the most reliable and accessible prevention tools available for sexual health.
Risk Reduction Method
There are many effective methods for reducing the risk of HIV transmission through sex. The
most widely known strategies for the prevention of HIV transmission through the sexual route
are often known as the ABC rules:
A stands for abstinence, which means refraining from premarital sexual intercourse.
B stands for ‘Be faithful’, which means maintaining faithful relationships with a long-term
partner.
C stands for ‘Condom use’, which means correct and consistent use of condoms in sexual
intercourse.
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Non-penetrative Sex
Some people may choose to have non-penetrative sexual contact instead of penetrative
intercourse (oral, anal or vaginal). Non-penetrative sexual practices constitute an alternative
way to satisfy sexual needs without being at risk of HIV infection. These alternative practices
to sexual intercourse include hugging, kissing, massaging, rubbing or other romantic touches
and masturbation, which are all considered to have an extremely low risk of transmitting HIV
infection.
This is because HIV is not transmitted from skin-to-skin contact. Only the relatively thin
tissues in a person’s rectum and vagina are vulnerable to HIV, and even then, they would have
to be directly exposed to the wet blood or sexual uids of an HIV-positive person who does not
have an undetectable viral load. Non-penetrative sex, where the penis does not enter the
vagina, anus or mouth, and when penetrative sex toys are not shared, is a safer sex method
that greatly decreases the risk of getting infected with HIV (however it must be remembered
that non-penetrative sex may be ‘low risk’ but it is not ‘no risk’). It still may be a risk factor for
the transmission of other sexually transmitted diseases.
Overview of condoms
A condom is a sheath-shaped barrier device used during sexual intercourse to reduce the
probability of pregnancy or an STI. Condoms are the only type of contraception that can both
prevent pregnancy and protect against HIV and other STIs.There are two types of condoms:
External condoms, worn on the penis, also called the male condoms.
Figure 10.2 - Male Condom
Wallet Pack (Frontside) Wallet Pack (Backside)
Female condoms (femidom) worn inside the vagina
Female condoms allow a woman to be able to choose an effective means of protection for herself
against STIs and HIV, without even asking her partner's opinion. The female condom is made
of polyurethane, which eliminates allergy problems connected with latex and it can be put in
place at any time.
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Condom Use
Figure 10.3 - Female Condom
Condoms are the only type of contraception that can both prevent pregnancy and protect
against HIV and other STIs.
Female condoms allow a woman to be able to choose an effective means of protection for
herself against STIs and HIV, without even asking her partner's opinion.
The female condom is made of polyurethane, which eliminates allergy problems connected
with latex and it can be put in place at any time.
Condoms come lubricated to make them easier to use, but one may also like to use additional
lubricant (lube). This is particularly advised for anal sex to reduce the chance of condom
splitting.
Table 10.1 - Instructions of using male and female condom
Instructions for using male condom Instructions for using female condom
Take the condom out of the packet, being Put yourself in a comfortable position, either
careful not to tear/damage it with jewellery lying, sitting or standing with one foot
or ngernails. Do not open the packet with resting on a chair. Open the individual
your teeth. female condom pack and take it out
carefully, especially be careful not to damage
the lining if you are wearing jewellery or
have long nails.
Place the condom over the tip of the erect Make sure that the inner ring is at the
penis. If there is air in the teat (end) of the bottom of the condom. Hold the female
condom, use your thumb and forenger to condom by this ring by squeezing it with
squeeze the air out of it. your thumb and index nger. Insert the ring
inside the vagina and push it in as far as
possible.
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HANDBOOK FOR HIV & STI COUNSELLORS
Gently roll the condom down to the base of Next, place your index nger inside the
the penis. female condom and push the femidom to the
back of the vagina by pushing on the ring.
When the femidom is in place, the external
ring must be outside the vagina.
After sex, take out the penis while it is still To remove the female condom, turn the
erect: hold the condom at the base of the external ring to close the opening completely
penis while you take the penis out. Remove and to stop the sperm from pouring out. Now
the condom from the penis, careful not to pull it gently.
spill semen.
Tie up the condom and throw it away in a Put the used femidom back in its pack and
bin, not down the toilet. Make sure your throw it in the bin. Do not throw it down the
penis does not touch your partner’s genital toilet.
area again.
If you have sex again, use a new condom. If you have sex again, use a new condom.
Use of lubricants
Only water-based lubricants are recommended for use with condoms. To use a water-based
lubricant with a condom, simply apply a small amount to the outside of the condom once it is
already in place. Avoid using excessive amounts, as this can reduce the effectiveness of the
condom or create a slippery sensation that may interfere with sexual activity. The use of
lubricants is recommended for several reasons like compatibility with latex, reducing friction,
easy to clean and safe.
What to do if a condom breaks
It is very rare for a condom to break when it is used properly. However, take the following
measures if the condom breaks:
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Condom Use
Withdraw the penis immediately.
Remove as much semen as you can.
Gently wash the outside of your genitals: avoid washing inside your vagina or anus
(douching); if you were having vaginal sex, go to the bathroom and urinate to ush away any
semen.
If you were not using any other contraceptive to prevent pregnancy,you may need to access
emergency contraception within 72 hours to prevent pregnancy.
If you were having oral sex, spit out any semen and rinse your mouth with water.
The person should be assessed for eligibility of non-occupational post-exposure prophylaxis
(PEP).
Myths and Misconceptions
Many people have incorrect information about condoms, which is not true and which should be
corrected to continue using condoms as a safer sexual practice. Some myths and
misconceptions which counsellors should address are as follows:
Table 10.2 - Condom myths and misconceptions
Condoms are unreliable and can break Sex does not feel as good with a condom.
or slip off easily.
Two condoms are better than one. Female condoms are reusable.
Female condoms can get lost inside the Condoms are indicative of sexual promiscuity
women’s body. by people who use them.
Condoms do not t. Condoms are only for penises.
Availability and accessibility of condoms
Under the NACP’s Targeted Intervention (TI) projects, condoms are made freely available
for use among the HRG individuals.
Condoms are also available and easily accessible at/with
a) Family planning clinics
b) Primary health centres/community health centres/district hospitals
c) Sampoorna Suraksha Kendras, ICTC, DSRC, One-stop centres, opioid substitution
therapy (OST) centres and ART clinics
d) NGOs and CBOs working on sexual health, etc.
e) Medical stores/Pharmacies/Vending machines/Non-traditional outlets
f) Frontline health workers like the ASHAs and ANMs
Condom social marketing (CSM) is a type of intervention in which condom brands are
developed, marketed with a promotional campaign and sold to a specic target population.
This is an innovative approach at eld level to increase condom availability and use; other
approaches include public, free and private distribution of condoms.
CSM can help communities overcome social and cultural resistance to practising effective
prevention of HIV and other STIs.
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HANDBOOK FOR HIV & STI COUNSELLORS
Barriers to condom use
Some common barriers to condom use include
Lack of knowledge
Misconceptions and myths
Stigma and social norms
Accessibility
Partner disapproval
Lack of negotiation skills
Substance abuse
It is important to address these barriers through education programmes, promoting condom
accessibility and destigmatizing condom use to encourage widespread and consistent use for
safer sexual practices.
Condom negotiation
There can be negotiations between an FSW and her clients on using condoms. For successful
negotiation, the following points are essential:
Communication is the backbone of negotiation. The way you communicate decides the
impact of the negotiation.
It involves identifying non-verbal cues, using the right words and expressing your thoughts
in a compelling and engaging way.
Often, negotiators are active listeners that help them understand the message from another
person.
Negotiation is not about what you say; it is more about how you say it. Therefore, it is
imperative to speak condently to make the person believe that your solution is benecial.
How to say NO to unsafe sex?
There are ve steps during condom use negotiation that will help say NO to sex without
condoms in ways that work:
Say NO! Use the word. Say it in a rm tone of voice.
Use actions and body language that support the NO message.
Repeat. One may need to say NO more than once.
Suggest an alternative. Offer something that is safer and healthier to do instead, if this is
someone you still want a relationship with.
Be sure your words and actions are real for the situation and are likely to work with the sexual
partner concerned.
Key Messages
Condom is a barrier against infections such as HIV/AIDS and STIs. It helps to prevent
pregnancy.
Regardless of gender, condoms offer protection to both sexual partners. They can be used
for a variety of sexual activities, including oral, anal and vaginal sex.
Only water-based lubricants are recommended for use with condoms. They are
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Condom Use
hypoallergenic, less prone to irritate or trigger allergic reactions and simple to remove
from the body and sex toys due to their water solubility.
Condoms are easily available at government health centres, family planning clinics, OSC
and OST centres, SSKs, medical stores, ASHAs and ANMs, NGOs and CBOs working on
sexual health.
Condoms should be kept in a cool, dry place at room temperature, typically at 20–25
degrees and away from sharp objects.
Important points to be discussed in counselling
It is important that the counsellors are comfortable in talking about condoms and
demonstrating.
Table 10.3 - Key points for the counsellors to explain condom usage to their clients
Motivate the client to use a condom every time they have sex with anyone.
Only correct and consistent use condom can keep a person safe from HIV/AIDS/STI.
Clarify the myths and misconceptions around condom usage.
It is very rare for a condom to break when it is used properly; but if it does split, break or
something else goes wrong like the condom slips off, there are some simple things that
can be done:
- Withdraw the penis immediately.
- Remove as much semen as you can.
- Gently wash the outside of your genitals: avoid washing inside your vagina or anus
(douching) as this can spread the infection further or cause irritation.
- If you were having vaginal sex, go to the bathroom and pee to ush away any semen.
- If you were not using any other contraceptive to prevent pregnancy, you may need to
access emergency contraception to prevent pregnancy. This should be done within 72
hours of having sex.
- If you were having oral sex, spit out any semen (or swallow it) and rinse your mouth
with water.
- Contact a doctor for assessment for eligibility of non-occupational PEP.
Build the skill of condom use: teach the client how to wear a condom and ask them to
repeat the process to check their learning.
Tell them about the places where condoms are available and accessible.
Provide the condoms, if available.
Remind them that every time they choose not to use a condom, they increase their risk of
contracting HIV and other STIs.
Barriers in accepting the condoms - There are barriers that may make it difcult for some
people to use condoms regularly or at all. Individual circumstances, cultural values and
societal inuences can all inuence these barriers in different ways.
How to address the barriers: Identify the barriers. Counsel while considering the issues.
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HANDBOOK FOR HIV & STI COUNSELLORS
There may be some myths. Discuss the same. For example, there is a myth that condoms are
used while having sex with a sex worker or outside the marriage and it is not used among
married couples/in stable relationships. Address this myth. There is another myth that
condom should not be used while expressing true love. There should not be any barrier. But
it may be explained to the client that love can be expressed by caring for each other.
a) Lack of knowledge: Many people may not have accurate information about the benets of
condom use and how to use them effectively.
b) Stigma and social norms: Condom use may be seen as a sign of promiscuity or a lack of
trust in a partner, leading to a reluctance to use them. Some people feel shy to buy
condoms. Guide them on condom availability.
c) Accessibility: If there is limited access to condoms, particularly in low-income or rural
areas, guide them on condom availability.
d) Partner disapproval: This is one of the most important reasons for not using condoms. Fear
of rejection, negative reactions or accusations of indelity from partners can contribute to a
reluctance to use condoms.
e) Counsellor should discuss this point in detail. Discuss various strategies to convince the
partner e.g., it is advised for better health, to avoid pregnancy etc. Offer partner
counselling.
f) Lack of negotiation skills: Some individuals may feel uncomfortable discussing condom use
with their partner or may lack the communication skills necessary to negotiate condom use
effectively. Gender plays a vital role in sex. Women, persons from HRGs are vulnerable
because they do not have power in sexual relations. It is a common practice that the
decisions are taken by men. So, empowerment of the clients should be the goal of
counselling. Also, advocacy with men should be done.
g) Another important point to remember is that many individuals, though they have sex, do
not openly discuss about it. They do not communicate their concerns, likes, dislikes, etc. So,
encourage clients to have an open dialogue about it with their partners and convince them
for condom use.
h) Substance abuse: Alcohol or drug use can impair judgment and decision-making abilities,
leading to a decreased likelihood of using condoms during sexual encounters. Make the
clients aware of this and ask to take due precautions.
References
Revamped and Revised Elements of Targeted Intervention for HIV Prevention and Care Continuum
among Core Population.
Induction training module for Counsellors under National AIDS Control Programme, an Integrated
Training Module for ICTC, ART and STI counsellors, 2014
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Screening and Management of
11 Sexually Transmitted Infections and
Reproductive Tract Infections
What is STI and RTI?
Table 11.1 - What is STI and RTI
Sexually Transmitted Infection (STI) Reproductive Tract Infection (RTI)
STI spread primarily through person-to- RTI is any infection of the reproductive
person sexual contact. tract.
Most of the STIs can also be transmitted In women, it includes the infection of
from an infective mother to her infant vagina, cervix, uterus, fallopian tubes
during pregnancy, atlabour and through and/or in ovaries.
blood products and tissue transfer. In men, it may involve testes, scrotum
It is very common to have STI and not and/or prostate but may also involve
have any symptom. More than 50% of external genitalia.
cases of all STIs may be asymptomatic Some RTI are caused in the same way as
(without any symptom). STI. But RTI could also be caused by
Therefore, absence of signs/symptoms overgrowth of normal organisms in the
does not guarantee that a person is free reproductive system (e.g.,bacterial
from STI. vaginosis) or they could be infections
A person may be infected with more than caused by improper medical procedures
one STI at a time. such as catheterization, termination of
pregnancy or IUD insertion.
HIV can also be transmitted through
sexual route and is an STI. Practices like douching, multiple sexual
partners and inconsistent condom use are
also associated with increased risk of RTI.
Not all reproductive tract infections are sexually transmitted, and not all sexually
transmitted infections are located in the reproductive tract.
The term ‘sexually transmitted infection’ is usually used in place of STD (sexually
transmitted diseases) to indicate that infections do not always result in a disease. However,
all cases of STIs are important.
Epidemiology of STI/RTI
India has an estimated annual STI prevalence of 6% among the adult population. This would
amount to around 33 million STI episodes in the current scenario.Women living with HIV are
more likely to develop persistent HPV infections with multiple high-risk HPV types at an
earlier age. They also have a more rapid progression to pre-cancer and cancer and four to ve
times greater risk of developing cervical cancer than women who are not living with HIV.
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HANDBOOK FOR HIV & STI COUNSELLORS
Causative Agents
Viral Bacterial Protozoal Fungal Parasites
Name of STI/RTI
HIV Syphilis Trichomoniasis Candidiasis Pubic lice
Genital herpes Gonorrhoea Scabies
(HSV 2) Chlamydia
Genital warts Bacterial vaginosis
(HPV)
Hepatitis B
Hepatitis C
Signs, Symptoms and Syndromes of STI/RTI
A symptom is what a client/patient complainsabout or reports to a doctor or a counsellor.
A sign is the observation of a doctor or a counsellor on examination of a client/ patient.
A syndrome refers to a set of medical signs and symptoms that are correlated with each
other and often associated with a particular disease or disorder.
Asymptomatic patient: A person who shows no symptoms but still has an infection is called
asymptomatic. Even when asymptomatic, their health may become worse, and they can
transmit the infection to another person, such as their sexual partner or to the unborn child in
the case of a woman. They require to be diagnosed and treated timely.
Table 11.2 - Signs and Symptoms of STI/RTI in Men, Women and Transgender persons
Anatomical Part Symptom
Oral (With history Blisters or ulcers in mouth, tongue and lips
of oral sex) Sore throat
Voice changes, difficulty in speaking or shortness of breath
Male Genitalia Urethral Discharge
Burning/pain during urination
Increased frequency of urination
Genital itching
Swelling in groin area/scrotal swelling
Blisters or ulcers on the penis, foreskin, urethral meatus and urethra
Genital warts
Female Genitalia Unusual discharge from vagina
Abnormal or heavy vaginal bleeding
Genital itching
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Screening and Management of Sexually Transmitted Infections and Reproductive Tract Infections
Pain while having sex (dyspareunia)
Lower abdominal pain (below belly button/ pelvic pain)
Blisters or ulcers on internal/external genitals
Genital warts
Anal/peri-anal Anal discharge (with history of receptive anal sex)
area Blisters or ulcers on anus or surrounding area
Pain while passing stools
Anal or peri-anal itching
Anal/peri-anal warts
Generalized Fever, body ache, muscle pain, dark-coloured urine,infertility
symptoms/
presentation
Note:
The signs, symptoms and syndromes of STI/RTI among transgender persons correspond to their current
anatomy and physiology as well as their engagement in risky behaviour.
Adequate history taking is important to understand the symptoms of transgender persons. The history should
involve the sexual behaviour as well as the details of the gender affirmation procedures.
Relationship between STI and HIV infection
The predominant mode of transmission of both HIV infection and other STIs is the sexual
route.The presence of STIs increases the risk of HIV transmission and acquisition in sexual
exposure. There could be a 2–9-fold increased chance of HIV transmission in the presence of
genital ulcer and a 2–5fold increase in the presence of genital discharge. Management of STIs
reduces HIV transmission.
Concurrent HIV infection alters the natural history and manifestations of STIs.STIs are a marker
for high-risk behaviour that could also lead to HIV infection.STI/RTI in HIV-positive people can
increase viral load and shedding of virus in genital fluids.A higher viral load increases the
efficiency of HIV transmission risk to others.Sexually active PLHIV are also at risk for STIs, and
they will have to be screened for STI/RTI regularly.
Syndromic Case Management (SCM)
Syndromic case management of STI/RTI is a public health approach to treatment. In this
approach, the healthcare provider uses the symptoms reported by the patient as well as the
signs that he/she observes during the physical and internal examinations to identify the
syndrome affecting the patient and gives treatments for all infections (if not the most
common ones) that could possibly cause that particular syndrome.
The syndromic approach has been considered as the backbone of these services at the
designated STI/RTI clinics (DSRCs)alongwith optimum utilization of available on-site
diagnostics facilities without delaying the prompt treatment of patients.
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Advantages of Syndromic Limitations of Syndromic Case
Case Management Management
Prompt treatment: Patient is diagnosed and Not useful in asymptomatic
treated in one visit. patients
Highly effective for selected syndromes Over treatment if a patient has
Relatively inexpensive since it avoids the use of only one STI that causes a
laboratory tests syndrome
Scientifically tested Increases chances for the
Easy to learn and practise development of antibiotic
Easy integration into primary healthcare systems resistance
Standardized treatment regimens
STI/RTI syndromes
1. Urethral Discharge
2. Vagino-cervical Discharge
3. Genital Ulcer Disease – Non-Herpetic
4. Genital Ulcer Disease – Herpetic
5. Painful Scrotal Swelling
6. Inguinal Bubo
7. Lower abdomen Pain
8. Anorectal Discharge
Treatment kits
Treatment kits, containing various drugs, are prepared as per the clients’ symptoms. After
clinical examination and counselling, the kits are given to the clients. The kits are colour
coded. Refer to Annexure for more details.
Table 11.3 – Important considerations for STI/RTI management
Important considerations for management of all STI/RTI
Educate and counsel client and sexual partner/s regarding STI/RTI, safer sex practices
and importance of taking complete treatment.
Sexually active PLHIV are also at risk for STI and they will have to be screened for STI/RTI
regularly.
Treat partner/s.
Advise sexual abstinence or condom use during the course of treatment.
Provide condoms, educate about correct and consistent use.
Refer all patients to an integrated counselling and testing centre (ICTC) for HIV/STI
counselling and testing.
Follow up after 7 days for all STI; 3rd, 7th and 14th day for lower abdominal pain (LAP);
and 7th, 14th and 21st day for inguinal bubo (IB).
If symptoms persist, assess whether it is due to re-infection or treatment failure and
advise prompt referral.
Consider immunization against Hepatitis B.
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Syphilis
Table 11.4 - Key points about Syphilis
Syphilis Key Points
Causative agent Caused by the bacterial spirochete Treponema pallidum
Stages Primary Syphilis: The infected person may present with a painless ulcer
that may last up to 2 to 6 weeks and heal even without treatment.
Secondary Syphilis: Skin rashes, fever, muscle pain, lasts 2–6 weeks.
This stage may be followed by a latent stage for a few years. The
stage is characterized with no signs and symptoms. The bacteria may
circulate in blood during this phase leading to infection of all the organs
in the body.
Tertiary Syphilis: The stage occurs after several years of infection and
can manifest as neurosyphilis (when brain/spinal cord is affected),
cardiovascular syphilis (when heart and aorta are affected) or late
benign syphilis (when the skin is primarily involved). The complications
can develop in 40% of people with latent infection in absence of
treatment.
Serological Two types of tests: Treponemal (detect antibodies to T. pallidum
testing proteins) and non-treponemal (detect antibodies against lipoidal
antigens, damaged cells):
Treponemal tests: TPHA, TPPA
Non-treponemal tests: RPR, VDRL
Note: Both tests used for screening, confirming active infection or
determining disease activity and treponemal tests can remain positive
even in inactive or resolved cases.
PoC/Rapid Tests Many Point-of-Care (PoC) or rapid tests use treponemal tests for
syphilis detection
Treatment Syphilis can be successfully treated using injection Benzathine Penicillin
or STI colour coded kit -3 or 4
Refer to the national EVTHS (Elimination of vertical transmission of HIV and Syphilis) guidelines for more
information (Chapter 16 in handbook).
Coordination among Facilities and STI Services for Sex Workers, MSM, TS and
TG, PWID
Under the TI programme, linkages with DSRC for quarterly routine medical check-up (RMC)
are highly promoted as part of the Differentiated Prevention Strategies.
Camp-based approach is adapted for STI assessment and treatment at prioritized
hotspots.
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TIs are currently providing referrals and linkages to various other facilities for the treatment
of STI and Syphilis.
Inter-referrals have been promoted between DSRC, SSKs, ART centres and TI programmes
for STI, HIV and Syphilis testing and monitoring.
Clinical Management of STI/RTI in High-Risk Groups
Effective prevention and treatment of STI/RTI among these core groups requires attention to
both symptomatic and asymptomatic infections and have the following two components:
Points Component
Treatment of As per the national syndromic case management guidelines
Symptomatic
Infections
Screening and Regular medical check-ups should be conducted at least once every
treatment of three months, where the healthcare provider (HCP) takes history
Asymptomatic and carries out a clinical examination including internal examination
Infections to detect presence of infection/s.
Presumptive treatment for asymptomatic gonococcal and
chlamydial infections. This should be administered only to sex
workers, MSM and TS/TG during their first clinic visit and should be
repeated ONLY if there is no regular check-up for six months
consecutively.
Biannual serologic screening for syphilis for sex workers, MSM, TS/TG
and PWID.
Important points to consider
Sex workers and MSM, TS&TG should be encouraged to attend the STI clinic for periodic
routine health check-ups.
During the visit, the clinic staff should take a detailed history and perform an
examination.
Regular medical check-up should include oral, rectal and genital examinations including
proctoscopy for all those who have a history of receptive anal intercourse.
All high-risk groups should be counselled at every opportunity (in the clinic and in the
community) on the importance of using condoms.
Service providers should be sensitive to the needs of the MSM, TS/TG population groups
and be empathetic and non-judgemental while providing services.
As part of the Differentiated Prevention Strategies of the TI programme, quarterly
routine medical check-up (RMC) is highly promoted among the core groups and referred
to DSRC and camp-based approach for STI in prioritized hotspots/populations for high-
priority HRGs.
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Key Messages
Sexually transmitted infections (STIs) are spread primarily through person-to-person sexual
contact. HIV and syphilis can be transmitted from an infective mother to her infant during
pregnancy, atlabour (vertical transmission) and through blood products and tissue transfer.
The term ‘reproductive tract infection’ (RTI) refers to any infection of the reproductive tract.
The presence of STIs increases the risk of HIV transmission and acquisition in sexual
exposure.
The syndromic case management (SCM) approach has been considered as the backbone of
the services at Designated STI RTI Clinics (DSRCs).
Counselling plays a vital role in the management of STI /RTI..
Women and STI- Women are more prone to get STI because of biological and social
vulnerability.
Partner management is needed to prevent STI reinfection and possible long-term effects of
untreated STI for the partner.
Clients need to feel convinced that
- The benets are greater than the possible problems.
- Partner notication and treatment is needed even if the partner does not show any
symptoms.
- The partner will be provided with condential STI treatment services.
Under the TI programme, linkages with DSRC for quarterly routine medical check-up
(RMC) are highly promoted as part of the Differentiated Prevention Strategies. For
pregnant women, the national EVTHS guidelines can be referred for information and
details.
References:
NACO. (2014). Induction Training Module for Counsellors Under National AIDS Control Programme-
An Integrated Training Module for ICTC, ART and STI Counsellors. New Delhi: National AIDS
Control Organization, Ministry of Health and Family Welfare, Govt. of India.
NACO. (2017). National Strategic Plan for HIV/AIDS and STI, 2017- 2024-Paving Way for an AIDS
Free India. New Delhi: National AIDS Control Organization, Ministry of Health and Family Welfare,
Govt. of India.
NACO. (2018). National Technical Guideline on Anti-Retroviral Treatment. New Delhi: National
AIDS Control Organization, Ministry of Health and Family Welfare, Govt. of India.
Revamped and Revised Elements of Targeted Intervention for HIV Prevention and Care Continuum
among Core Populations, Strategy Document, NACO
National Operational Guideline for ART Services, NACO, 2021
National Guidelines for HIV Care and Treatment, NACO, 2021
NACO. (2022) National Guidelines on Elimination of Vertical Transmission of HIV and Syphilis
(EVTHS)
Medicine update, Chapter 84, Universal Work Precautions and Post-Exposure Prophylaxis (PEP) for
HIV Following needle stick Injury, Alok Vashishtha, BBRewari
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HANDBOOK FOR HIV & STI COUNSELLORS
Management of occupational exposure including post-exposure prophylaxis for HIV, January, 2009,
NACO
WHO Guidelines on Hand Hygiene in Health Care (Advanced draft) at:
http://www.who.int/patientsafety/information_centre/ghhad_download/en/index.html The SIGN
Alliance at: http://www.who.int/injection_safety/sign/en/
Notice published in the Gazette of India, Extraordinary, part II, section 3, subsection (i) dated 28th
March, 2018, Government of India, Ministry of Environment, Forest and Climate change.
CDC. (2019, May). Centers for Disease Control and Prevention. Retrieved from HIV/AIDS:
https://www.cdc.gov/hiv/basics/pep.html
International HIV/AIDS Alliance. (2006). Let's Talk About HIV Counselling and Testing-Facilitators'
Guide: tool to build NGO/CBO capacity to mobilise communities for HIV counselling and testing.
Brighton BN1 3XF, United Kingdom: International HIV/AIDS Alliance.
103
Screening and Management of Sexually Transmitted Infections and Reproductive Tract Infections
Annexure: RTI/ STI Syndromic Case management
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HANDBOOK FOR HIV & STI COUNSELLORS
Post-Exposure Prophylaxis,
12 Universal Work Precautions
and Pre-Exposure Prophylaxis
Post-Exposure Prophylaxis
Post-Exposure Prophylaxis (PEP) for HIV refers to comprehensive management instituted to
prevent the transmission of HIV following a potential exposure. The potential exposure for HIV
can be broadly categorized as occupational or non-occupational.
Occupational Exposure
Occupations exposure refers to exposure to blood-borne infections (HIV, Hepatitis B & C)
during performance of job responsibility in workspaces. Healthcare providers are prone to
accidental exposure to blood and other body uids or tissues while performing their work
duties. Standard workplace precautions are likely to mitigate the occupational risk of blood-
borne pathogens like HCV, HBV, HIV in healthcare personnel.
Health Care Personnel
Healthcare personnel (HCP)are dened as people, paid or unpaid, working in healthcare
settings who are potentially exposed to infectious materials (e.g., blood, tissue and specic body
uids and medical supplies, equipment or environmental surfaces contaminated with these
substances). Occupational exposure includes percutaneous injury (with needlestick or cut with
a sharp instrument), contact with mucous membranes of mouth/eyes and non-intact skin
(chapped skin or dermatitis) with blood and body uids of a HIV-infected person.
Non-occupational exposure
Non-occupational exposure refers to exposure to blood-borne infections (HIV, Hepatitis B & C)
outside occupational settings. This includes unsafe sexual exposures and sexual assault.
Risk of exposure from different body fluids
Exposure to body uids Exposure to body uids is
considered ‘at risk’ considered ‘not at risk’ unless
these uids contain visible blood
Blood, semen, vaginal secretions, cerebrospinal Tears, sweat, urine and faeces, saliva,
uid, synovial, pleural, peritoneal, pericardial uid, sputum, vomitus
amniotic uid Note: Unless these secretions contain
Other body uids contaminated with visible blood visible blood
Any direct contact (i.e., contact without barrier protection) to the concentrated virus in a
research laboratory requires clinical evaluation. Transmission of HIV infection after human
bites has been rarely reported.
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Post-Exposure Prophylaxis, Universal Work Precautions and Pre-Exposure Prophylaxis
Average Risk of Acquiring HIV, Hepatitis B, Hepatitis C after Occupational
Exposure
The average risk of acquiring HIV infection following different types of occupational exposure
is low compared to the risk of acquiring infection with HBV or HCV. In terms of occupational
exposure, the important routes are needlestick exposure (0.3 % risk for HIV, 9–30% for HBV,
and 1–1.8% for HCV) and mucous membrane exposure (0.09% for HIV).
Standard Workplace Precautions (SWP)
Universal precautions mean control measures that prevent exposure to or reduce the risk of
transmission of blood-borne pathogenic agents (including HIV) and include education,
training, use of personal protective equipment such as gloves, gowns and masks, hand
washing practices and employing safe work practices.These include the following:
Handwashing before and after all medical procedures;
Safe handling and immediate safe disposal of sharps: avoid recapping of needles; use
special containers for sharps disposals; use needle cutter/destroyers; use forceps instead
of fingers for guiding sutures; use vacutainers where possible.
Safe decontamination of instruments;
Use of protective barriers whenever indicated to prevent direct contact with blood and
body fluids such as gloves, masks, goggles, aprons and boots. Healthcare personnel with a
cut or abrasion should cover the wound before providing care.
Safe disposal of contaminated waste;
Always use protective gear: consider all blood samples as potentially infectious.
Follow universal precautions. Practise safe handling of sharp instruments. Use needle
destroyers.
Standard of care for individuals exposed to HIV
PEP services should be provided for all occupational/non-occupational exposures. Written
informed consent needs to be obtained for HIV testing from the person concerned. PEP
should be taken in accordance with the national HIV counselling and testing guidelines.
Everyone possibly exposed to HIV should be assessed by a trained healthcare worker
assessing eligibility for PEP, examination of any wound and first-aid treatment.
Practices that influence risk and how to reduce risk of occupational exposure
Certain work practices increase the risk of needlestick injury such asrecapping needles,
transferring a body fluid between containers, handling and passing needles or sharps after
use, failing to dispose of used needles properly in puncture-resistant sharps containers,
poor healthcare waste management practices etc.
Strict compliance with universal safety precautions will help the staff to stay safe.
All hospital staff members must know whom to report to for PEP and where PEP drugs are
available in case of occupational exposure.
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Management of the Exposed Person
PEP includes first aid, counselling, risk assessment and relevant baseline laboratory
investigations and depending on the risk assessment, the provision of short term (28 days) of
antiretroviral drugs, with follow-up and support including maintaining confidentiality.
The first dose of PEP should be administered ideally within 2 hours (but certainly within the
first 72 hours) of exposure and the risk evaluated as soon as possible. If the risk is
insignificant, PEP could be discontinued if already commenced.
Management of Exposure Site–First Aid (in case of occupational exposures)
Do not panic.
PEP must be initiated as soon as possible, preferably within 2 hours of exposure.
For skin: If the skin is pierced by a needle For the eye
stick or sharp instrument Irrigate the exposed eye immediately
Immediately wash the wound and with water or normal saline.
surrounding skin with water and soap Sit in a chair, tilt the head back and ask a
and rinse. colleague to gently pour water or normal
Do not scrub. saline over the eye.
Do not use antiseptics or skin washes. If wearing contact lenses, leave them in
Do not use bleach, chlorine, alcohol, place while irrigating, as they form a
betadine. barrier over the eye and will help protect
it. Once the eye is cleaned, remove the
Do not put pricked/cut finger in the
contact lenses and clean them in the
mouth, a childhood reflex.
normal manner. This will make them safe
to wear again.
Do not use soap or disinfectant on the
eye.
After a splash of blood or body fluids and For the mouth
for unbroken skin Spit fluid out immediately.
Wash the area immediately. Rinse the mouth thoroughly, using water
Do not use antiseptics. or saline and spit again. Repeat this
process several times.
Do not use soap or disinfectant in the
mouth.
Establish Eligibility for PEP
The exposed individual should have confidential counselling and assessment by an
experienced physician. The exposed individual should be assessed for pre-existing HIV
infection as PEP isintended for people who are HIV negative at the time of their potential
exposure to HIV. Exposed individuals who are known or discovered to be HIV positive should
not receive PEP. They should be offered counselling and subsequently link to comprehensive
HIV services. Consult the designated physician of the institution for management of the
exposure immediately.
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Post-Exposure Prophylaxis, Universal Work Precautions and Pre-Exposure Prophylaxis
Counselling for PEP
For an informed consent, exposed persons (clients) should receive appropriate information
about what PEP is and the risks and benefits of PEP. It should be made clear that PEP is not
mandatory. The client should understand details of the window period, baseline test, drugs
that are used, their safety and efficacy and issues related to these drugs during pregnancy
and breastfeeding. He/ she should be counselled on safe sexual practices.
Psychological support: Many people feel anxious after exposure. Every exposed person
needs to be informed about the risks and the measures that can be taken. This will help to
relieve part of the anxiety, but some may require further specialized psychological support.
Considerations for non-occupational exposures
In cases of sexual assault, PEP should be given to the exposed person as a part of the overall
package of post-sexual assault care. The cases of unsafe risky sexual exposures should be
evaluated for eligibility of PEP and can be advised PEP if eligible. The cases should be
evaluated for STI and managed according to the national STI algorithms. For children who
have suffered assault must be administered PEP, the dosage should be as per age and weight
bands and haemoglobin levels. In all cases, appropriate and adequate counselling must be
provided regarding possible side effects, adherence and follow-up protocol.
The victims of sexual assault should additionally receive the following services:
Emergency contraception for non-pregnant women;
Tetanus toxoid for any physical injury of skin or mucous membranes;
Referral to appropriate authority.
Expert opinion may be obtained in situations like any delay in reporting exposure (> 72
hours),unknown source, known or suspected pregnancy (do not delay PEP initiation),
breastfeeding issues, source patient is on ART or possibly has HIV drug resistance, major
toxicity of PEP regimen etc. Refer/consult if in doubt or complicated cases (e.g., major
psychological problem).
Follow-up
Follow up the client at 7 days, 14 days, 28 days and 12 weeks after starting PEP; follow up HIV
testing at 4 weeks, if negative, test again at 12 weeks; management of side effects due to
PEP.
Pre-Exposure Prophylaxis
Pre-exposure prophylaxis (PrEP) refers to the use of antiretroviral medication to reduce the
chances of getting infected by people at risk of acquiring HIV infection. It is highly effective
and provides significant protection against HIV infection.
Eligibility for PrEP
PrEP shall be offered to sexually active HIV-negative individuals who are at substantial risk of
acquiring HIV. It is important that a careful evaluation is done for assessing the risks and
benefits before prescribing PrEP to individuals. To be eligible for PrEP, persons must meet all
the following criteria:
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HANDBOOK FOR HIV & STI COUNSELLORS
Confirmed HIV negative, using rapid antibody testing, following the HCTS algorithm on the
day of PrEP initiation;
At substantial risk of acquiring HIV infection;
No contraindication to use of any medication used for PrEP;
Does not have a current or recent (within the past one month) illness suggestive of acute
HIV infection along with a history of probable exposure to HIV.
Assessed as ready to adhere to PrEP and willing to attend follow-up evaluations including
repeated HIV testing and monitoring.
Benefits of PrEP
PrEP adds another effective HIV prevention option to the list of prevention strategies. It can
be provided as an additional method to help protect people who are unable to negotiate
condom use with their partner(s), or people who inject drugs but are not able to obtain new
injection equipment, or people who do not use condoms or new injection equipment
consistently.
PrEP does not eliminate the risk of HIV infection and it does not prevent STIs or unintended
pregnancies. It should, therefore, be offered as part of a combination prevention package
that includes risk reduction counselling, HIV testing, condoms and lubricants, STI screening
and treatment, contraception, needle exchange and opioid replacement therapy. It is not to
be consumed lifelong, but can be started during periods of higher risk and stopped during
lower risk periods.
Special Situations
There are situations that call for special attention and care of clients under PrEP. Patients with
certain clinical/ special conditions require special attention and follow-up by the clinician such
as the following:
Pregnancy
PrEP may be initiated or continued during pregnancy in women at substantial risk of HIV
acquisition. If a sero-discordant couple desires pregnancy, PrEP can be one of the strategies
for safer conception. Clinicians should educate HIV-discordant couples who wish to have a
child about the potential risks and benefits of all available alternatives for safer conception
and if indicated, make referrals for assisted reproduction therapies.
The clinicians should also discuss with them about the available information related to
potential risks and benefits of beginning or continuing PrEP during pregnancy so that an
informed decision can be made. Once the decision of taking PrEP is made, the clinician must
ensure that
The HIV positive partner is on ART and virally suppressed;
PrEP is initiated at least 20 days ahead of unprotected sex;
Most fertile period may be advised to the couple for increasing chances of conception.
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Post-Exposure Prophylaxis, Universal Work Precautions and Pre-Exposure Prophylaxis
Breastfeeding
PrEP may be initiated or continued during breastfeeding in women at substantial risk of HIV
infection. If a woman becomes infected with HIV during breastfeeding, the risk of
transmission to the infant may be higher because of high viral load during sero-conversion.
Therefore, PrEP should be initiated or continued in women who are at substantial risk.
Hepatitis B
Hepatitis B vaccination is recommended for people at substantial risk of HBV or HIV infection.
Vaccination should be considered if there is no documented history of a completed vaccine
series for HBV. PrEP can be provided whether or not HBV vaccination is available. For clients
with HBV infection, care should be taken as per the National Technical Guidelines for PrEP.
PrEP Regimens
A combination of two anti-retroviral drugs is recommended:
Tenofovir disoproxil fumarate (TDF) + emtricitabine (FTC)/ lamivudine (3TC) daily
Important Considerations for PrEP
Consistent and correct condom use should be promoted along with PrEP.
PrEP should be initiated only after eligibility assessment.
It should be taken as prescribed by the doctor. If the client is not willing to take PrEP as per
advice, the HCP can choose not to provide PrEP.
PrEP can be used to reduce the risk of HIV transmission in high-risk sexual encounters and
injecting drug use. It may also be used for safer conception in HIV-discordant couples.
Follow-up should be continuous and as per the advice of the doctor. Regular investigations
(e.g., HIV screening, KFT etc.) should be ensured for continued prescription. The first
follow-up should be after 30 days. Regular follow-up should be after 90 days.
Key Messages
Awareness about PEP: Counsellors should provide information to the healthcare staff that
post-exposure counselling and HIV testing facilities are available at the ICTC. Information
on PEP should also be given.
In case of exposure, do the pre-test counselling to the client. The client might be anxious/
panic due to the exposure. Address the concerns and provide support. Discuss first aid.
Ensure that first aid is taken care of.
Explain that the chances of HIV infection are low (compared to infection through other
sources) in case of injuries at the hospital. Give information on PEP and discuss how this
measure may help him/her.Also discuss details like eligibility assessment, how many days to
take it, side effects etc.
Do not assume that all healthcare workers have adequate information about the spread
and consequences of HIV, HBV and HCV. Provide the information. Discuss the window
period. Counsel as you do it for other clients.
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HANDBOOK FOR HIV & STI COUNSELLORS
Correct the myths about HIV, HBV and HCV, if any. Assess if the client has any
misconceptions about PEP. If yes, correct them.
Send all the clients for occupational/non-occupational exposure to the medical officer for
clinical assessment. If the client is put on PEP drugs, do adherence counselling.
Discuss universal safety precautions.
Some people are always prone to injuries and accidents. So, if some clients are coming
again and again due to injuries, assess the reasons and address them. E.g., Some people
are always anxious and so prone to injuries as they cannot focus on the tasks; some people
do not care for self, some people are overconfident and do not perceive the risk etc.
Common PrEP Myths
1. You do not need to use condoms on PrEP.
2. You can start taking PrEP after you’ve been exposed.
3. PrEP is only for gay men.
4. You do not need to take PrEP every day.
These myths should be addressed in counselling.
References
National Technical Guidelines for Pre-Exposure Prophylaxis, NACO
National Operational Guideline for ART Services, NACO, 2021
National Guidelines for HIV Care and Treatment, NACO, 2021
Rebecca G. Kinney, M. D. (2018). Occupational Postexposure Prophylaxis. National HIV Curriculum,
1- 29.
WHO. (2014). Guidelines on Post-Exposure Prophylaxis HIV and the use of CO-TRIMOXAZOLE
Prophylaxis for HIV Related Infections among Adult, Adolescents and Children: Recommendation for
a Public Health Approach. Geneva, Switzerland: World Health Organization.
Statutory Orders and Notications Issued by the Ministries of the Government of India (Other than the
Ministry of Defence), The Gazette of India, July 9, 2022/ASADHA 18, 1944
The Human Immunodeciency Virus and Acquired Immune Deciency Syndrome (Prevention and
Control) Act, 2017
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Anti-retroviral Treatment
13 and Management of PLHIV
Objectives of ART centre
The main objective of an ART Centre is to provide a comprehensive package of care, support
and treatment services that are effective, inclusive, equitable and adapted to the needs of
PLHIV.
Functions of ART centres
ART centres are mandated to give comprehensive and holistic care to PLHIV. Functions of
ART centre can be categorized as medical, psycho-social and programmatic as indicated below:
Category Key Functions
Medical Provide ART to all PLHIV
Functions
Provide baseline and follow-up investigations to PLHIV, including
CD4 cell count and viral load testing
Provide prophylaxis and management of opportunistic infections
Provide TB preventive and management services as per guidelines
Identify PLHIV with advanced HIV disease for appropriate
management and refer to higher level of care as needed to reduce
mortality
Monitor, manage and follow up PLHIV for adherence, retention and
adverse effects (if any)
Referral/e-referral of PLHIV with treatment failure to SACEP for
review for second line/third ART and complicated adverse effects
Psycho-social Provide linkages with other health services, including non-
Functions communicable diseases and other comorbidities
Provide psychological support to PLHIV and caregivers
Provide counselling for adherence to ARV drugs
Educate PLHIV on proper nutrition and healthy living
Assist in the disclosure of HIV results to spouse/family
Counselling for testing of spouse/partners/children
Step up counselling to PLHIV who have poor adherence and are
virally unsuppressed
Provide appropriate counselling to PLHIV belonging to special groups
(key population, children, adolescents, migrants, pregnant women
etc.)
Facilitate linkages to access social protection schemes
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HANDBOOK FOR HIV & STI COUNSELLORS
Programmatic Contribute to achieving goal of 95:95:95 to ‘End the AIDS’ epidemic
Functions as a public health threat by 2030 in line with Sustainable
Development Goals (SDG)
Proper recording and timely reporting as per national guidelines
Tracking of missed for ART rell (MIS) and lost to follow-up (LFU)
cases in coordination with DAPCU, CSC, ICTC, link workers, TI
NGO and other NGO approved by NACO/SACS
Coordination with National Tuberculosis Elimination Programme
(NTEP) for management of HIV-TB co-infected patients and to
ensure availability of drugs for anti-TB treatment (ATT) and TB
preventive treatment (TPT)
Mentoring the LAC and coordination with LAC staff for ARV drug
indent, monthly reporting CD4 and viral load test
Sensitize hospital staff on care support and treatment (CST) services
Link Art Centres
This is a differentiated service delivery model for decentralized ART services near the
patient’s residence rolled out in 2008.
The goal of this model is to make treatment services easily accessible to PLHIV and promote
adherence by addressing the barriers associated with inconvenience due to frequent visits,
need for long-distance travel and cost to the patients. These main functions of LACs include
Monitoring PLHIV on ART;
Drug refill to patients on ART;
Treatment of minor OIs;
Identification and management of adverse effects and reinforce adherence on every visit.
Anti-Retroviral Treatment for HIV
The primary goals of ART are maximal and sustained reduction of plasma viral levels and
restoration of immunological functions. The reduction in the viral load also leads to reduced
transmissibility and a reduction in new infections. The defined goals of ART are depicted in
Table 13.1:
Clinical goal: Increased survival and improvement in quality of life
Virological goal: Greatest possible sustained reduction in viral load
Immunological goal: Immune reconstitution, that is both quantitative and qualitative
Therapeutic goal: Rational sequencing of drugs in a manner that achieves clinical,
virological and immunological goals while maintaining future treatment options, limiting
drug toxicity and facilitating adherence
Preventive goal: Reduction of HIV transmission by suppression of viral load.
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Anti-retroviral Treatment and Management of PLHIV
Principles of Anti-retroviral Therapy
A continuous high level of replication of HIV takes place in the body right from the early
stages of the infection. At least one billion viral particles are produced during the active stage
of replication. Anti-retroviral drugs act on various stages of the virus replication in the body
and interrupt the viral replication process. The ARV drugs act on viral replication and are
labelled according to the site of their action.
Benefits of ART
• It prolongs life. • It reduces mother-to-child transmission
• It improves the quality of life. of HIV.
• It decreases occurrences of OIs. • There are fewer orphans.
• Livelihood can stay intact. • There is a decreased stigma surrounding
HIV infection since treatment is now
• Households can stay intact. available.
• HIV transmission is lowered.
Side-effects of ARV drugs
Counsellor may also explain ART to client in the following manner:
As a counsellor, you can advise your client to begin ART as soon as they are diagnosed
with HIV.
ART does not cure HIV. Therefore, the body will need the medications every day in order
to stay healthy.
Healthy behaviours such as a good diet, exercise, adequate rest and abstaining from
drugs/smoking/alcohol are important habits to begin adopting.
Drug side effects are unwanted and undesirable effects to a drug. These happen in some
patients and can be mild, but rarely severe.
As a counsellor, you should tell the patients about the very common sideeffects and
suggest ways that these can be managed by the patient.
It will help if you tell them what they can expect. This is called anticipatory guidance.
You should also help them understand how they can get advice on managing other
sideeffects or any worries they have. Teach them how to use the Treatment Education
Leaflets.
Explain to the patient that many patients experience an adjustment period when starting
a new therapy.
Tell them that this period usually lasts about four to six weeks when the body adapts to
the new drug. During this time, some patients may experience headache, nausea, muscle
pain and occasional dizziness.
Tell your client that most of these sideeffects lessen or disappear as the body adjusts to
medication. As the stable patients on ART for at least six months are linked out to LACs, it
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HANDBOOK FOR HIV & STI COUNSELLORS
is unlikely that a counsellor at the LAC will come across short-term or medium-term
toxicities. Thus, counsellors need to educate the clients about chronic toxicities.
A counsellor may be able to identify signs of treatment failure and refer the client to a
physician in a timely manner so that necessary changes in treatment may be made.
Considerations before Initiation of ART
All people with confirmed HIV infection should be referred to the ART centre for registration
in HIV care. The following principles need to be kept in mind:
Principles Details
Preparedness counselling The patient should be adequately prepared, and informed
consent should be obtained before HIV care and ART.
Caregiver support Each patient should have an identified caregiver. Caregivers
must be counselled and trained to support treatment,
adherence, follow-up visits, and shared decision-making.
Co-trimoxazole preventive Patients with clinical stages 3 and 4 or CD4 count < 350
therapy (CPT) cells/mm3 must be put on CPT.
TB screening and All patients should be screened for TB using the 4S-symptom
preventive therapy tool (cough, fever, night sweats, weight loss) and those who
do not have TB need to be started on preventive therapy
(TPT) in addition to ART.
OI Treatment before ART ART should not be started in the presence of an active OI.
All PLHIV are clinically evaluated and existing active OIs
should be treated or stabilized before commencing ART. The
OIs and HIV-related illnesses need treatment or stabilization
before commencing ART.
All persons diagnosed with HIV infection should be initiated on ART regardless of the CD4
count or WHO Clinical Staging or age group or population sub-groups.
The current NACO guidelines (2021) on when to start ART
Ensuring good adherence to treatment is imperative for the success of the treatment as well
as for the prevention of drug resistance. To achieve this, counselling must start from the first
contact of the patient with the clinical team. Counselling should include preparing the patient
fo r t re a t m e n t a n d p rov i d i n g p s y c h o - s o c i a l s u p p o r t t h ro u g h a n i d e n t i fi e d
caregiver/guardian/treatment buddy and support networks. All patients should undergo
counselling sessions (preparedness counselling) and co-trimoxazole prophylaxis, TPT (after
assessment of patients, when prescribed by MO ART centre).
All efforts should be made to trace the patients who have defaulted on their visits or are lost
to follow- up to initiate ART in all PLHIV registered at the ART centres. NGOs and positive
network linkages should be established by each ART centre for its respective locality.
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Anti-retroviral Treatment and Management of PLHIV
Counsellors should use seven-point counselling tool for ART preparedness (attached as
annexure) to guide them through the process.
Step 1: Education about HIV and ART
Step 2: Identify the patient’s motivation to stay alive and healthy
Step 3: Identification of caregiver
Step 4: Identify the potential barriers to adherence or retention
Step 5: Identify strategies to ensure good adherence
Step 6: Devise a treatment plan that suits the patient the best
Step 7: Plan for the next appointment
Rapid ART Initiation for Newly Diagnosed PLHIV at ART Centre
The introduction of the ‘Treat All’ recommendation supports the rapid initiation of ART,
including the offer of same-day initiation where there is no clinical contraindication. Rapid
ART initiation is defined as “ART initiation within seven days from the day of HIV diagnosis”.
Following a confirmed HIV diagnosis and clinical assessment, same day/rapid ART initiation
should be offered to all PLHIV adequately prepared and ready for initiation. However, if an
active OI is present, ART initiation may be deferred as required.
PLHIV who do not have any such conditions can be fast tracked for ART initiation.
PLHIV who have any such symptoms would require further evaluation for diagnosis and
management of common OIs/advanced HIV disease/comorbid conditions before ART
initiation.
CD4 recovery
CD4 cells are the soldiers of our body, who fight germs from causing infection in the body.
HIV virus makes a home in the CD4 and reduces its number and function.
A baseline CD4 count before ART initiation is essential to determine the need for starting co-
trimoxazole prophylaxis therapy (CPT) and the baseline immunological status of PLHIV. Even
when the viral load testing is routinely done, CD4 monitoring remains relevant in certain
situations. CD4 counts are essential for diagnosing IRIS, stopping CPT, monitoring PLHIV with
HIV-2 and HIV-1 and 2 co-infection. Timing of testing should be adjusted so that samples for
both CD4 and VL testing can be collected by a single prick
CD4 monitoring can be stopped for any HIV-positive patient, aged more than 5 years, if the
CD4 count is greater than 350 cells per cubic millimetre and viral load count is less than or
equal to 1000 copies per ml, when both tests are conducted at the same time. CD4 testing
should be restarted if the patient has suspected treatment failure that is virological failure
(more than 1000 copies/ml) or suspected clinical failure or if the patient has undergone a
switch in regimen.
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HANDBOOK FOR HIV & STI COUNSELLORS
Figure 13.1 - Rapid ART initiation algorithm in PLHIV
(Adopted from national guidelines for HIV Care and Treatment 2021 )
Symptoms screening Yes, for any
Cough/fever/weight loss/night sweats/ symptoms
persistent/other serious symptoms
No
Physical examination
Signs & serious illness
1. Temperature >39°C
2. Respiratory rate >30/min
3. Heart rate >120/min
4. Altered mental status
(e.g. confusion, strange behaviour, Yes, for any
reduced consciousness) symptoms Appropriate diagnosis,
5. Other neurological conditions (seizures, management! Expert
paralysis/pares is, difculty in talking, consultation/ Referral,
rapid deterioration of vision, neck if required
stiffness )
Day 1 6. Unable to walk unaided
7. Any other condition that requires
emergency management
No
Comorbid conditions Yes, for any
• Whether the patient has TS? comorbid
• Whether the patient has known history of condtion
kidney diseases or uncontrolled diabetes
or hypertension
No
Readiness assessment
• Preparedness counselling
• For PLHIV with psychosocial concerns or
comorbid substance use, involve relevant
persons like family members, relatives,
peers, counsellors, etc. for enhanced
counsell ing and support
Day 1 Initiate ART- Preferably same day
preferably (if patient is ready)
• ART to be dispensed for one month
• Concurrently send samples for CD4 count
and other baseline investigations as per
NACO guidelines
ART initiation
as soon as
appropriate action
Follow-up has been taken
• Review test result: If test reports are not (as per NACO
normal, PLHIV to be called back to ART guidelines) ,
centre (as soon as possible, within 2 depending on the
weeks of ART initiation) reason for deferral
Within
• ART counsellor to call all patients & ask (opportunistic
3-5 days
about general well-being of patients infection,
preferably
within 2 weeks of ART initiation comorbidity,
• Medical ofcer should do appropriate etc.)
management of Advanced Disease,
adjustments in ART regimen, OI prophylax
is, co-morbidity management, etc.
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Anti-retroviral Treatment and Management of PLHIV
Viral Load
Section 2.2.7 of National Guidelines for HIV Care and Treatment says “Dolutegravir causes
rapid viral suppression: It helps in achieving rapid viral suppression. It has been found to
reduce the viral copies to <50 copies/ml within 4 weeks and this helps reduce the chances
of transmission.”
Chapter 2.7, under Timing of Viral Load testing: “For all patients on first-line ART, plasma
viral load testing should be done at 6 months and 12 months after ART initiation and
thereafter annually.”
For all patients on second-or third-line ART, plasma viral load testing should be done every
6 months after initiation of second- or third-line ART.
The medical officer can request for additional plasma viral load test when deemed
necessary for clinical management (e.g., during one drug substitution, new clinical event).
Plasma viral load testing is recommended for all HIV-positive pregnant women during 32 to
36 weeks of pregnancy (regardless of duration of ART) to determine the risk of HIV
transmission to the baby.
When to Suspect Treatment Failure:
Suspect treatment failure when viral load is more than 1000 copies/ml.
CD4 counts are monitored in PLHIV with HIV-2 infections, or combined HIV-1 and 2
infections.
When to Suspect Treatment Failure:
Suspect treatment failure when viral load is more than 1000 copies/ml.
CD4 counts are monitored in PLHIV with HIV-2 infections, or combined HIV-1 and 2
infections.
Factors contributing to treatment failure
Table 13.1 - Factors contributing to treatment failure
Contributing Factor Explanation
Not taking HIV virus is an error-prone virus and makes errors during
medications as replication. With poor adherence, virus replication increases,
prescribed (Daily at the new virus is a mutant virus similar to COVID virus (delta
a fixed time, without variant etc.) and ART may not work on the new virus.
missing even one Drug interactions can also reduce the drug levels and make
dose) ART ineffective, especially since DTG interacts with multi-
vitamins, antacids, iron, calcium etc. DTG should be given 2
hours before or 6 hours after these medications.
As frequency of missing doses increases, number of mutant
viruses increase leading to ART regimen not being effective
and leads to treatment failure.
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Follow-up and Monitoring
Step up adherence counselling in patients with poor adherence and unsuppressed viral
loads (VL>1000 copies/ml)
Step-up adherence counselling is important in understanding possible reasons for non-
adherence in a patient and then providing guidance to form an adherence plan. The
counsellors should try to review psychological, behavioural, emotional and socio-economic
factors that may lead to non-adherence in a patient and provide customized counselling with
the objective of improving adherence to treatment.
A minimum of three sessions are recommended for step-up adherence counselling but
additional sessions can be conducted as needed. (Table below provides details of each
session.) If the adherence of the patient is found to be adequate, a repeat viral load test is
conducted 3 months after the suspected treatment failure point to assess the benefits of
step-up adherence counselling. It is preferred that all counselling sessions are done by the
same counsellor to ensure consistency, continuity, and proper documentation of issue
resolution. These sessions can be conducted when the patient visits to collect his/her
medication.
Table 13.2: Overview of step-up adherence counselling sessions
Counselling Session Counselling Issues to be handled
Session 1 Review patient’s understanding of viral load and discuss possible
(Just after test reasons for high viral load
results indicating i. Assess possible barriers to adherence:
suspected
• Knowledge of medication – dosage and timing
treatment failure)
• Motivation to take medicines
• Patient response to side effects (if any)
• Mental health (check for depression and other reasons)
ii. Discuss the patient’s support systems.
iii. Check the patient’s history with referral services such as
support groups, medical clinics and evaluate their response to
such services.
iv. Support patient in developing an adherence plan that addresses
the identified issues.
v. Check the patient treatment adherence (both pill adherence
and appointment adherence) in the treatment card to create a
baseline.
Session 2 Review patient adherence between first and second sessions and
(15 days or 1 month – discuss any emerging issues or gaps.
as deemed fit by i. Follow up on any referral services that the patient undertook
the counsellor at post the first session.
ART centre after ii. Support patient in modifying the adherence plan to tackle the
Session-1) identified issues.
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Anti-retroviral Treatment and Management of PLHIV
iii. Check patient treatment adherence again, and record it in the
white card on a regular basis.
Session 3 Review patient adherence between second and third sessions and
(15 days or 1 month discuss any emerging issues or gaps.
as deemed fit by i. Support patient in modifying the adherence plan to tackle the
the counsellor at identified issues.
ART centre after
ii. Decide next course of action based on adherence:
Session- 2)
• If adherence is good, plan a repeat plasma viral load test post
3 months of good adherence.
• If adherence is not adequate, plan further sessions with the
patient before repeating plasma viral load test. Explain the
importance of adhering to the treatment and risk of
treatment failure due to non-adherence.
Session after repeat Discuss results of the repeat plasma viral load test.
plasma viral load I. Decide next steps based on repeat plasma viral load test
test results:
If plasma viral load count <1000 copies/ml, appreciate the
patient for his/her success and suggest continuation of current
regimen; repeat plasma viral load as per the scheduled
frequency of the patient.*
ii. If plasma viral load count ≥1000 copies/ml, prepare the patient
for a change in regimen.
Note: On a case-by-case basis, in critically ill patients with high plasma viral load, all the counselling sessions
may need to be completed over a shorter span of time.
Next Viral load test to be done after 12 months of the last viral load test in PLHIV on first-line ART
Next Viral load test to be done after 6 months of the last viral load test in PLHIV on second-line ART
Substitution versus Switch
Substitution refers to replacement of ARV drug(s) in PLHIV due to adverse effects of drug,
drug–drug interactions or programme policy. This does not indicate change of regimen due to
treatment failure.
Switch refers to the loss of antiviral efficacy to the current regimen. When the entire regimen
is changed because of treatment failure, it is referred to as the switch. Currently, the national
HIV programme provides free first line, second line and third line ARVs to more than 16 lakh
patients through these ART Centres. (NACO, 2023)
What is U=U
Undetectable means the amount of HIV in the blood is too low to be detected in viral load
test and report comes as TND (Target Not Detected). It means that PLHIV who achieve and
maintain an undetectable viral load by taking ART daily as prescribed cannot sexually transmit
the HIV virus to others.
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Undetectable = Untransmittable is applicable only for sexual and vertical route of transmission
but not for the people sharing needle and blood transfusion.
U=U (TND) has the power to dismantle HIV stigma and discrimination by giving life with HIV a
new face; because ART helps PLHIV have long, healthy lives, achieve viral suppression and
prevent transmission to people they have sex with, HIV no longer needs to be viewed as a
death sentence and people with HIV shouldnot be viewed as posing a risk to other people. As
such, the stigma and discrimination associated with fears of death and transmission can be
alleviated.
There are specific challenges in adapting U=U (TND):
It may take as long as six months of treatment to achieve viral suppression, and viral
suppression must be maintained to ensure that the virus is not transmitted to a sexual
partner.
U=U does not mean that the person living with HIV is cured of HIV.
Adherence to daily treatment: Taking HIV medicine as prescribed is required to achieve
and maintain an undetectable viral load. Poor adherence, such as missing multiple doses in
a month, increases a person’s viral load and their risk for transmitting HIV.
TND or undetectable viral load results: Virus migrates from blood vessels and settles
down and rests in reservoirs and hence blood test does not show the viral count. As virus
is not present in blood and secretions, patient does not transmit the virus to sexual partner.
If patients stops/misses the medicine, the virus will wake up and start replicating and
reappear in the blood vessels.
- Knowledge of viral load: Regular viral load testing is critical to confirm that an
individual has achieved and is maintaining an undetectable viral load. Ensuring that
demand generation is in place and increasing knowledge among the PLHIV is needed
and remains a challenge.
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- Protection against other STIs and pregnancy: Maintaining an undetectable viral load
does not protect from getting other STIs or pregnancy. Other prevention strategies,
such as condom use, are needed to provide protection from STIs and pregnancy.
- Low awareness about the benefits of viral suppression: Knowledge of the prevention
benefits of viral suppression may help motivate people with HIV and their partners to
adopt this strategy.
- If you inject drugs, never share needles or injection equipment with anyone else. Even
if the amount of HIV in your blood is so low that a test cannot detect it, you can still
pass HIV to someone if you share needles or injection equipment with them.
State AIDS Clinical Expert Panel (SACEP)
Table 13.3 – About SACEP
Need for SACEP Patients with suspected ARV treatment failure, severe adverse effects
and complicated clinical cases are referred for review by a panel of
experts called State AIDS Clinical Expert Panel (SACEP) at Centre of
Excellence /ART plus centres for further evaluation and timely
switch/substitution to appropriate ART.
Constitution SACEP is constituted at Centre of Excellence (CoE) and at ART plus
andmeeting centre by the Programme Director of CoE and the Nodal Officer of the
schedule ART plus centre respectively. SACEP meets weekly at the Centre of
Excellence (CoE) or paediatric CoE (pCoE) or ART plus centre to review
all cases referred in that week and in case of high backlog, SACEP may
meet more than once a week
Functions of 1. Review and determine eligibility for switching to an appropriate
SACEP ART regimen for cases referred by attached ART centres. Prescribe
the new regimen if required.
2. Review and decide on the substitution of appropriate alternative
ART regimens if necessary for cases referred by attached ART
centres. Prescribe the new regimen if substitution is decided.
3. The SACEP coordinator organizes meetings, coordinates with panel
members, communicates recommendations to referring ART
centres and ensures patient follow-up according to SACEP
guidance. SACEP reports will also sent to SACS and NACO.
When should a 1. Patients with suspected ARV treatment failure (If VL ≥1000
patient be copies/ml even when treatment adherence is more than 95% for
referred to three consecutive months)
SACEP?
2. Patients with suspected moderate to severe ARV adverse effects
to decide for substitution of one/more ART drugs of different class
3. PLHIV with drug-related complications or management of severe
OIs that cannot be managed at ART centres
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4. Patients from private sector on a regimen other than preferred
regimen under NACP can be referred to SACEP after enrolment
under care at the ART centre for opinion about most suitable
regimen under the programme for them.
Step-up PLHIV with viral load ≥1000 copies/ml should undergo stepwise
adherence adherence counselling for three months. Repeat viral load testing
counselling and (along with other lab investigations) must be done once treatment
e-referral to adherence is >95% for three consecutive months. Patient should be
SACEP for review simultaneously informed that in case VL is not suppressed, e-referral
for second/third will be done to SACEP and he/she would be called back to ART centre
line for switch (based on SACEP recommendation).
Key Messages
• ART includes drugs that act at various stages of the HIV life cycle to interrupt HIV
multiplication. It delays the progression of HIV by reducing viral load, improving CD4 count
and thus the immune system, prolongs life and improves its quality.
• The counsellors should advise PLHIV to begin ART as soon as they are diagnosed with HIV.
ART should be started as early as possible after the HIV diagnosis and continued for life,
following the national guidelines and the advice of the healthcare provider.
• Before initiating ART, the patient should be prepared, consented, screened for TB and OIs
and prescribed CPT and TPT as needed.
• Preparedness counselling is vital before initiating the ART. Explain the role of ART medicine
in managing HIV. Explain how ART works (Refer Annexure ).
• High degree of adherence is essential for optimal virological suppression and therefore
counsellors should identify PLHIV having risk factors associated with poor adherence or
poor retention such as financial/distance-related issues, migration, lack of understanding,
mental health, comorbidity/co-infection, advanced HIV disease, alcoholism, substance
abuse etc., and must provide individualized focused counselling.
• Quality counselling sessions for preparedness should be continued even after ART
initiation, especially, during the first three months of starting ART. A minimum of four
sessions should be done as part of preparedness counselling. Peer counselling should also
be a part of the initial counselling.
• Counsellors should explain U=U policy to the clients. Undetectable =Untransmittable (U=U)
means that persons with a consistently undetectable viral load have minimal chance of
transmitting the virus sexually to their contacts, if adherent to ART. Explain, “If you are
taking the treatment as directed, the virus will be supressed and not detected in the
blood. This means that you have achieved an important milestone in your treatment.
Though the virus is not eradicated, there are less chances that the virus is transmitted to
another person.”
• Patients with suspected ARV treatment failure, severe adverse effects and complicated
clinical cases are referred for review by a panel of experts called SACEP. A counsellor may
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be able to identify signs of treatment failure and refer the client to a physician in a timely
manner so that necessary changes in treatment may be made.
• How Counsellors Can Explain Adherence to PLHIV
Explain how ART works and prepare the client to initiate ART.
- Our body has an immune system that protects us from getting sick, just like a house
protects us from the rain and cold.
- If left untreated over time, the HIV virus will take over a body’s immune system, leaving
a person ill with OIs, just like a house that is left uncared for.
- If a person is sick from HIV, he/she can begin taking medicines called anti-retroviral
treatment. These medicines reduce the amount of HIV in the body. As a result, the
body’s immune system can fight off disease and the person can become healthy again.
Therefore, taking ART is like repairing a house. Based on several factors including the
CD4 count, a doctor prescribes ART to such people.
- ART is several different medications. A person must take all of them, every time, every
day for the rest of his/her life for the treatment to be effective.
- ART does not cure HIV. Therefore, the body will need the medications every day in
order to stay healthy. Going without medications, even for a short time, is like not
repairing the house.
- If a person does not take his/her medicine, HIV will multiply in the body and continue to
damage the immune system and taking ART in the future will not be able to stop it.
• Explain the effects of non-adherence.
- Discuss drug resistance (Annexure
“Think of your body as a pot with a tap. When you take ART medicine regularly, the
body has enough medicine to fight the virus. After a while, however, usually about 24
hours, the level of medicines decreases. Therefore, you have to take the medicine as
per the prescribed doses to keep the medicine in the blood. If you do not do this,
resistance to ART medicines will develop. The medicines will not work against the HIV
virus. Then HIV continues to grow in the body and will destroy CD4 cells (the soldier),
leading to weakening of the immune system, opportunistic infections, weight loss
etc.”
- Ensure regular follow-up.
- If clients are not adhering to the treatment, assess the reasons, discuss the challenges
and take appropriate measures. E.g.See if any support is available from family
members/community members NGOs; if clients have mental health issues, refer to the
psychiatry department.
- If clients have problems of side effects, help address them(refer Annexure for details).
- Do not blame or scold the clients. This will be discouraging.
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- Discuss simple tips to remember about tablets: e.g., set alarm, associated with some
activity such as after meals while drinking water.
- Assess adherence fatigue. Usually clients say these statements if they have fatigue. “It
is not helping me. I am going to stop the medicine”; “I am tired of eating the tablets.
How much a person can eat it?”; “...I forgot to take them.” Explain to clients, “This
phase is called fatigue and it is experienced by many clients. Though it looks difficult,
people can overcome it.” In such cases, reinforce the adherence messages. Use case
studies, experience-sharing, support group, interactive methods to encourage the
clients. Seek the help of caregivers.
References:
Integrated training module for ICTC, ART, and STI Counsellors, NACO, Nov 2014
National Operational Guideline for ART Services, NACO, 2021
National Guidelines for HIV Care and Treatment, NACO, 2021
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Annexure: Antiretroviral Therapy (ART)
These are the main groups of antiretroviral drugs available at present:
1. Nucleoside reverse transcriptase inhibitors (NRTIs)
2. Non-nucleoside reverse transcriptase inhibitors (NNRTIs)
3. Protease inhibitors (PIs)
4. Integrase inhibitors (Integrase strand-transfer inhibitor – INSTI)
Principles of Anti-retroviral Therapy
• A continuous high level of replication of HIV takes place in the body right from the early
stages of the infection. At least one billion viral particles are produced during the active
stage of replication. Anti-retroviral drugs act on various stages of the virus replication in
the body and interrupt the viral replication process. The ARV drugs act on viral replication
and are labelled according to the site of their action.
How ART Works
HIV virus enters the CD4 cell of the human body and multiplies rapidly leading to the surge
in viral load. The Anti-retroviral therapeutic drugs help to obstruct the passages or
pathways of virus entry thus preventing their attachment and multiplication thereby
resulting in a decreased viral load. ART drugs are classified based on the nature of the drugs
to obstruct specific pathways inside the CD4 cell. The current regimen consists of TLD; i.e.
Tenofovir and lamivudine- Nucleoside reverse transcriptase inhibitors (NRTIs), Dolutegravir –
Integrase inhibiter.
Annexure: Seven-Point Counselling Tool for ART Preparedness
Seven-point counselling tool for ART preparedness
Explain the purpose of the session: Acknowledge that as facility staff you are there to
support patients. Explain that you will assist them by discussing together any barriers they
may have and assist them in creating an individualized adherence plan to help them take
their treatment correctly. Be open and alert to any personal difficulties and struggles with
aspects of the information
STEP-1: Education • Ask questions to assess understanding of HIV and ART.
about HIV and
• Provide education on HIV and ART using the pointers provided in
ART
the checklist (HIV is a chronic manageable disease that requires
lifelong medication).
• Explain benefits of ART (ART stops HIV from making more virus,
allowing you to be healthier, U=U).
• Explain importance of adherence and lifelong treatment.
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STEP-2: Identify • Ask patient to think about things that make them want to stay
patient’s healthy and to live fully.
motivation to
• Ask them to think about the important people in their lives.
stay alive and
healthy, • Ask them to identify specific things that they really want to have in
life, for example, to go to school or work, take care of family or
anything that is specific to the person
STEP-3: Identify Assist the patient to identify support system by asking the following
caregiver. questions:
• Who could support you in taking your treatment? Family/friends or
others
• How important do you think it is to disclose your health status?
• Counsel the caregiver about importance of treatment adherence
and follow-up visits.
• Discuss any social or personal issues that the patient may have and
support the patient to address the same.
STEP-4: Identify • Encourage the patient to be frank about personal issues (as per
the potential checklist) that may affect their adherence and help them to
barriers to address those issues.
adherence or
• Acknowledge common barriers that other patients have
retention.
experienced to make the space safe and avoid judgements.
• Invite patient to express beliefs or concerns that may interfere with
their treatment.
• Provide patient with appropriate information/support (counselling,
peer support, treatment buddy, need-based referral) which will
help them address the issue/s that have been identified.
STEP-5: Identify • Ask: What could help you to remember to take the treatment?
strategies to
• Discuss treatment reminders and adherence options based on the
ensure good
specific needs of the patient: phone calls by treatment buddy, SMS,
adherence.
ICT-based tools, alarm, calendar, TV shows etc.
STEP-6: Devise a • Advise the patient to take ART at a fixed time everyday, preferably
treatment plan at night. However, if this is not feasible, ask for the best time to
that suits the take ART as per the schedule of the patient.
patient the best.
• Many PLHIV do not have any private place to store their medicines
and are not able to take them in privacy. Ask: What safe place
could you identify to store your ART? How can you always carry one
or two doses with you?
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• How will the patient remember or who will remind him/her to take
the medication if he/she forgets? What reminder tools will the
PLHIV use?
• What will you do in case you forget to take a dose? If the pill of the
once-daily regimen of TLD is missed, then it should be taken as
soon as patient remembers within 12 hours. Missed doses can be
taken up to 6 hours later in a twice-daily regimen. Are any other
family members on ART? If yes, try to align the due dates for
family-centric approach.
• Is the patient on medication (including prevention or management
of OI) for any other illness? If yes, explain about the adherence,
duration, drug–drug interactions and timing/spacing of medications.
• Visit/contact the ART centre if you have new symptoms
(IRIS/adverse effects).
STEP-7: Plan for • Schedule due date for next visit in consultation with the patient.
the next
• Remind PLHIV about the next due date to visit the ART centre and
appointment.
explain the importance of regular clinic attendance for monitoring
of efficacy, adverse effects and adherence.
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ART Preparedness Counselling Checklist/Form
Pre-ART No:______________ ART NO: ______________
Mobile/Phone number verified: Yes No
Complete Address documented on White Card: Yes No
STEP 1: Education about HIV and ART:
PLHIV acceptance of HIV positive status What is HIV? Routes of HIV transmission
Positive living Meaning of viral load (U=U)
ART Awareness: The following basic information about ART has been provided:
What is ART? ART is a lifelong treatment Benefits of ART Importance of adherence (>95%)
STEP 2: Identify patient's motivation to stay alive and healthy
What is the most important thing for you in life?
Other ...................................................
STEP 3: Identification of caregiver
Family Career Studies Getting married
Caregiver identified-Family member/ Friends/Others/ None
Have you disclosed your status to the caregiver?
Caregiver counselled on adherence and follow-up visits
Any other family/personal issues.............................
STEP 4 and 5: Identify the potential barriers to adherence/retention and strategies to overcome
Adherence to ART is important to avoid development of drug resistance
Strict adherence required (>95%)
Potential Barriers:
Beliefs/Myths Physical illness Substance use Depression
Pill burden Social functions Fear of disclosure Lack of knowledge about ART
Financial/travel issues Feeling healthy Forgetfulness Adverse effects
Child behaviour/refusing Timing Caregiver Drug stock out
Long wait Stigma Others _____________
Interventions:
Services
Counselling (individual) Counselling (group) Peer support Treatment buddy
Link to Govt. schemes/NGOs Home visits by ORWS Need-based Referrals _____________
Reminder Tools
Written instructions Phone calls SMS ICT-based tools
Alarms Calendar TV shows
Other ______
STEP 6: Devise a treatment plan that suits the patient the best
Timing Morning Afternoon Evening Dosage OD BD
Storage of ARV drugs Safe place (............................ )
Always carry additional pills with you when you go out/travel
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Anti-retroviral Treatment and Management of PLHIV
Annexure: Opportunistic Infections and HIV-related conditions and ART
initiation
Clinical Picture Action
Any undiagnosed active Diagnose and treat first; start ART when stable or
infection with fever simultaneously, based on clinical assessment by MO/SMO of ART
centre
TB Start ART as soon as possible within 2 weeks of initiating TB
treatment, regardless of CD4 cell count.
Caution is needed for PLHIV with TB meningitis since immediate
ART is associated with more severe adverse events.
PCP Treat PCP first; start ART when PCP treatment is completed.
Invasive fungal diseases: Start treatment for oesophageal candidiasis first; start ART as
Oesophageal soon as the patient can swallow comfortably.
Candidiasis, Penicilliosis, Treat penicilliosis and histoplasmosis first; start ART when
Histoplasmosis patient is stabilized or OI treatment is completed.
Cryptococcal Meningitis Treat cryptococcal meningitis first. ART initiation should be
deferred until there is evidence of sustained clinical response
to anti-fungal therapy due to risk of life-threatening Immune
Reconstitution Inflammatory Syndrome (IRIS). After 4–6 weeks
of induction and consolidation treatment, ART can be initiated.
Bacterial Pneumonia Treat pneumonia first; start ART when treatment is completed.
Malaria Treat malaria first; start ART when treatment is completed.
Acute diarrhoea that Diagnose the cause and treat diarrhoea first; start ART when
may reduce absorption diarrhoea is stabilized or controlled.
of ART
Non-severe anaemia Start ART if no other causes for anaemia are found (HIV is often
(Hb< 9 g/dl) the cause of anaemia).
Skin conditions such as Start ART (ART may resolve these problems).
PPE and Seborrhoeic
Dermatitis, Psoriasis, HIV-
related Exfoliative
Dermatitis
Suspected MAC, Start ART (ART may resolve these problems).
Cryptosporidiosis and
Microsporidiosis
Cytomegalovirus Start treatment for CMV urgently and start ART after 2 weeks
Retinitis of CMV treatment.
Toxoplasmosis Treat toxoplasmosis; start ART after 6 weeks of treatment and
when the patient is stabilized.
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Annexure: Commonly used NRTIs and Adverse Effects
Generic Name Dose Adverse effects
Tenofovir Disoproxil 300 mg once daily Renal toxicity, bone demineralization
Fumarate (TDF)
Zidovudine (AZT) 300 mg twice daily Anaemia, neutropenia, bone marrow
suppression, gastrointestinal
intolerance, headache, insomnia,
myopathy, lactic acidosis, skin and nail
hyperpigmentation
Lamivudine (3TC) 150 mg twice daily or Minimal toxicity, rash (though very rare)
300 mg once daily
Abacavir (ABC) 300 mg twice daily or Hypersensitivity reaction in 3% to 5%
600 mg once daily (can be fatal), fever, rash, fatigue,
nausea, vomiting, anorexia, respiratory
symptoms (sore throat, cough,
shortness of breath); Rechallenging
after reaction can be fatal.
Types of Side Effects of ARV:
ARV Drugs Very common side Potentially serious Side effects
effects: Warn side effects: Warn occurring later
patients and suggest patients and tell them during treatment:
how to manage. to seek care. Discuss with
patients.
Tenofovir Nephrotoxicity (low
incidence), Fanconi’s
syndrome and rarely
acute renal failure, can
reduce bone mineral
density
Dolutegravir Nausea, diarrhoea,
insomnia, rashes,
hepatotoxicity
Zidovudine (AZT) ▪ Nausea Seek urgent care:
▪ Diarrhoea ▪ Anaemia = pallor,
▪ Headache fatigue, shortness
of breath, muscle
▪ Fatigue
pain
▪ Anaemia
▪ Skin pigmentation
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Anti-retroviral Treatment and Management of PLHIV
ARV Drugs Very common side Potentially serious Side effects
effects: Warn side effects: Warn occurring later
patients and suggest patients and tell them during treatment:
how to manage. to seek care. Discuss with
patients.
Stavudine (d4T) Nausea, diarrhoea Seek care urgently: Changes in fat
▪ Pancreatitis distribution:
(infection in
Lipodystrophy:
pancreas)/Lactic
arms, legs,
acidosis, severe
buttocks, cheeks
abdominal pain
become thin;
▪ Fatigue and breast, belly, back
shortness of breath, of neck become
persistent nausea fat
and vomiting
▪ Seek advice soon:
▪ Peripheral
neuropathy =
Tingling numbness
or painful feet or
legs or hands
Lamivudine (3TC) ▪ Nausea Seek care urgently:
▪ Diarrhoea ▪ Yellow eyes
▪ Skin rash with
involvement of
mucosa and
exfoliation
Nevirapine (NVP) ▪ Nausea
▪ Diarrhoea
▪ Mild skin rash
Efavirenz (EFV) ▪ Nausea Seek care urgently:
▪ Diarrhoea ▪ Psychosis or mental
▪ Strange dreams confusion
▪ Difficulty sleeping ▪ Skin rash
▪ Memory problems
▪ Headache
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Annexure 6: What to do for side effects?
Side Effect What to Do Go to the Clinic if
Headache • Rub the base of your head and • Your vision
temple with your thumbs gently. becomes blurry or
Rest in a quiet dark room with your unfocussed
eyes closed. • Aspirin or
• Place a cold cloth over your eyes paracetamol does
and forehead. not stop pain
• Avoid things with caffeine such as • You have frequent
coffee, string tea and carbonated or very painful
drinks. headaches
• Take 2 tablets of paracetamol every
4 hours with food.
Dry Mouth • Rinse your mouth with clean, warm • You have white
water and salt. spots on your
• Avoid sweets. tongue or in your
mouth
• Avoid things with caffeine such as
coffee, string tea and carbonated • You have trouble
drinks. swallowing food
Skin rashes • Wash often with unscented soap • If side effects
and water. persist, visit your
• Keep the skin clean and dry. doctor
• Use calamine lotion to soothe
itching.
• Avoid the sun when you have a rash.
Diarrhoea • Eat small meals more frequently • There is blood in
each day. the stool
• Eat easy-to-digest food such as • You have diarrhoea
bananas and rice. more than 4 times a
• Drink clean, boiled water. day
• Boil water for 20 minutes to make it • You also have fever
safe. • You are thirsty but
• Take oral rehydration solution(ORS). cannot eat or drink
properly
• Avoid spicy or fried food.
Anaemia • Eat fish, meat, chicken, legumes. • You have been tired
(Signs that you have • Eat spinach, asparagus and dark, for 3 to 4 weeks,
anaemia include pale leafy greens. and you are feeling
palms and fingernails) more and more
• Take iron tablets as prescribed by a
tired.
doctor.
• If your feet swell
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Anti-retroviral Treatment and Management of PLHIV
Side Effect What to Do Go to the Clinic if
Feeling dizzy • If you feel dizzy, sit down until the • If the side effects
(These side effects dizziness goes away. persist visit your
may occur when taking doctor
• Try not to lift anything heavy or
Efavirenz. They usually
move quickly.
go away after a few
• Take Efavirenz right before you go to
weeks.)
sleep.
Tingling feet and hands • Wear loose-fitting shoes and socks. • The tingling does
• Keep feet uncovered in bed. not go away or gets
worse
• Walk a little, but not much.
• The pain is
• Soak your feet in warm water/
preventing you
massage with a cloth soaked in
from being able to
warm water.
walk
• Try ibuprofen to reduce pain and
swelling (you can take up to 400 mg
every 8 hours with food. Do not take
ibuprofen for more than two days
without visiting the clinic.)
• Ask your doctor if you can take • You also have fever
drugs with food. • You have sharp
• Eat lots of small meals rather than pains in the
big meals. stomach
• Take sips of clean, boiled water, • There is blood in
weak tea, or ORS until the vomiting the vomit
stops. • Vomiting lasts
• Avoid spicy or fried foods. more than a day
• Try to do something that makes you • You are very thirsty
happy and calm right before you go but cannot eat or
to sleep. drink properly
Unusual or bad dreams • Avoid alcohol and street drugs as
these will make things worse.
• Avoid food with a lot of fat.
Feelings of sadness or • Talk about your feeling with others. • You have serious,
worry (This is sad or very
worrying thoughts
common with
Efavirenz.) • You are thinking
about killing
yourself
• You are very
aggressive or
scared
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HANDBOOK FOR HIV & STI COUNSELLORS
Annexure: How to explain to client how ART works
• Our body has an immune system that protects us from getting sick, just like a house
protects us from the rain and cold.
• If left untreated over time, the HIV virus will take over a body’s immune system, leaving a
person ill with opportunistic infections, just like a house that is left uncared for.
• If a person is sick from HIV, he/she can begin taking medicines called anti-retroviral
treatment. These medicines reduce the amount of HIV in the body. As a result, the body’s
immune system can fight off disease and the person can become healthy again.
Therefore, taking ART is like repairing a house. Based on several factors including the CD4
count, a doctor prescribes ART to such people.
• ART is several different medications. A person must take all of them, every time, every day
for the rest of his or her life for the treatment to be effective.
• ART does not cure HIV. Therefore, the body will need the medications every day in order
to stay healthy. Going without medications, even for a short time, is like not repairing the
house.
• If a person does not take his/her medicine, HIV will multiply in the body and continue to
damage the immune system and taking ART in the future will not be able to stop it.
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Anti-retroviral Treatment and Management of PLHIV
Annexure: How to explain drug resistance to the client
• Resistance to ART medicines develops, most commonly due to poor adherence and the
medicines will not work against the HIV virus. Then HIV continues to grow in the body and
will destroy CD4 cells (the soldier), leading to weakening of the immune system,
opportunistic infection, weight loss, diarrhoea, cough, fever etc.
• Think of your body as a pot with a tap. When you take ART medicine regularly, the body
has enough medicine to fight the virus. After a while, however, usually about 24 hours, the
level of medicines decreases. Therefore, you have to continuously take the medicine
(usually every 24 hours, but it depends on the medicine and recommended dose) to keep
the medicine in the blood.
• But medication only stays in our bodies for a short time, like a bottle that has a leak in the
bottom. Therefore, we must continue to take medication to keep enough of it in our body
at all times.
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HANDBOOK FOR HIV & STI COUNSELLORS
• When a person is infected with HIV, there are viruses that live inside
the body. The virus can be seen in the body in the figure as purple
dots. As long as we keep enough medication in our body, the
medicine can keep the virus from reproducing.
• But if we do not take medicines on time, the HIV virus gets an
opportunity to develop resistance against HIV medicine. Resistance
is the ability of the virus to oppose the effect of the medicine. If you
miss the medicine more than two times, the chances of HIV viruses
developing resistance to HIV medicine are very high. These resistant
viruses can be seen in the body as yellow dots.
• These resistant viruses then reproduce in our bodies. When a person
returns to taking medicine on time, the drugs cannot kill the resistant
virus. So, the medicine no longer works, and HIV takes over the body.
• In order for ART to work properly, it must remain in our body at all
times. However, over time, the level of medicine decreases in our
body.
Therefore, we need to continue taking ART medicine every day at a
fixed time (medicine taking time must be fixed as per convenience and
prescribed by the doctor) to keep enough in our body.
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Anti-retroviral Treatment and Management of PLHIV
Annexure: Calculating Adherence
There are a number of ways to measure adherence like self-reporting by patient, pill count,
home visit, patient diary etc. Pill count is the most used method to assess adherence. In each
follow-up visit, the patient should be asked to bring the pill box with the unconsumed
remaining pills. For more than one type of pill, adherence needs to be calculated for all drug
combinations separately and reasons for different adherence patterns to different drugs
should be explored.
The following formula is used to calculate adherence:
Total number of pills the patient has actually taken
Adherence (in %) = X 100
Total number of pills that the patient should have
taken in that period
Number of pills given to the patient – Number of
pills balance in the bottle
This is equal to X 100
Number of pills the patient should have taken
Examples
• Tab TLD (Single pill daily) = Number of pill balance 9, patient returns on 28th day.
Adherence calculation: (30 – 9) / 28 X 100 = 75%
• ALD Regimen: Tab AL (one tablet once a day) + Dolutegravir (one tablet once a day)
Number of pill balance AL 5; Dolutegravir 5; patient returns on 25th day.
Adherence calculation: (30 – 5)/(25x1) x 100 = 25 / 25 x 100 = 100%
• TL+ATV/r Regimen: TL once a day; ATV/r once a day; patient returns on 32nd day;
Pill box: Remaining tablets TL: Nil; ATV/r 1
TL Adherence = (30 - 0) / 32 x 100 = 30 / 32 x 100 = 94%
ATV/r adherence = (30 - 1) / 32 x 100 = 29 / 32 x 100 = 91%
Whenever a combination of two separate drugs is given, calculation has to be done for
individual tablet and whichever adherence is lower, that has to be considered for
reporting purpose as ‘overall adherence’.
Overall adherence in this patient is 91%.
• Tab ZL +LPV/r (ZL one pill twice daily and LPV/r two pills twice daily dose) = Number of pill
balance = 11 ZL and 25 LPV/r, patient returns on 25th day.
ZL Adherence = (60 - 11) / (25x2) x 100 = 49 / 50 x 100 = 98%
LPV/r adherence = (120 – 25) / (25x4) x 100 = 95 /100 x 100 = 95%
Adherence calculation: Individual drug combination adherence needs to be calculated and
whichever is lower can be considered for reporting purpose.
Overall adherence in this patient is 95%.
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HANDBOOK FOR HIV & STI COUNSELLORS
Step-up adherence counselling form
ART No. ART Regimen: Date of ART initiation
Date of viral load Viral load result: Due date for next VL
Session-1
Name of counsellor........................ Date: ......................... ART adherence (last 3 months) 1..... 2.....3.....
Yes/No Comments
Does patient have ART adherence & risks of poor adherence
adequate knowledge
about VL results
ART drug dosage (No. of pills and timing)
Name and relation of the caregiver
Support system
Address and phone no. of caregiver
Barriers:
Forgot Beliefs/Myths Lack of knowledge about ART Adverse effects
Physical illness Substance use Depression Pill burden
Social functions Feeling healthy Child behaviour/refusing Timing
Fear of disclosure Caregiver Financial/travel issues Drug stock out
Long wait Stigma Other
Interventions:
Services
Counselling (individual) Counselling (group) Peer support
Treatment buddy Link to Govt schemes/NGOs Home visits by ORWs
Need-based referrals
Tools
Written instructions Phone calls SMS
ICT-based tools Alarms Calendar
TV shows Other
Remind that goal is to achieve suppressed VL
Adherence plan........................................................................... ..................................
Next due date to visit ART centre is ............................................ Counsellor's Signature
Session-2
Name of counsellor........................ Date: ....................... ART adherence of previous month..................
Yes/No Comments
Appreciate if adherence>95% and motivate him/her to
Follow-up of
maintain the same
session 1
Were strategies discussed in session 1 implemented?
If not, Why?
Barriers:
Forgot Beliefs/Myths Lack of knowledge about ART Adverse effects
Physical illness Substance use Depression Pill burden
Social functions Feeling healthy Child behaviour/refusing Timing
Fear of disclosure Caregiver Financial/travel issues Drug stock out
Long wait Stigma Other
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Anti-retroviral Treatment and Management of PLHIV
Interventions:
Services
Counselling (individual) Counselling (group) Peer support
Treatment buddy Link to Govt schemes/NGOs Home visits by ORWs
Need-based referrals
Tools
Written instructions Phone calls SMS
ICT-based tools Alarms Calendar
TV shows Other
Remind that goal is to achieve suppressed VL
Adherence plan........................................................................... ..................................
Next due date to visit ART centre is ............................................ Counsellor's Signature
Session-3
Name of counsellor........................ Date: ......................... ART adherence of previous month:.................
Yes/No Comments
Appreciate if adherence>95% and motivate him/her to
Follow-up of
maintain the same
session 1
Were strategies discussed in session 1 implemented?
If not, Why?
Barriers:
Forgot Beliefs/Myths Lack of knowledge about ART Adverse effects
Physical illness Substance use Depression Pill burden
Social functions Feeling healthy Child behaviour/refusing Timing
Fear of disclosure Caregiver Financial/travel issues Drug stock out
Long wait Stigma Other
Interventions:
Services
Counselling (individual) Counselling (group) Peer support
Treatment buddy Link to Govt schemes/NGOs Home visits by ORWs
Need-based referrals
Tools
Written instructions Phone calls SMS
ICT-based tools Alarms Calendar
TV shows Other
Remind that goal is to achieve suppressed VL
..................................
Adherence plan...........................................................................
Next due date to visit ART centre is ............................................ Counsellor's Signature
Repeat Viral Load
Date of repeat viral load test:.................................. Viral load result:..................................
Appreciate
If VL<1000 copies/ml Reminder for next due date to visit ART centre
Reminder for next VL testing date....................
SACEP procedure explained
If VL>1000 copies/ml SACEP e referral/referral initiated
SACEP recommendations implemented
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HANDBOOK FOR HIV & STI COUNSELLORS
Annexure: Programmatic Definitions
First Line ART The initial regimen prescribed for an ART-naive patient
Second line ART The subsequent regimen used in sequence immediately after first
line therapy has failed
Third line ART The subsequent regimen used in sequence immediately after
second line therapy has failed
Substitute Refers to replacement of ARV drug(s) for PLHIV due to adverse
effects of drug, drug–drug interactions or programme policy:.This
does not indicate change of regimen due to treatment failure.
Switch Refers to the loss of antiviral efficacy to the current regimen: when
the entire regimen is changed because of treatment failure, it is
referred to as the switch.
Pre-ART l(LFU) PLHIV not initiated on ART and with no clinical contact or visit to
health facility for more than or equal to 28 days
MIS A patient ‘On-ART’ will be labelled as ‘Missed (MIS)’ if the patient
does not turn up for pill pickup any time within 90 days of due date.
On ART LFU PLHIV on ART with no clinical contact or ARV pickup for 90 days or
more since last due date (missed appointment)
Stopped treatment PLHIV on ART whose treatment is stopped on medical advice (in
discussion with the clinical team)
Opted out* If a PLHIV is contacted through outreach (home visit) and expresses
his/her unwillingness to continue ART services under national
programme (after adequate counselling) and provides in writing
about the same*
Died If death of a patient is confirmed by family members/relatives/local
authorities during outreach and valid documentation is provided
Transferred out Transferred out refers to a situation when a patient seeks transfer
from one ART centre to another. PLHIV will be labelled as
‘transferred out’ only when patient reaches recipient ART centre
and transfer has been accepted in IMS by recipient ART.
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Anti-retroviral Treatment and Management of PLHIV
Annexure: ‘MIS’
• A patient ‘On-ART’ will be labelled as ‘Missed (MIS)’ if the patient does not turn up for pill
pickup any time within 90 days of due date.
• The patient can be labelled as ‘MIS’ consecutively for three months:M1, M2, M3.
• Patients coming any time during that month are not termed as MIS. PLHIV missing an
appointment date but coming during the same month will not be termed as MIS.
Example: Raju is on TLD and collected his ARV drugs on 6 January 2023, next scheduled
visit is 6 February 2023. He did not turn up in the month of February.
1. If Raju does not come for pill pickup by 28th February, then he should be termed as
MIS-1 (if he comes on 22nd February, he will not be termed as MIS).
2. If he does not come by 31st March, then he should be termed as MIS-2.
3. If he does not come by 30th April, he should be termed as MIS-3.
4. If he does not come for pill pickup by the end of 31st May, he should be termed as
‘LFU’’.
5. As Raju collected pills on 21st May, his on-ART status will change from MIS to on-ART.
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Prevention and Management of
14 Opportunistic Infections and Comorbidities
Introduction to Comorbidities and Opportunistic Infections
An opportunistic infection (OI) is a disease caused by a microbial agent in a person with a
compromised host immune system like PLHIV. PLHIV with low CD4 cell counts are more
susceptible to a multitude of opportunistic micro-organisms including protozoa, fungi, viruses
and bacteria, which are generally innocuous in healthy individuals. OIs have been the major
cause of morbidity and mortality among PLHIV.
PLHIV who are on ART and virally suppressed are living longer and require a comprehensive
health and well-being approach that extends beyond HIV care. While signicant progress is
made in the control of HIV/AIDS, the country is also undergoing a major epidemiological
transition non-communicable disease (NCD). NCDs are increasingly contributing to overall
disease burden. An NCD is a non-infectious health condition that cannot be spread from person
to person. These diseases generally last for a long period of time and are chronic in nature.
Opportunistic infections • Tuberculosis
• PCP
• Cryptococcal meningitis
Comorbidities (NCD) • Hypertension
• Diabetes
• Cardiovascular disease
• Cancer
• Depression
Opportunistic Infections
Many of the common OIs are preventable, especially with early/rapid ART initiation. Since
opportunistic events tend to recur, sometimes prophylaxis or preventive therapy needs to be
continually given even after previous successful treatment until the patients achieve immune
restoration.
With early ART initiation, appropriate prevention and management of OIs make an additional
and desirable impact to reduce the incidence of OIs along with the use of simple preventive
measures such as eating properly cooked food, drinking boiled water, handwashing after toilet
use, avoiding situations with a high risk of infection and appropriate and timely
immunizations.
The prophylaxis or preventive therapy of preventable OIs is recommended based on the
prevalence of OIs, immune status of the patient as well as access to ART.
Prevention of OIs under NACP: The incidences of OIs have markedly declined in recent years
because of the widespread availability of ART and early ART initiation in PLHIV. Along with
ART, appropriate prevention and management of OIs make an additional and desirable
impact.
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HANDBOOK FOR HIV & STI COUNSELLORS
Prevention can be either primary or secondary.
• Primary prevention: Prophylactic or preventive drug given before the appearance of an
OI is called ‘primary prophylaxis/prevention’.
• Secondary prevention: Prophylactic or preventive drug given after the successful
completion of treatment of OI is called ‘secondary prophylaxis/prevention’.
Table 14.1 - Prevention of OIs under NACP
Type of Prevention Opportunistic Infection Drug
Primary To prevent PCP Cotrimoxazole
To prevent tuberculosis (TB) Isoniazid
To prevent cryptococcal infection Fluconazole
(if CrAg test is not available in PLHIV
with CD4 count <100 cells/mm3
Secondary To prevent recurrence of PCP Cotrimoxazole
To prevent recurrence of TB Isoniazid
To prevent recurrence of cryptococcal infection Fluconazole
Tuberculosis
Tuberculosis (TB) is caused by bacteria Mycobacterium tuberculosis (M. tuberculosis) that most
often affect the lungs (pulmonary TB), however it is curable and preventable. TB is spread
from person to person through the air. TB can also affect other organs, including bones and
joints, kidneys, brain, genitals, urinary tract, spine, lymphatic system, intestines, etc. In other
words, it could affect all organs except hair and nails. When TB affects any organ other than
the lungs, it is called extra-pulmonary TB (EPTB). The symptoms and signs of EPTB will
depend on exactly which organ is involved (e.g., headache if TB meningitis, effusion if joint
involvement, etc.).
Breakdown of TB infection into active TB disease is most likely to happen in rst two years
after infection, more likely when a person is immune-compromised (e.g., HIV infected). 10% of
individuals with TB infection will develop TB disease in their lifetime. Each individual with
active but untreated TB can infect 10–15 people per year. 60% of HIV-positive individuals with
TB infection will develop TB disease. TB patients may stay infected for many years, probably
for life. The vast majority (90%) of people without HIV infection who are infected with M.
tuberculosis do not develop the disease. Patients who do not take regular treatment and
complete it properly may develop more dangerous forms of TB, known as drug-resistant TB,
which they can spread to others.
Multidrug-resistant TB (MDR TB) is caused by an organism that is resistant to at least
isoniazid and rifampin, the two most potent drugs for TB. These drugs are used to treat all
people with TB. Extensively drug resistant TB (XDR TB) is a rare type of MDR TB that is
resistant to isoniazid and rifampin, plus any uoroquinolone and at least one of three
injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin). Because XDR TB is
resistant to the most potent TB drugs, patients are left with treatment options that are much
less effective. XDR TB is of special concern for people with HIV infection or other conditions
that can weaken the immune system. These persons are more likely to develop TB disease once
they are infected, and also have a higher risk of death once they develop TB.
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Prevention and Management of Opportunistic Infections and Comorbidities
Types of TB:
• Microbiologically conrmed TB: Presumptive TB patient with biological specimen
positive for AFB, or positive for MTB on culture, or positive for TB through Quality Assured
Rapid Diagnostic molecular test.
• Clinically diagnosed TB:
- A presumptive TB patient who is not microbiologically conrmed but diagnosed with
active TB by a clinician on the basis of X-ray, histopathology or clinical signs with a
decision to treat the patient with a full course of anti-TB treatment.
- In children, this is based on the presence of abnormalities consistent with TB on
radiography, history of exposure to an infectious case, evidence of TB infection (positive
TST) and clinical ndings suggestive of TB in the event of negative or unavailable
microbiological results.
TB Case denitions as per NTEP
Microbiologically Presumptive TB patient with biological specimen positive for
conrmed TB case AFB, or
positive for MTB on culture, or positive for TB through Quality
Assured
Rapid Diagnostic molecular test
Clinically diagnosed Presumptive TB patient who is not microbiologically conrmed
TB case but diagnosed with active TB by a clinician on the basis of X-ray,
histopathology
or clinical signs with a decision to treat the patient with a full
course of anti-TB treatment
Pulmonary TB Any microbiologically conrmed or clinical diagnosed case of TB
involving lung parenchyma or trachea – bronchial tree
Extra-Pulmonary TB Any microbiologically conrmed or clinically diagnosed case of
TB involving organs other than lungs such as pleura lymph node,
intestine, joints, bones, etc.
• Miliary TB is classied as PTB because there are lesions in the lungs.
• A patient with both pulmonary and extra-pulmonary TB should be classied as a case of
PTB.
Screening of Presumptive Pulmonary TB patients
A person at ICTCs, TIs and SSKs and OSCs with cough for more than 2 weeks, with or without
other symptoms suggestive of TB, should be promptly identied as presumptive pulmonary TB
patient. They are to be referred to a designated microscopy centre (DMC) for sputum
examination using the request form for examination of biological specimen. Patients with
EPTB, HIV and Paediatrics (after X-ray screening in case of children) can be directly referred
for CBNAAT.
4S (symptoms) Screening
4S screening is to be done for all clients at all NACP facilities, such as ICTCs, TIs, other closed
settings like prisons, SSKs and ARTC. At ARTC, all PLHIV, during every visit, should be
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HANDBOOK FOR HIV & STI COUNSELLORS
screened for 4S in all the health facilities without fail. PLHIV/CLHIV found positive for any of
the four symptoms (4S+), should be considered presumptive TB and fast-tracked for TB
diagnostic work-up.
The four symptoms are current cough, fever, weight loss and night sweats. For CLHIV, the
four symptoms are current cough, fever, weight loss/poor weight gain and history of contact
with TB case.
Figure 14.1 - Algorithm of ICF – four-symptom (4S) screening at the ART centre
Intensive case nding of tuberculosis among PLHIV 4-Symptom screening
Adults and Adolescents Children
Any of the following Any of the following
1. Current cough 1. Current cough
2. Fever 2. Fever
3. Weight loss 3. Poor weight gain/Reported weight loss
4. Night sweats 4. History of contact with a TB case
Yes No
Investigate for TB & other diseases Assess for contraindication to IPT
TB Not TB Other diagnosis
No Yes
Follow-up, assess and Give appropriate
Treat
consider isoniazid treatment and
for
preventive therapy (IPT) consider IPT if no
TB Give IPT Difer IPT
if no contraindications contraindications
Screen for TB regularly at and each encounter with a health worker or a visit to health facility
Understanding of dual disease impact
Impact of HIV on TB Impact of TB on HIV
Increases susceptibility to TB disease Most common opportunistic infection in
PLHIV
An HIV-infected person who is newly Major cause of morbidity and mortality in
infected with TB bacilli has higher PLHIV
likelihood of developing TB as compared to
anon-HIV-infected person.
Higher TB recurrence in HIV-infected The immune response to TB bacilli
people increases HIV replication. As a result of the
increase in viral load in the body, there may
be more rapid progression of HIV infection
and patient starts developing symptoms of
various opportunistic infections.
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Prevention and Management of Opportunistic Infections and Comorbidities
Impact of HIV on TB Impact of TB on HIV
Increased death risk in HIV-TB co-infected Dual infection accelerates deterioration.
patients than HIV non-infected TB
Interaction of the diseases may result in
patients.
difculties in diagnosing TB among PLHIV
due to atypical clinical presentation of TB
disease.
The risk of recurrence of TB even after There is high risk of TB transmission in
successful TB treatment is much higher in HIV care settings, due to high TB load and
HIV-infected persons. concentrated presence of vulnerable
patients.
Strategies for Prevention and Management of TB in PLHIV
• Intensied TB Case Finding (ICF) with timely ATT (to cut TB transmission): Intensied
case nding using 4-symptom complex for TB screening; fast-tracking and referral of
symptomatic patients for testing (NAAT) and other appropriate investigations, as required,
for TB diagnosis;
• Prompt and effective treatment of active TB in PLHIV in accordance with the NTEP
guidelines;
• Early ART initiation among PLHIV;
• TB preventive therapy (TPT);
• Airborne infection control in healthcare facilities
Fixed Dose Combinations
Management of PLHIV co-infected with drug-sensitive TB case is being provided at ARTC
under single window services. Fixed dose combinations (FDCs) refer to products containing
two or more active ingredients in xed doses, used for a particular indication(s). In NTEP,
treatment will be given as per the weight bands for
• Adults: 4FDC (given in IP) consists of HRZE and 3FDC (given in CP) consists of HRE.
• Paediatric TB: Intensive phase has 3FDC + tab ethambutol.
• Continuous phase has 2FDC + tab ethambutol.
Care, Support and Treatment
• TB is a curable disease
• The average course of the treatment for drug-sensitive TB is six months.
• For those with a drug-resistant form of TB, the duration of treatment is often longer, up to
two years.
• Drug-sensitive TB is treated with a combination of drugs (Isoniazid, Rifampicin,
Ethambutol and Pyrazinamide)
• It is very important that people who have TB are treated, nish the medicine and take the
drugs exactly as prescribed.
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HANDBOOK FOR HIV & STI COUNSELLORS
• If they stop taking the drugs too soon, they can become sick again; if they do not take the
drugs correctly, the TB bacteria that are still alive may become resistant to those drugs. TB
that is resistant to drugs is harder to treat.
• A pregnant woman diagnosed with drug-sensitive TB can start treatment during
pregnancy.
• A Direct Benet Transfer (DBT) scheme called ‘Nikshay Poshan Yojana’, nutritional
support for Rs. 500/- every month to TB patients can be availed once they are notied on
the Nikshay platform.
Sideeffects of anti-tuberculosis drugs
In most TB patients, ATT is well tolerated. However, some patients may experience some
sideeffects to these anti-tuberculosis drugs. These side effects may be classied as minor or
severe.
• Minor side effects include mild gastrointestinal upset, mild itching, joint aches and
drowsiness. Most of these will go away within a short time.
• Serious side effects are rare but also occur. These include burning sensation in the hands
and feet, impaired vision, ringing in the ears, loss of hearing, dizziness, loss of balance,
ongoing nausea or jaundice and require to be immediately reported to the medical ofcer
for evaluation.
Counsellors should encourage clients to promptly seek medical opinion in case of
side effects and not to stop medicines on their own.
TB HIV collaboration
PLHIV are 18 (15–21) times more likely to develop TB than people without HIV. TB is a
leading cause of hospitalization and death among adults and children living with HIV,
accounting for one in ve HIV-related deaths globally. The prevention, diagnosis and
treatment of TB and HIV-associated TB are key elements of the internationally endorsed
comprehensive package of services given under a single window delivery mechanism at the
health facility level.
National TB Elimination Programme (NTEP) and NACP
• Reduce the dual burden of both the diseases
• Early identication and treatment of both the diseases (TB among PLHIV and HIV among
TB patients)
• Prevention of TB as an OI
• Prevention of deaths to reduce mortality in co-infected patients
Linkage of HIV-Infected TB Patients to CPT and ART
Cotrimoxazole preventive therapy (CPT) has been shown to reduce morbidity and mortality of
HIV-infected patients in general and HIV-infected TB patients in particular. As per National
guidelines, all HIV-infected TB patients are to be linked to CPT and ART services
irrespective of CD4 count.
ART is highly effective at reducing mortality among HIV-infected TB patients. All PLHIV
diagnosed with active TB are to be initiated on ART regardless of CD4 count, after initiation of
TB treatment in accordance with the NTEP guidelines.
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Prevention and Management of Opportunistic Infections and Comorbidities
Fast Tracking of Symptomatic TB
• Ensure that any TB suspect at the ART centre should be attended by the MO (ART) on
priority and should also be prioritized for testing and laboratory investigations.
• Instigating practices of good cough hygiene for all patients, with any duration of cough, at
all ART centres for airborne infection;
• Diagnostic and treatment services for MDRTB patients: PLHIV identied as
presumptive DR-TB/MDR cases at ARTC may be referred to DR-TB sites under NTEP for
further diagnosis and management of the same.
The key to reducing the risk of tuberculosis transmission at health facilities is early
diagnosis and prompt initiation of NTEP treatment regimens until cure. Infectious TB
patients become rapidly non-infectious once they are started on directly observed
treatment under NTEP.
Drug-resistant TB: Drug-resistant TB can occur when the drugs used to treat TB are
misused or mismanaged. Examples of misuse or mismanagement include the following:
• People do not complete a full course of TB treatment or are exposed to DRTB with someone
known;
• Healthcare providers prescribe the wrong treatment (the wrong dose or length of time);
• Drugs for proper treatment are not available;
• Drugs are of poor quality.
Multidrug-resistant TB is caused by TB bacteria that are resistant to at least isoniazid and
rifampicin, the two most potent TB drugs. These drugs are used to treat all persons with TB
disease.
Eligibility for TB Preventive Therapy
• Isoniazid is one of the most effective bactericidal anti-TB drugs that protect against
progression of latent TB infection (LTBI) to active disease (against endogenous
reactivation). It also prevents TB reinfection post exposure to an open case of TB.
• The effects of TPT augment the effects of ART on reducing the incidence of TB. With the
concomitant administration of both ART and TPT, there is a likelihood of restoration of TB-
specic immunity by ART and the benecial effect of TPT may be prolonged. TPT does not
promote INH resistance when used to treat LTBI.
• All adults and adolescents living with HIV should be screened for TB with a clinical
algorithm. Those who do not report any one of the four symptoms of current cough, fever,
weight loss and night sweats are unlikely to have active TB and should, therefore, be
assessed for TPT initiation.
• All children living with HIV more than 12 months of age, who do not report with current
cough, fever, poor weight gain and history of contact with a TB case, are unlikely to have
active TB and should, therefore, be assessed for TPT initiation.
• Infants aged <12 months living with HIV who are in contact with a person with TB and
who are unlikely to have active TB on an appropriate clinical evaluation or according to
national guidelines should receive TPT.
• If there is any doubt about the TB status of a patient, TPT should be delayed.
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Contraindications to Isoniazid or INH
TPT should not be provided to patients in the following conditions:
• Active TB disease
• Active hepatitis
• Signs and symptoms of peripheral neuropathy such as persistent tingling, numbness and
burning sensation in the limbs; regular and heavy alcohol consumption and symptoms of
peripheral neuropathy
• Concurrent use of other hepatotoxic medications
• Contact with MDR-TB case
• PLHIV who have completed DRTB treatment
TPT with IsoniazidInitiation and Follow-up
All the 4S -ve patients should be assessed by SMO/MO to determine eligibility for TPT. TPT
should be considered for both on-ART and pre-ART patients (if found 4S -ve). TPT should be
initiated if not contraindicated. TPT drugs must be provided monthly (30 days) to all eligible
patients.
4S screening should be done for all the patients (on ART and pre-ART) on TPT during every
visit to exclude active TB. In case a patient becomes 4S +ve during the TPT course, he/she
should be investigated for TB and if found positive, TPT should be stopped, and appropriate
anti-TB treatment should be initiated.
Airborne Infection Control Measures
• Well-ventilated waiting and seating arrangements
• Fast-tracking of screening of patients with respiratory symptoms/chest symptoms for early
referral, diagnosis and treatment initiation;
• Health education on cough etiquette (IEC material to be displayed).
Viral Hepatitis
Viral hepatitis is inammation of the liver due to viral infection. Viral hepatitis can be caused
by the ve known hepatitis viruses namely A, B, C, D and E (HAV, HBV, HCV, HDV and
HEV). Chronic HBV and HCV are silent diseases, but if left untreated may lead to cirrhosis
and liver cancer. Therefore, prevention, early diagnosis and treatment are essential to combat
viral hepatitis. The co-infection may lead to rapid progression and complications and affect the
management of hepatitis and require a modication in the regimen of ARV drugs.
Testing for hepatitis B and C
Screening serological tests and molecular tests are required to establish a diagnosis of hepatitis
C (HCV) and hepatitis B (HBV) for evaluation for further management.
(i) Screening test: Rapid diagnostic test
• HCV: Anti-HCV antibody test (anti-HCV)
• HBV: HBV surface antigen test (HBsAg)
(ii) Molecular test: Viral load testing
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• HBV DNA: For decision on treatment
• HCV RNA: For conrmatory test
Routine investigations like complete blood count, including platelets, estimation of liver
enzymes alanine transaminase and aspartate aminotransferase are essential to decide whether
a client is cirrhotic (complicated) or non-cirrhotic (uncomplicated). Apart from these, renal
function tests also must be done before treatment is initiated.
Modes of transmission: Parenteral transmission of viruses occurs following exposure
through transfusion of contaminated blood or blood products, unprotected sex, in utero
transmission from a pregnant woman to her baby and possible horizontal transmission.
Figure 14.2 - Hepatitis B and C
Others Others
Unsafe
Mother to Child Unsafe
instruments Injections/needles
Unsafe Mother to
Injections Child
Sexual Sexual
Mode Mode
Blood Blood
Hepatitis B Hepatitis C
Counselling and screening for HBV and HCV
The clients who attend the facilities may be at risk for HBV or HCV disease due to high-risk
behaviours, especially the IDUs. The counsellor needs to inform the clients about the
signicance of getting tested for HBV and HCV.
(i) Pre-test counselling: Explain the details about HBV and HCV.
• What they are; how they spread; symptoms; consequences; prevention
• All clients should be assessed by the counsellor for the presence of the risk factors of
both HBV and HCV. Risk factors:Child of HBV-positive mother; history of injecting
drug use; needle stick injury; recipient of transfusion of blood/blood product; history of
repeated tattooing; occupational exposure to blood/bodily uids; history of dental
treatment; history of surgery; high-risk sexual behaviours; history of receiving unsafe
injection
• All clients (direct walk-in and referred) must be informed that testing for HBV and
HCV at the ICTCsis conducted through a simple, easy-to-do rapid diagnostic test that
provides the result within 30 minutes.
• HCV is a curable disease and HBV is a vaccine-preventable disease and can be
managed with lifelong treatment.
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• Inform that HBV and HCV diagnosis and treatment services are available at the
government health facilities free of cost under the NVHCP.
• Informed consent must be obtained for testing.
(ii) Post-test counselling
• Explain the results of the screening of HBV and HCV.
• Inform that HBV and HCV diagnosis and treatment services are available at the
government health facilities free of cost under the NVHCP and that molecular testing
must be done if clients are reported as positive.
(iii) Post-test counselling and linkages to treatment services for clients who are
HBV or HCV positive
• Explain the meaning of the antibody-positive HCV test or antigen-positive HBV
(HbsAg) test and counsel on the need for quantitative HBV DNA and HCV RNA
testing.
• Explain the need for a haemogram with platelets, liver and kidney function tests for
staging and management of the disease.
• Explain that the client may be chronically infected or have cleared the virus in the
past in case of antibody-positive HCV test.
• Provide basic HBV and HCV disease, prevention and treatment information.
• All HBV- and HCV-positive clients screened positive need to be linked to treatment
sites (treatment centres/model treatment centres) under the NVHCP. Encourage
voluntary disclosure of HIV status by the client to the treating physician.
• Explain HCV is a curable disease with treatment of 12 weeks (84 days), extendable to
168 days in severely complicated cases.
• Explain HBV is manageable with lifelong treatment and all clients who are positive
may not require treatment.
• Discuss the importance of minimizing risk behaviours to avoid transmitting HBV and
HCV infection to others, and encourage notication and screening of needle sharing
and other risk factors.
• Encourage and offer HBV testing for bloodline relatives after conrmation.
• Encourage HCV testing among family members in case of evidence of unsafe injection
practices from unregistered medical practitioners.
• Discuss healthy life practices, including stopping or reducing alcohol intake.
(iv) In case of clients diagnosed with HIV and HBV and/or HCV
• In case a client has co-infection of HIV and HBV and/or HCV, they should be referred
to the ART centre. Further, it will be the responsibility of the ART centre to link the
client to a model treatment centre under the NVHCP.
• Explain to the client how co-infection of HIV with HBV or HCV may deteriorate their
health despite taking ART regularly and lead to rapid deterioration in liver function.
Also, inform the client that their ARV regimen may need modication in case of co-
infection.
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• Give information about infection control practices to prevent the spread of infection to
other household members.
• Clients must be provided with the NVHCP referral slip available at the ICTCs and
ART centres.
• Condentiality/shared condentiality of HIV status must be ensured.
• Ensure posters on the NVHCP are displayed at the NACP service delivery centres and
provide any other IEC material on HBV and HCV that is available for distribution to
clients.
(v) Designated health facilities (treatment centres/model treatment centres)
• HBV- or HCV-positive clients should be referred to the treatment centres/model
treatment centres under the NVHCP depending on their condition. The treatment
centres are located at district hospitals and designated sub-district hospitals, CHCs
and PHCs, while the model treatment centres are in designated medical
colleges/tertiary care hospitals. All co-infected cases of HIV–HBV, HIV–HCV and
HIV–HBV and HCV should be referred to the model treatment centres as it is
important for a hepatologist to evaluate the condition and function of the liver before
treatment.
• Once a client reaches the relevant centre, they should meet with the physician/MO
and they will be managed as per NVHCP guidelines.
Prevention of HBV and HCV
(I) Vaccination for HBV:
• All infants born to HBV-positive pregnant women need to be immunized within 24
hours of birth followed by routine vaccination under the immunization programme.
• Vaccination of all healthcare workers with HBV vaccine at 0, 1 and 6 months.
(ii) Safety of blood and blood products:
• Promote information regarding the availability of safe blood and blood products at
licensed blood banks and referral of donors screened positive for HBV and HCV to a
treatment centre for further management.
(iii) Injection safety and infection control:
• Safe injection practices such as universal precautions while respecting socio-cultural
practices like tattooing, religious ceremonies (like mundans) and ear/body piercing,
etc.
• Inspection of use of new packaged needles/syringes for therapeutic injections.
Comorbidities
Non-communicable diseases (NCDs), also known as chronic diseases, do not spread from person
to person. These illnesses take a long time to develop and do not present symptoms in the early
stages. They require treatment for several years, and some require lifelong treatment. The
main types of NCDs are diabetes, coronary heart disease, stroke, cancers and chronic
respiratory diseases (such as chronic obstructive pulmonary disease and asthma). Some of the
major risk factors include unhealthy /unbalanced diets, lack of physical activity,
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smoking/tobacco use and excessive use of alcohol. NCDs are now becoming one of the leading
causes of non–AIDS-related morbidity and mortality in PLHIV.
The following ve components are recommended for prevention and management of NCDs in
PLHIV:
• Health promotion (primordial prevention)
• Screening for early detection
• Diagnosis
• Management (including lifestyle changes and pharmacologic therapy)
• Regular follow-up: Monitoring achievement of treatment goals and monitoring adherence,
side effects and drug–drug interactions
I) Health Promotion
Health promotion is critical to promote a healthy lifestyle and reduce specic risk
behaviours, e.g., unhealthy diets, physical inactivity, tobacco use and harmful drinking for
prevention of NCDs. All PLHIV should be counselled on health behaviours and
comprehensive healthy lifestyles.
Table 14.1 - Health Promotion Counselling Messages for PLHIV
Health Behaviour Counselling Messages
Physical activity • Aim for an active lifestyle with moderate physical activity (at least
150 minutes/week).
• Consider yoga and meditation for overall well-being.
Weight control • Manage weight to maintain a healthy BMI.
• Encourage overweight/obese individuals to lose weight through a
mix of diet and dynamic activity.
Diet • Choose a balanced diet with whole grains, vegetables, fruits and
pulses.
• Adapt diet based on local food availability.
• Limit salt intake to less than 5 grams (1 teaspoon) daily.
• Reduce consumption of sugar, fatty meat, dairy fat and fried foods.
Tobacco cessation • Emphasize the multiple benets of quitting tobacco.
• Discourage non-smokers/chewers from starting tobacco use.
• Support and strongly advise current users to quit tobacco.
Avoidance of alcohol • Encourage avoiding alcohol consumption whenever possible.
• Provide counselling support for those with alcohol use disorder or
excessive drinking.
Adherence to • Explain medication doses and frequency, especially in relation to
treatment ART and additional medications.
• Stress the importance of adhering to NCD medicines alongside ART.
• Highlight the need to continue medication even when there are no
symptoms.
• Educate about potential side effects and prompt reporting of any
adverse reactions.
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ii) Screening, Diagnosis, Management for early detection and regular follow-up: Adult PLHIV
will have to undergo screening, diagnosis and initial management of hypertension, diabetes
mellitus, cardiovascular disease, common cancer and mental health.
1. Hypertension
• All PLHIV above the age of 18 years should undergo screening by healthcare providers
through blood pressure (BP) measurement at the time of registration into HIV care or
ART initiation and every 6 months after ART initiation
• The diagnosis of hypertension should be done by a physician, using a validated device,
and following a standardized BP measurement procedure.
• Hypertension for patients below 80 years of age is systolic blood pressure less than 140
mm Hg and diastolic blood pressure less than 90 mm Hg.
• Hypertension for patients 80 years or older is systolic blood pressure less than 150 mm
Hg and diastolic blood pressure less than 90 mm Hg.
• Immediate referral to appropriate facility and provider shall be done in cases of
hypertensive urgencies and hypertensive emergencies
2. Diabetes
• All PLHIV should undergo screening, through random blood glucose test at
- registration into HIV care or ART Initiation
- 1–2 months after ART initiation and then at every 6 months
- at change of regimen (substitution or switch).
• Screening, diagnosis and management through lifestyle modication can be provided
by trained MO.
• Initiation of oral hypoglycaemic agents shall be done by physician.
• Continuation of treatment can be provided by trained MO in PLHIV with controlled
diabetes.
• Management and follow-up by physician are recommended in patients with
uncontrolled hyperglycaemia despite maximum doses of metformin and sulfonylurea,
patients with foot ulcers and patients with vision impairment.
3. Cardiovascular disease
Cardiovascular diseases like ischemic heart disease, coronary heart disease and stroke
are one of the major causes of mortality and morbidity among the general population.
With changes in lifestyle, the incidence is increasing and PLHIV are also affected by
these ailments.
While diagnosis and management of ischemic heart disease (narrowed heart arteries)
and stroke are best done at facilities with advanced interventions,
• Assessment shall be done at time of registration in HIV care or ART initiation, at 3
months and 6 months of ART and shall be repeated every 6 months thereafter.
• All patients with history of angina (chest pain), breathlessness on exertion and lying
at, numbness or weakness of limbs, loss of weight, increased thirst, polyuria
(urinates more than usual), pufness of face, swelling of feet, passing blood in urine,
pitting oedema (swollen part of the body has a dimple (or pit) after you press it for a
few seconds) and tenderness in abdomen need to be referred to a physician for
further assessment and management.
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4. Common Cancer (Oral,Breast, Uterine and Cervical)
• Create awareness about the early warning signs of cancer like the following:
- Change in bowel or bladder habits;
- Wound that does not heal;
- Unusual bleeding or discharge;
- Thickening or lump in the breast or elsewhere;
- Indigestion or difculty swallowing;
- Obvious change in a wart or mole;
- Nagging cough or hoarseness of voice;
• Educate patients on self-examination and reporting for unusual signs/symptoms.
• Women should be counselled on breast awareness. The rst person to detect any
lump in the breast is the woman herself, which is by teaching a woman to be aware of
any of the following signs at the earliest possible:
- Change in size
- Nipple that is pulled in or changed in position or shape
- Rash on or around the nipple
- Discharge from one or both nipples
- Puckering or dimpling of skin
- Lump or thickening in the breast
- Constant pain in the breast or armpit
• Symptomatic screening for common cancers and their risk factors and appropriate
referrals for diagnosis and management shall be done for all PLHIV.
- Screen all women and girls living with HIV who have initiated sexual activity for
cervical cancer symptoms during the time of ART initiation.
- Ask for tobacco use and counsel on adverse effects of tobacco and encourage to quit
tobacco use.
- Refer for clinical screening within 3 years if the initial test is negative.
- Ask all women living with HIV above 30 years of age for breast cancer symptoms
- All PLHIV of age >30 years should be screened using oral visual examination at
the time of ART initiation.
- PLHIV receiving radiotherapy or surgical intervention shall continue taking ART.
Referrals
• If symptoms told by the client pertain to cervical cancer, refer to a gynaecologist/lady MO
wherever available or NCD clinic at CHC/DH for conrmation and further management.
• If any positive ndings are noted during clinical breast examination, refer to surgeon for
further evaluation (USG, biopsy, etc.), diagnosis and management.
• If any abnormality is noted during oral visual examination, PLHIV need to be referred to a
surgeon/ENT specialist for further evaluation, diagnosis and management.
Mental health screening, diagnosis and management of depression among PLHIV
PLHIV are prone to psychological ailments due to HIV per se as well as opinions and
experiences regarding HIV in their surroundings. They may face multiple types of
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psychological issues like depression, anxiety, internalized stigma, etc. Any such issue can
signicantly hamper adherence and mental well-being.
Depression is a common mental disorder, which presents as persistent sadness or loss of
interest or pleasure in daily living accompanied by disturbed sleep or appetite, feelings of guilt
or low self-worth, tiredness, poor concentration, difculty making decisions, agitation,
hopelessness and suicidal and self-harm thoughts or acts.
Depression is two to three times more prevalent in PLHIV than in the general population. It is
a signicant contributing factor to poor adherence to ART and poor HIV treatment outcomes
including treatment failure.
Screening for depression:
All PLHIV should receive basic screening for depression before initiating ART and thereafter
every 6 months using the following two questions:
• During the past two weeks, have you often been bothered by feeling down, depressed or
hopeless?
• During the past two weeks, have you often been bothered by little interest or pleasure in
doing things?
Any patient who answers ‘yes’ to either of the above questions, and all patients with a
detectable viral load after 6 or more months on, should undergo a more thorough screening for
depression using the PHQ-9 screening tool(Refer Annexures).
At the time of ART initiation, the patient shall also be screened for history of manic symptoms
(feeling very happy, elated or overjoyed, talking very quickly, feeling full of energy, being easily
distracted, being easily irritated or agitated, being delusional, hallucinating and disturbed or
illogical thinking), suicidal ideation or homicidal ideation. If any signs/symptoms suggestive of
bipolar disorder/suicidal/homicidal tendencies are identied, the client should be referred to a
psychiatrist.
Mental health in children and adolescents living with HIV
Childhood and adolescence are critical periods in development. The environment where
children and adolescents grow up shapes their well-being and development. Early negative
experiences at home, at school or with peers, such as exposure to violence, mental illness of a
parent or other caregiver, bullying and poverty, increase the risk of mental illness.
Mental health disorders during childhood and adolescence are dened as delays or disruptions
in developing age-appropriate thinking, behaviours, social skills or regulation of emotions.
These problems are distressing to children and disrupt their ability to function well at home, at
school or in other social situations.
Thus, there is a need to screen children and adolescents for mental health-related issues. This
need is more urgent in children/adolescents with HIV.
The assessment of mental health issues of children and adolescentsis important and should be
done. If they have one or more signs suggestive of a mental health condition, they need an
evaluation by a paediatrician, psychiatrist and a clinical psychologist.
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Table 14.2: Warning signs indicating presence of a mental health condition in children/ adolescents
1. Persistent sadness for two or more weeks
2. Withdrawing from or avoiding social interactions
3. Hurting oneself or talking about hurting oneself
4. Talking about death or suicide
5. Outbursts or extreme irritability
6. Out-of-control behaviour that can be harmful
7. Drastic changes in mood, behaviour or personality
8. Changes in eating habits
9. Loss of weight
10. Difculty sleeping
11. Frequent headaches or stomach aches
12. Difculty concentrating
13. Changes in academic performance
14. Avoiding or missing school.
Key Messages
• Opportunistic infections (OIs) are intercurrent infections that occur in PLHIV. OIs are
common in PLHIV due to immunosuppression. So, they become prone to various OIs.
• The incidence of OIs has markedly declined in recent years because of the widespread
availability of ART, early ART initiation in PLHIV as well as appropriate prevention and
management of OIs.
• Management of OIs is based on syndromic evaluation and treating the cause.
Vaccinations and good personal hygiene will help prevent OIs.
• HIV and TB are two diseases that have a synergistic impact on each other, increasing the
risk of morbidity and mortality for co-infected patients. TB is an infectious disease that
spreads through air. When a patient with untreated pulmonary TB coughs, sneezes or
talks, they involuntarily throw TB germs into the air in the form of tiny droplets.
• There are two types of TB mainly affecting the lungs, causing lung (pulmonary) TB. In
some cases, other parts of the body may also be affected, leading to extra-pulmonary TB
(‘extra’ here means outside).
• To reduce the dual burden of HIV and TB, four strategies are recommended: intensied
case nding, TB preventive therapy, infection control and ART for all PLHIV.
• Persons with cough for more than 2 weeks, with or without other symptoms suggestive of
TB, should be promptly identied as presumptive pulmonary TB patients. They are to be
referred to designated microscopy centre (DMC) for sputum examination.
• 4-symptom screening to nd TB among PLHIV; assess if PLHIV have cough, fever, weight
loss and night sweats.
• Ensure that any TB suspect at the ART centres should be attended by the MO (ART) on
priority and should also be prioritized for testing and laboratory investigations. Instigate
practices of good cough hygiene for all patients, with any duration of cough, at all ART
centres for airborne infection.
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• Isoniazid Preventive Therapy (TPT), for prevention of TB among PLHIV, was launched in
India on World AIDS Day 2016. HIV/TB collaborative activities in India aim to reduce
the dual burden of disease by providing prevention, diagnosis and treatment services for
both infections.
• Treatment adherence is very important for TB. To assess and foster adherence, a patient-
centred approach to administration of drug treatment should be planned.
• Treatment failure will lead to drug resistance. The patients develop multi-drug-resistant
TB (MDR TB). It is contagious if not treated.
• Non-communicable diseases (NCD) are non-infectious health conditions that cannot be
spread from person to person. These diseases generally last for a long period of time and
are chronic in nature. NCDs are increasingly contributing to overall disease burden.
PLHIVs are at high risk for NCD. Hypertension, diabetes, cardiovascular disease,
common cancer, arthritis, and depression are some common examples of NCDs.
• They are inuenced by risk factors such as unhealthy diet, lack of exercise, smoking and
alcohol.
• PLHIV are more prone to NCDs due to immune activation, medication side effects, co-
infections and aging.
• PLHIV need health promotion, screening, diagnosis, management and follow-up to
prevent and treat NCDs.
• India has launched a national programme to eliminate HCV by 2030 and reduce the
burden of other types of viral hepatitis.
• The programme provides free diagnostics and drugs for HCV and HBV at government
health facilities.
• Testing for hepatitis B and C requires screening tests (anti-HCV and HBsAg) and
molecular tests (HCV RNA and HBV DNA) to conrm the diagnosis and decide the
treatment.
• Pre- and post-test counselling and screening for HBV and HCV at the ICTCs involve
educating patients about the nature, transmission, symptoms, consequences, prevention
and treatment of viral hepatitis.
• NCDs, also known as chronic diseases, are now becoming one of the leading causes of
non–AIDS-related morbidity and mortality in PLHIV.
• The main types of NCDs are diabetes, coronary heart disease, stroke, cancers, and chronic
respiratory diseases. Some of the major risk factors include unhealthy/unbalanced diets,
lack of physical activity, smoking/tobacco use and excessive use of alcohol.
• Five components are recommended for prevention and management of NCDs: Health
promotion, screening for early detection, diagnosis, management (including lifestyle
changes and pharmacologic therapy),regular follow-up: monitoring achievement of
treatment goals and monitoring adherence, side effects and drug–drug interactions.
• PLHIV are prone to have mental health issues like depression, anxiety, internalized
stigma, etc. Any such issue can signicantly hamper adherence and mental well-being.
Regular screening and referral to psychiatry is required in such cases.
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Role of the counsellors
• Educate PLHIV about OIs and and NCDs. Do preliminary assessment for OIs and NCDs
and make appropriate referrals.
• Address concerns, clarify doubts. Provide guidance and support while availing services of
other centres.
• OIs/NCDs are additional psychological and nancial burden for the client.It creates stress
and the life of the person gets affected. This results in poor adherence. So, provide support
and address various concerns clients are experiencing due to the illness. For instance,
clients may experience helplessness and hopelessness. It such a situation, a counsellor may
say, “I know you are going through a difcult situation. But it is not going to be like this
forever. If you follow the treatment properly, you will experience the difference in your
health”; “Here many people come with various health issues. Some have similar issues like
you, some have more complications. Still, those who follow the instructions and take proper
treatment experience good health.” Show condence in the client by saying, “You will be
able to do this”. The clients may feel that the illness and the treatment are a burden. You
may say, “Iunderstand. It is challenging/difcult, but not impossible. After a few days, you
will get used to the new lifestyle”. These messages are crucial to enhance adherence.
• Adherence counselling should be done for all OIs/NCDs.
• Mental health assessment of all PLHIV must be done. PHQ 2 should be administered before
starting ART. Screening for other mental illnesses also should be done. In case of mental
health issues,the client should be referred to the psychiatry department.
References:
• NACO (2021). National Guidelines for HICV Care and Treatment
• Training Module, NTEP Guidelines for Programmatic Management of Tuberculosis Preventive
Treatment
• UNODC &TISS. (2011). COUNSELLING IN TARGETED INTERVENTION FOR INJECTING
DRUG USERS-A RESOURCE GUIDE. MUMBAI: UNODC and TATA INSTITUTE OF SOCIAL
SCIENCES, MUMBAI, INDIA.
• WHO. (2015). Consolidated Guidelines on HIV Testing Services. 20 Avenue Appia, 1211 Geneva 27,
Switzerland: World Health Organization.
• NTEP Training Module 1-4
• TB India Report,2023
• NTEP Guidelines for Programmatic Management of Tuberculosis Preventive Treatment in India, July
2021
• Source: Mental illness in children: Know the signs; available at
https://www.aacap.org/AACAP/Families_and_Youth/ Facts_for_Families/FFF-Guide/Normality-
022.aspx
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Annexure: Ten-point counselling tool
Integrated 10 points counselling tool on TB/drug resistant TB
1. Tuberculosis (TB) is the most common opportunistic infection in people living with HIV
(PLHIV) and leading cause of death in PLHIV.
2. TB is an infectious disease caused predominantly by Mycobacterium tuberculosis. The
infection occurs most commonly through droplet nuclei generated by coughing, sneezing
etc., inhaled via the respiratory route. TB usually affects the lungs, but may affect other
parts of the body as well.
• An HIV-negative person infected with TB has a 10% lifetime risk of developing TB
disease.
• HIV increases the risk of progression from TB infection to TB disease and PLHIVs have
a 60% lifetime risk of developing TB disease.
3. People having cough of 2 weeks or more, with or without other symptoms, are referred to
as pulmonary TB suspects (presumptive TB case). They should have 2 sputum samples
examined at designated microscopy centre (DMC).
4. A person with extra-pulmonary TB may have symptoms related to the organs affected
along with symptoms like enlarged cervical lymph modes, chest pain, pain and swelling
of the joints, etc. Extra-pulmonary TB can be conrmed by other investigations.
5. All PLHIV should be regularly screened for TB using a clinical symptom-based algorithm
consisting of any one of the symptoms of cough of any duration, fever, weight loss or night
sweats at the time of initial presentation for HIV care and at every visit to a health
facility or contact with a healthcare worker afterwards.
6. Diagnosis and treatment services for TB are available free of cost through National
Tuberculosis Elimination Program (NTEP)
• 2 sputum smear examinations are necessary for the diagnosis of pulmonary TB. During
the course of treatment, the progress is monitored by means of follow-up sputum
examinations.
• Anti-TB drugs are provided as xed dose combinations (FDCs) as per weight band.
• Treatment is provided by ‘Treatment Provider’ at a place near the patient’s home.
• Cure from TB can only be ensured by taking complete and regular treatment. Without
correct and complete treatment, a patient can become very ill or develop drug-resistant
TB.
7. PLHIV diagnosed with TB should be linked to ART services at the earliest, irrespective of
CD4 count. Cotrimoxazole preventive therapy should be provided to all HIV–TB co-
infected patients to prevent OI.
8. An HIV–TB co-infected patient should be referred to nearest NTEP certied culture and
drug sensitivity laboratory facility/CBNAAT facility for diagnosis of drug-resistant TB.
These cases will be managed as per latest guidelines on ‘Programmatic management of
drug-resistant TB in India under NTEP’.
9. The client’s information is to be kept condential and this information is not furnished
under any circumstances to any other person except ‘Shared condentiality’ with the
treating physician and public health system DOT provider for better case management
and to get benet of prophylactic/treatment options available for him/her.
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Annexure: Patient health questionnaire-9
Patient Health Questionnaire-9 (PHQ-9)
S. Over the last 2 weeks, how often have you been Not Several More Nearly
No. bothered by any of the following problems? at days than every
(Use “✓” to indicate your answer) all half the day
days
1 Little interest or pleasure in doing things 0 1 2 3
2 Feeling down, depressed or hopeless 0 1 2 3
3 Trouble falling or staying asleep or sleeping too much 0 1 2 3
4 Feeling tired or having little energy 0 1 2 3
5 Poor appetite or overeating 0 1 2 3
6 Feeling bad about yourself, or that you are a 0 1 2 3
failure or have let yourself or your family down
7 Trouble concentrating on things, such as 0 1 2 3
reading the newspaper or watching television
8 Moving or speaking so slowly that other people 0 1 2 3
could have noticed Or the opposite - being so
dgety or restless that you have been moving
around a lot more than usual
9 Thoughts that you would be better off dead or 0 1 2 3
of hurting yourself in some way
Total Patient Health Questionnaire: Scores and Conditions
score Conditions Recommendations
0–4 Depression unlikely • Repeat screening as per schedule.
5–9 Mild depression • Provide supportive counselling and continue to
monitor.
• If patient is on EFV, substitute with a different
ARV after ruling out treatment failure.
10–14 Moderate depression • Provide supportive counselling through trained
counsellor.
15–19 Moderate to severe • If patient is on EFV, substitute with a different
depression ARV after ruling out treatment failure; and
20–27 Severe depression • Referral to psychiatrist for further assessment and
antidepressant medication
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Prevention and Management of Opportunistic Infections and Comorbidities
Annexure
Key supportive counselling messages to PLHIV with depression
Component Key message
Psycho-social support • Explain about depression and assure that it can be
managed.
• Feeling of hopelessness, worthlessness, negative emotions
are part of depression and will revert with proper
counselling and treatment.
• Inform about course of counselling and treatment.
• Identify supportive family members and involve them as
appropriate.
• Involve peers and community support groups.
Self-management skills • Continue ART as prescribed.
• Identify activities that they used to nd interesting and
pleasurable: encourage participation in these activities.
• Get regular and sufcient sleep (appx. 7 to 8 hours).
• Physical activities to be increased.
• Contact ARTC/ healthcare facility immediately if thoughts
of self-harm occur.
Reduce stress • Identify and try to reduce stress points.
• Identify and discuss stress-increasing points such as health
issues, family and relationship problems, gender-based or
partner violence, nances, stigma and discrimination.
• Identify and discuss problem-solving techniques.
• Suggest stress management such as meditation and
relaxation techniques.
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Nutrition in the Context of
15 HIV and Adherence
Nutrition in context of HIV/AIDS
Nutrition assessment is one of the important components of ART preparedness counselling.
Nutritional assessment helps counsellors understand the dietary habits, nutritional status and
needs of the patients and advise nutritional interventions accordingly. Based on the needs, the
counsellors facilitate linkages with nutritional supplementation schemes of government
departments and NGOs.
• HIV and frequent opportunistic infections increase the use of energy and nutrients in the
body.
• Proper nutrition helps in the process. It helps in dealing with side effects of medicine,
managing HIV-related symptoms and hence leads to a productive life. Proper nutrition
keeps the immune system stronger so PLHIV can better ght disease.
• If the increased energy and nutrient needs are not met in PLHIV, they may lose weight and
become undernourished.
• This undernourishment can weaken the body’s immune response even more.
• The weakened immune system results in repeated infections, which can make the PLHIV
develop AIDS more quickly.
• HIV also impacts the digestive system and liver, thus leading to poor absorption of
nutrients. Hence, it is important to consider the right quantity and quality of frequent
meals.
• Repeated infections further increase nutritional needs, leading to poor nutritional status,
and so the cycle continues.
Strategies to meet nutritional requirements of PLHIV
Consuming a variety of foods from each of the main groups daily is important to maintain good
nutritional status to help ght illness.
What can the HIV counsellor do?
The HIV counsellors can provide suitable nutrition counselling that helps in breaking the
vicious cycle between HIV and malnutrition. Counsellors are also expected to refer children
and adults with malnutrition to specialists such as paediatricians, internists and dieticians.
Aspects of nutrition counselling
The counsellor should always remember that nutrition counselling should be simple,
practicaland tailored to the client’s needs. It should consider the patient’s socio-economic
status, religious and cultural beliefs. To assess and identify the client’s needs, the counsellor
should collect the following information about the client:
• Dietary intake (amount and kind of food eaten);
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Nutrition in the Context of HIV and Adherence
• Presence of HIV-related symptoms or illnesses (e.g., oral thrush, mouth sores, dental
problems, vomiting, diarrhoea, depression, appetite loss, altered taste) that may affect food
intake of the client;
• Methods of food preparation;
• Food access (availability) to the client i.e., food security;
• Sanitation and hygiene conditions in which food is prepared, i.e., food safety.
Counselling on dietary intake
Counselling on dietary intake simply refers to the question of ‘what to eat?’. The counsellor
should help the client to understand the need to have a diet which is diverse enough to provide
him/her with the necessary nutrients.
The daily diet for a healthy PLHIV adult should include all three food groups:
• Energy-giving food like whole cereals, sugar, starchy vegetables and fruits;
• Body-building food like pulses, eggs, nuts, milk and milk products;
• Protective food like fruits, vegetables and water.
Consuming a variety of foods from each of the main groups daily is important to
maintain good nutritional status to help ght illness.
Table 15.1 - Aguidefordailydietfor adults
Cereals Rice, roti, bread, dalia and upma, i.e.,energy-giving foods. (6–11
servings) 1 serving cereal = 1 roti/1 bread slice/ ½ katori rice
Pulses Soyabean, rajma and green gram dal, which provide protein,
vitamins and soluble bre – that is body-building foods. (2-3
servings) 1 serving pulse = 1 katori cooked dal
Milk products and Milk products and animal foods are body-building foods. These
animal foods are rich in fat and cholesterol. So, encourage clients to make a
careful selection (2–3 servings). 1 serving milk products = 1 cup
milk/1katori curd;
1servingmeat= 1 egg/ 2 pieces of meat/ chicken approximately
100g per piece
Fruits and vegetables Rich in minerals, vitamins, antioxidants and bre, i.e.,
protective foods. Fruits (2–4 servings) and vegetables
1 serving fruit = 1 medium-sized fruit
1 serving vegetables = vegetables
Sweets and oil Should be consumed sparingly
Note: Avoid high fat and fried food. Consume healthy food and eat in small and frequent meals (5–6 meals/day),
drink plenty of water and liquids at least 7–8 glass per day, Avoid caffeine, alcohol and smoking. Exercise regularly.
For more details, refer to annexure.
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Eight critical nutrition practices to prevent malnutrition among PLHIV:
i. Regularly monitor weight.
ii. Increase energy intake by eating a variety of foods, especially energy-rich foods. This
is critical for periods of illness.
iii. Drink plenty of boiled or treated water.
iv. Practice a healthy lifestyle by avoiding alcohol, tobacco, sodas and other coloured,
sweetened or carbonated drinks.
v. Maintain hygiene and sanitation.
vi. Exercise regularly.
vii. Seek early treatment of infections and manage symptoms with dietary practices when
possible.
viii. Return to the usual eating patterns when HIV-related symptoms or illnesses resolve.
Managing HIV-related symptoms through diet, weight loss and food safety
The counsellor can help PLHIV to select those foods and nutrition practices that help in
managing the effects of HIV-related symptoms.
Table 15.3 - Symptom management through diet
Symptoms Symptoms Management through Diet
Diarrhoea • Eat small amounts of food more often.
• Eat bananas, mashed fruit, soft boiled white rice, rice kanjee and
porridge (daliya) to help slow down the diarrhoea.
• Eat food at room temperature; very hot or very cold foods stimulate
the bowels and make diarrhoea worse.
• Drink a lot of uids (soups, diluted fruit juice, clean boiled water,
weak tea and oral rehydration solution).
• Avoid high-fat or fried foods.
• Avoid coffee and alcohol.
• Avoid foods that cause gas or stomach cramps, such as beans, cabbage
or onions.
• Limit or eliminate milk and milk products such as yoghurt (dahi) to
see whether the symptoms will improve.
• Remove the skin from fruits and vegetables.
Loss of appetite • Eat small, frequent meals (5–6 meals/day);eat nutritious snacks.
• Add avour to food and drink.
• Drink plenty of liquids.
• Exercise lightly and do light activity.
• Take walks before meals: Fresh air helps to stimulate appetite.
• Having family or friends assist with food preparation and sharing a
meal provides a psychological ambience that aids appetite.
Mouth sores • Eat foods cold or at room temperature.
• Eat soft and moist food such as porridge (daliya), mashed potatoes or
mashed non-acidic vegetables or fruit.
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Nutrition in the Context of HIV and Adherence
Symptoms Symptoms Management through Diet
• Avoid caffeine, alcohol and smoking, which can irritate mouth sores.
• Avoid citrus fruits, tomatoes, spicy foods and very sweet, sticky or
hard foods.
• Soften your food by soaking it in liquid (milk, broth, juices, soup).
• Drink uids with a clean straw to ease swallowing.
• Clean and rinse your mouth after each meal.
Nausea and • Eat small, frequent meals (5¬–6 meals/day);eat bland food.
vomiting • Avoid food with strong or unpleasant odours.
• Avoid an empty stomach as this makes nausea worse. Avoid lying
down immediately after eating.
• Avoid coffee and alcohol.
• Drink plenty of liquids.
Constipation • Eat bre-rich fruits (mangoes, guavas, jackfruit), vegetables (beans,
peas, pumpkin, carrots, green vegetables) and sprouts.
• Drink at least eight glasses of uids a day, especially boiled water.
• Drink a cup of warm water in the morning before eating to help the
bowels move.
• Do light exercises like taking frequent short walks.
Anaemia • Eat organ meat, sh and eggs. Eat cereals like ragi and bajra.
• Eat a variety of green leafy vegetables (radish greens, mint, chaulai,
cauliower leaves and sundaikai). The best way for the body to utilize
iron from plant sources is to combine food rich in vitamin C like amla,
guava, oranges and lemons.
• Take jaggery and dates between meals.
Counselling on dietary intake
Number of meals the client eats each day: Normally, the client should take 4–5 meals per day
(breakfast, lunch, dinner and one or two snacks a day). But during acute illness, the client
should be served small frequent meals on a 2-hourly basis (that is 5–6 small meals) as the
bodily requirements for food increase. Palatable snacks like sooji, idli, dhokla or vegetable
sandwich should be incorporated. Each meal should be made nutrient-dense as the appetite is
poor.
• Counsel the client to eat a variety of food items.
• Assess whether the client’s diet is nutritious or not. Counsel the client that diet can be
made nutrient-dense by adding locally available ingredients such as milk powder to kheer;
adding honey/jaggery (gud) to drinks and food; adding vegetables to roti, rice and pulse
preparations; adding dal to soups and rasams; adding besan to paratha/chapati to make
paustik roti; adding peanuts to upma, poha or pulao.
• Check whether the client has habits like smoking or drinking alcohol and encourage the
client to avoid alcohol or smoking as they affect the appetite.
When counselling on dietary intake, it is critical to remember that the dietary needs
of PLHIV are greater than those of non-infected people.
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Counselling PLHIV for weight loss
The counsellor should inform the client that weight change over a given period indicates how
his/her nutritional status has changed. Unintentional weight loss indicates poor food intake or
disease that affects food digestion, absorption or utilization. For an average adult, serious
weight loss is indicated by a 10% loss of body weight or 6–7 kg in one month. Refer to the
appropriate health provider as needed.
Following points are communicated to clients to gain weight:
• Increase the quantity of food. Increase intake of cereals, pulses and nuts.Eat four to six
small meals instead of two or three big meals.
• Make meals energy dense by adding peanuts, gingelly seeds, jaggery and oil/ghee/butter.
• For stimulating appetite, have vegetable clear soups, rasam, jaljeera or chicken soup. Eat
fruits like mango, banana, chikkoo, grapes, papaya etc.
• Prepare mixed our laddoos or til/peanut chikki/laddoo made with jaggery. Consume these
foods between meals.
• Chew food well before swallowing.
• Prepare some premixes with roasted cereals and pulses. Cook them in milk/water with
sugar/jaggery to a consistency of porridge or sheera/halwa and consume them in between
meals. The addition of cardamom can enhance the avour.
• If affordable, consume a boiled egg every day.
Counselling on food safety
Food safety is very important. Food should be stored and prepared with proper hygiene. The
consequences of food-borne illness are more severe for people with low immunity such as
PLHIV.
• Maintain clean surroundings and cooking utensils to stop food-borne illnesses from
spreading.
• Protect food from rodents, insects and animals.
• Wash hands thoroughly before and after cooking. Use clean water for cooking.
• Keep raw and cooked foods separate to stop germs from spreading. This is particularly
important for raw meat.
• Wash all fresh fruits and vegetables thoroughly.
• Cook food thoroughly to kill germs, but avoid overcooking vegetables.
• Eat cooked food immediately.
• Store food carefully.
• Eating outside food is generally discouraged. This is particularly true for raw vegetables,
fruits or curd. Fresh home-made food is the safest because the client would have taken
adequate care to ensure it is free from infective agents.
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Nutrition in the Context of HIV and Adherence
Nutritional Care of HIV-Exposed and Infected Children (>6 months)
For all infants more than 6 months of age, complementary feeding should be started
irrespective of HIV status and initial feeding options. The guiding principles for
complementary feeding are as follows:
Table 15.4- Guiding principles for complimentary feeding
Sr. No. Guiding Principle
1 Introduce complementary foods at 6 months of age (180 days) while continuing to
breastfeed.
2 Start at 6 months of age with small amounts of food and increase the quantity
and frequency as the child gets older while maintaining frequent breastfeeding.
3 Gradually increase food consistency and variety as the infant grows older.
4 Feed a variety of nutrient-rich and energy-dense food from the family pot to
ensure that all nutrient needs are met.
5 Practise responsive (active) feeding, applying the principles of psychosocial care,
good hygiene and proper food handling.
6 All breastfeeding should stop only when a nutritionally adequate and safe diet,
without breast milk, can be provided by complementary feeds.
7 Assess the child’s nutritional status regularly. HIV-positive children:
Classify appropriately as one of the three – growing, poor weight gain/conditions
with increased nutritional needs or severe acute malnutrition.
8 In addition to age-specic needs, HIV-positive children who are growing
appropriately will require additional 10% energy based on actual weight.
9 In addition to age-specic needs, HIV-positive children who have poor weight
gain or have conditions with increased nutritional needs will require additional
20–30% energy based on actual weight.
10 In addition to the age-specic needs, HIV-positive children with severe acute
malnutrition (SAM) will need therapeutic feeding to provide 50–100% additional
calories and should be referred to appropriate facility for management of SAM.
Management of children with severe acute malnutrition
The major causes of morbidity and mortality among CLHIV less than 5 years of age are
pneumonia (including PCP), TB, bloodstream infections, diarrhoeal disease and SAM. Children
with SAM have signs of visible wasting, bilateral oedema (build-up of uid in the body) and
severely impaired growth. They must be identied and managed correctly since they are at a
very high risk of mortality. These children should be evaluated at an ART centre for the
following:
a) Anaemia
b) Opportunistic infections including TB
c) Drug side effects
d) Treatment adherence
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e) Treatment failure
f) Immune reconstitution inammatory syndrome (IRIS).
Unless associated complications are appropriately managed, improvement in diet alone may
not result in normal growth, weight recovery or improvement in clinical status.
As per the Nutrition Guidelines for HIV-Exposed and Infected Children (0–14 years of age),
children with SAM require 50%–100% extra energy every day after the period for stabilization
till nutritional recovery (usual duration 6–10 weeks). They should be treated with therapeutic
feeding. Children with no medical complications may be managed at home if they still have a
good appetite. They can receive good supervision at home and therapeutic feeds can be
provided.
Children who are sick and have associated complications like infections, have a poor appetite
or are unable to eat must be referred for inpatient care by trained staff with experience in
nutritional rehabilitation.
PLHIV who are well-nourished are likely to
• Have a better quality of life and be able to work;
• Enjoy good health, remain active, care for themselves and help with the care of children
and other dependents;
• Have fewer illnesses and recover more quickly from infections, thus reducing costs for
healthcare;
• Maintain a good appetite and stable weight.
A table of some common myths and misconceptions about nutrition for PLHIV, along
with the facts and explanations.
Table 15.5 - Myths and misconceptions about nutrition for PLHIV
Myth Fact
There is one, single food that No single food can provide all the nutrients that the body
can ensure good health and needs. A balanced diet that includes a variety of foods is
protect from HIV. essential for good health and immunity.
PLHIV need to eat more PLHIV do not need to eat more protein than the
protein than other people. recommended amount for their age, sex and activity level.
Too much protein can strain the kidneys and liver, which
may already be affected by HIV or ART.
PLHIV should avoid fats and Fats and oils are important sources of energy and essential
oils. fatty acids, which help the body absorb fat-soluble vitamins
(A, D, E and K). PLHIV should not avoid fats and oils, but
choose healthy types such as olive oil, canola oil, nuts,
seeds, avocados and fatty sh. These fats can help lower
cholesterol and inammation and improve heart health.
PLHIV should limit saturated fats (found in butter, cream,
cheese, fatty meats, etc.) and trans fats (found in processed
foods, baked goods, margarines, etc.), as these can increase
the risk of cardiovascular disease.
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Nutrition in the Context of HIV and Adherence
Myth Fact
PLHIV should eat more sugar Sugar provides empty calories that do not have any
to gain weight. nutritional value. Eating too much sugar can lead to weight
gain, tooth decay, diabetes and other health problems.
PLHIV should avoid raw Raw fruits and vegetables are rich sources of bre,
fruits and vegetables since vitamins, minerals and phytochemicals that can boost
immunity and digestion. Wash before eating. Cooking
fruits and vegetables can destroy some of their nutrients
and reduce their benets.
PLHIV should drink alcohol Alcohol can interfere with the absorption and metabolism
to cope with stress or improve of ART drugs and other medications. It can also damage
appetite. the liver, which is responsible for processing drugs and
toxins. Alcohol can also impair the immune system,
increase inammation, dehydrate the body and affect mood
and mental health.
Key Counselling Messages
• Nutrition assessment is one of the important components of the ART preparedness
counselling. Nutritional counselling helps counsellors understand the dietary habits,
nutritional status and needs of the patients and advise nutritional interventions
accordingly.
• For the purpose of nutritional assessment, the counsellor should ask the client to recall
the 24-hour menu the client is following:
- “Can you tell me what your daily meal is like on an average day (An average day is a
day on which you might go to work or to school.)?”
- “What do you have in the morning when you get up? Do you have breakfast? At what
time? When do you have lunch and dinner?”
- “What do you eat in each meal? What is the quantity?”
- “Can you tell me what your meal is like on a special day (e.g., a Sunday or a religious
festival)?”
- “Can you tell me what your meal is like on a day when you fast?”
If needed, the counsellor should discuss how the client could modify existing meal patterns
to make them more nutritious. Take care to make suggestions that are affordable to the
client. E.g., some clients do not eat breakfast due to lack of time and cost. So, suggest some
cost-effective and less time-consumingfood to include in the breakfast e.g.eggs/sprouts/
banana etc.
• Assess why some clients do not have anutritious diet. Explore the possible reasons and
address the same as follows:
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Table 16.6- Reasons of non-nutritious diet and possible counselling points
Myth Counselling points
No awareness Give information. Discuss the importance of nutrition.
Use BCC material to explain in simple language.
Clients think that it is not Suggest some low-cost but nutritiousdiet. Include
affordable eggs/sprouts/bananasin the meals. Make use of
jaggery/gud, and add vegetables to the roti,rice,dal etc.
No time Simple ways can be suggested e.g.instead of making
roti–subji, make paratha/khichadi with dal and
vegetables. Have salad and curd with it.
No energy to make Simple food can be cooked. Inform the clients thatif they
start having nutritious food, their energy levels will
increase.
Also nd out the reasons for low energy. Refer the client
to the medical ofcer.
Do not like the food which is One has to develop the habit of eating specic food and
advised or not used to follow following the pattern (4–5 meals a day). Initially, it is
meals pattern suggested difcult to follow but later on clients may get used to it.
Explore if any other reason is there. E.g. family members may not be supportive. These
issues should be addressed.
• Counsellors should check with the clients what is doable, what is not doable and suggest
accordingly. Try to understand the possible hurdles. Discuss how to address them.
• Nutrition counselling should include not only the person infected with HIV/AIDS but
also the family.
• Counsel for critical nutrition practices to prevent malnutrition.
• Referrals and linkages: Guide the patients about various programmes and schemes that
provide direct nutritional support or monetary benet for the nutritional support: e.g.,
anganwadi. Patients may avail of nutrition services from other health programmes or
from NGOs as per eligibility.
• Nutrition counselling is not one-time counselling. It should be done every time clients
visit the centre. Follow up on whether the nutrition plan is being followed, what are the
challenges etc. Modify it as per need. Every time, motivate them to follow it. Otherwise,
after a few days they go back to the old pattern. So, encouragement is very important.
• Community-based activities can be conducted with support from NGOs (where possible)
e.g., competition for nutritious food cooking, quiz on nutrition, etc.
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Nutrition in the Context of HIV and Adherence
References:
• Nutrition Guidelines for HIV-Exposed and Infected Children (0-14 Years of Age)
• Nutrition myths debunked: World Food Programme. UN World Food Programme. (n.d.).
https://www.wfp.org/stories/nutrition-myths-debunked
• S, F. A., Madhu, M., Udaya Kumar, V., Dhingra, S., Kumar, N., Singh, S., Ravichandiran, V., &
Murti, K. (2022). Nutritional aspects of people living with HIV (PLHIV) amidst COVID-19 pandemic:
An insight. Current Pharmacology Reports, 8(5), 350–364. https://doi.org/10.1007/s40495-022-
00301-z
• Fenneld. (2023, May 15). 8 common myths about HIV and AIDS. Cleveland Clinic.
https://health.clevelandclinic.org/myths-about-hiv/
• National Operational Guideline for ART Services, NACO, 2021
• National Guidelines for HIV Care and Treatment, NACO, 2021
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Annexure: Nutrients, their functions and commonly available sources
The table below shows the category of foods/nutrients, their function in our body and commonly
available sources of such nutrients. The daily diet for a healthy adult PLHIV should include all
three food groups:
Around 63 thousand (36.72–104.06 thousand) new HIV infections were estimated in 2021.
Almost 92% of total new infections were reported to be among the population aged 15 years or
older, including around 24.55 thousand (14.27–40.69 thousand) among women. Around 42
thousand PLHIV died of AIDS-related mortality in the same reference period.
Table - Nutrients, their functions and available sources
Nutrients Function Commonly Available Sources
Energy-giving To provide energy to our body Carbohydrate-rich foods are rice,
foods: wheat, potato, sugar, honey, bajra,
To maintain body
(Carbohydrate jowar etc. Rich sources of fat are
temperatures, for metabolic
and fat) sh, walnuts, corn, soyabean and
purposes
sunower oil. Similarly, nuts,
mustard, olive oil and sh are the
sources of monounsaturated fat.
Body-building Proteins are the building Protein-rich foods are pulses, peas,
foods blocks of our body. nuts, beans, soyabeans, milk, egg,
(Protein) sh and meat.
Protective foods Minerals are needed for bones, Green leafy vegetables, egg yolk,
(Iron, calcium, teeth, healing of wounds, jaggery and organ meat are good
zinc, iodine, ghting infections, converting sources of iron. Milk products, methi
sodium) food into energy and body leaves and almonds are good sources
repair. of calcium. Whole grains, yeast,
nuts, seafood (lobster, salmon) and
pulses are rich sources of zinc. For
sodium and iodine, intake of iodised
salt is very important.
Vitamins Prevent infections, develop Intake of green and leafy vegetables,
(e.g., Vitamin A, antibodies, healthy skin, pulses, eggs, milk and milk
B, C, D, E, K) eyesight, absorption of calcium products, fruits (citrus fruits for
and antioxidants against Vitamin C), sh, nuts, seeds, grain
ageing and cereals and exposure to sunlight
is essential for the maintenance of
different types of vitamins in our
body.
Fibres Important in the process of Rich sources of bre are vegetables,
digestion and absorption grains, oats, pulses and fruits with
skins like apples and plums
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Elimination of Vertical Transmission
16 of HIV and Syphilis (EVTHS)
India’s commitment to the dual elimination of HIV and Syphilis
India has programmatically moved towards achieving the global 95:95:95 targets by 2025.
These targets aim to ensure that 95% of all pregnant women diagnosed with HIV are aware of
their status, 95% of pregnant women diagnosed with HIV are on treatment and 95% of all
infants born to women living with HIV have HIV-negative status. However, achieving these
targets requires sustained commitment and action to address the scale of challenges ahead.
Despite this, the progress in EVTHS has also been signicant. While the registration of
pregnant women in ante-natal care (ANC) services was 95% in 2021–2022, the HIV testing
reported in pregnant women for HIV was 84% and for syphilis was 57%. ART coverage in
pregnant mothers with HIV infection was 64% against a target of 95%. Adequate treatment
coverage in pregnant women seropositive for syphilis was 78% against a target of 95%.
What is vertical transmission?
Vertical transmission refers to the transmission of infection from mother to child, which can
take place during pregnancy (in-utero), during labour and delivery (perinatal) or postpartum
through breastfeeding. In recent years, substantial efforts have been made to prevent vertical
transmission of HIV and syphilis.
Newer four prongs of EVTHS under NACP-V
Prong 1: Primary prevention of HIV and syphilis among women of childbearing age. This can
be achieved by providing sexual and reproductive health services and other relevant health
services to women at an early age. It is important to engage with the community structures
and work collaboratively to increase awareness and improve access to prevention services.
Prong 2: Preventing unintended pregnancies among women living with HIV by offering
suitable counselling, guidance and contraception to women living with HIV, to address their
unmet needs for family planning and birth spacing. This will help in improving the health
outcomes for these women and their children.
Prong 3: Prevent HIV and syphilis transmission from pregnant women to their children by
providing pregnant women with HIV testing and counselling services, as well as access to ARV
drugs during pregnancy, delivery and breastfeeding. Additionally, it is crucial to ensure that
screening and management services for syphilis are readily available and accessible to
pregnant women.
Prong 4: Providing care, support and treatment to infected pregnant women, their partners
and HIV-exposed infants (HEIs) and management of syphilis-exposed infants (SEIs). This
includes ensuring access to ART to manage HIV. Additionally, it is essential to ensure
adequate management of syphilis in pregnancy and screening and management of SEIs.
Adequate management of infants diagnosed with congenital syphilis is also essential.
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HANDBOOK FOR HIV & STI COUNSELLORS
The newer four prongs of EVTHS under NACP V
Table 16.1 - Newer four prongs of EVTHS under NACP-V
Prong 1 Prong 2 Prong 3 Prong 4
HIV Primary Preventing Prevent HIV and Provide care,
prevention of unintended syphilis support and
HIV, especially pregnancies transmission from treatment to
among women of among WLHIV pregnant women infected pregnant
childbearing age to their children women, their
partners and
HIV-exposed
Primary prevention of syphilis, infants;
Syphilis especially among women of management of
childbearing age syphilis-exposed
infants
Table 16.2 - Risk of HIV transmission from mother to child with and without ARV interventions
ARV intervention Risk of HIV transmission
No ARV; breastfeeding 30–45%
No ARV; no breastfeeding 20–25%
Short course with one ARV; breastfeeding 15–25%
Short course with one ARV; no breastfeeding 5-15%
Short course with two ARVs; breastfeeding 5%
3 ARVs (ART) with breastfeeding 2%
3 ARVs (ART) with no breastfeeding 1%
Primary Prevention
This includes a mix of commodity services (like differential HIV testing, STI screening), non-
commodity services (like counselling and risk reduction) and referral services to engage women
who are ‘atrisk’ of acquiring HIV/syphilis to ensure that they stay negative and healthy.
Counselling
• Inform, educate and counsel adolescents on adolescent health issues and refer clients to
health facilities, HCTS conrmatory facilities, de-addiction centres, non-communicable
disease clinics etc.
• Counsellor at ART centre should counsel the adolescents living with HIV for safer sex
practices, positive and healthy living and prevention of transmission of HIV/syphilis.
• Counsellor should provide counselling services to high-risk populations regarding safer sex
practices, behaviour change and condom promotion for the reduction of STI/RTIs.
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• Women in the reproductive age group should be encouraged to establish and maintain
routine gynaecological care, nutritional care and management of NCDs through regular
visits to health facilities.
Essential package of services for the prevention of vertical transmission
of HIV
Table 16.3 - Essential package of services for prevention of vertical transmission of HIV
Essential Services Key Points
Routine HIV counselling and Offered to all pregnant women; involve partners and
testing family members
Provision of ART for all HIV+ Regardless of CD4 count, for prevention
pregnant/breastfeeding women
Ensuring institutional deliveries Reducing stigma and discrimination among
for HIV+ women healthcare workers; ensuring safer childbirth
environment
Comprehensive care for various STIs, RTIs, TB, opportunistic infections, hypertension
conditions and diabetes
Provision of plasma viral load Determines HIV transmission risk
testing at 32–36 Weeks
Nutrition counselling Provision of nutrition counselling and psychosocial
support to HIV-infected pregnant women
ARV prophylaxis for infants Administered within 72 hours of birth
Follow-up care for HEIs and Integrated into routine healthcare services
immunization
Co-trimoxazole prophylactic Administered from six weeks of age
therapy (CPT)
Enhance community follow-up and Support for HIV+ pregnant women and families,
outreach through local networks
Management of HIV-Exposed Infants
Immediate care and ARV Based on national guidelines: At birth, ARV
prophylaxis for newborns prophylaxis should be provided, preferably within one
hour or within 72 hours of delivery.
Coordination for newborn ARV For infants of newly identied HIV+ mothers during
prophylaxis labour. Labour room nurse should coordinate for ARV
prophylaxis.
Infant feeding Infant feeding should be started based on the
counselling provided during the ANC period. Mothers
who are identied HIV positive during labour should
be counselled for infant feeding options by the labour
room nurse.
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Essential Services Key Points
Monitoring ARV prophylaxis Initiated and monitored for newborns
adherence
CPT initiation and monitoring Begins at six weeks for prophylaxis
Follow-up of infant growth, It should take place at the ART centre at 6 weeks, 6
development monitoring, clinical months, 12months and 18 months from birth. Early
assessment infant diagnosis should take place at a collocated
HCTS conrmatory site.
Additional monitoring of growth Regular monitoring at specic intervals (10 weeks, 14
and development weeks, 9months and 15 months from birth at
healthcare centres
ART Initiation for HIV+ Infants If HIV+ status is conrmed
Conrmatory testing and regular At 18 months or after 3months breastfeeding
follow-Up cessation
Referral of infant for syphilis care Appropriate care for co-infected mothers
if mother is co-infected
Note: When an infant cannot be taken to an ART centre, care can be provided at a linked ART centre under the
supervision of the medical ofcer. In a few cases, if the child cannot be taken to a linked ART centre as well, the
medical ofcer of the centre may coordinate with the nearest health facility (preferably one which has a medical ofcer
trained to manage HEIs) or through teleconsultation for providing essential HIV care.
Dual Prophylaxis of HEI
Dual prophylaxis for high-risk infants is considered when:
• Infants born to HIV-positive mother not on ART;
• Maternal viral load not done after 32 weeks of pregnancy;
• Maternal plasma viral load not suppressed after 32 weeks of pregnancy;
• Mother newly identied HIV positive within 6 weeks of delivery.
Dual prophylaxis includes Syrup Nevirapine and Syrup Zidovudine. The duration of the dual
prophylaxis is as follows:
• In case of exclusive replacement feeding: From birth till 6 weeks of age;
• In case of exclusive breastfeeding: From birth till 12 weeks of age.
Early Infant Diagnosis
Children who contract HIV while in the womb or during birth tend to experience a rapid
progression of the HIV disease within the rst few months of their life, which often results in
death.
The goal of Early Infant Diagnosis (EID) is to detect HIV infection in infants who were exposed
to the virus and initiate ART as soon as possible to reduce their chances of morbidity and
mortality.
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Elimination of Vertical Transmission of HIV and Syphilis (EVTHS)
Infant Feeding Guidelines
a) Counselling mothers on feeding strategy
Antenatal counselling for infant feeding is vital, starting early after HIV diagnosis. HIV-
positive mothers should be informed about exclusive breastfeeding (EBF) or exclusive
replacement feeding (ERF) options with education on pros and cons. Healthcare providers
must be trained to assist parents in making informed choices. Discussions should occur
before delivery, emphasizing ART adherence for EBF and explaining both strategies.
Family context should guide decisions, tailored to each mother’s needs. Counsellors play a
key role in supporting successful implementation of chosen feeding option.
b) Exclusive Breast Feeding (EBF)
• The recommended feeding option, as per WHO and national guidelines, is exclusive breast
feeding for a minimum of 6 months.
• After 6 months of EBF, mothers should introduce appropriate complementary feed while
continuing to breastfeed their infants.
• Even if practising mixed feeding, EBF is still recommended during the rst 6 months. This
is not a reason to stop breastfeeding in the presence of ARV drugs.
• Breastfeeding can be continued for up to 24 months or beyond, regardless of the child’s HIV
status.
c) Exclusive replacement feeding (ERF):
The six criteria to be used to assess suitability for ERF are as follows:
Table 16.4 - Six criteria to assess suitability for ERF
Mothers known to be HIV infected should give replacement feeding to their infants only
when ALL the following conditions are met:
1. Safe water and sanitation are assured at the household level and in the
community.
2. The mother or any other caregiver can reliably afford to provide sufcient and
sustained replacement feeding (milk), to support the normal growth and
development of the infant.
3. The mother or caregiver can prepare it frequently enough in a clean manner so
that it is safe and carries a low risk of diarrhoea and malnutrition.
4. The mother or caregiver can, in the rst six months, exclusively give
replacement feeding.
5. The family is supportive of this practice.
6. The mother or caregiver can access healthcare that offers comprehensive child
health services.
d) Benets and Risks of Exclusive breastfeeding and Exclusive Replacement
Feeding
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Table 16.5 - Benefits and risks of EBF and ERF
Exclusive breastfeeding (EBF) Exclusive Replacement feeding (ERF)
Benets Breast milk contains all the No risk of HIV transmission
nutrients the baby needs in the through feeding
rst six months. Other family members may be
Breast milk is easy to digest. involved in feeding when mothers
Breast milk protects the baby from need help
diarrhoea, pneumonia and other The expense of obtaining
infections. appropriate milk, water, fuel, the
Breast milk is readily available added task of cleaning utensils
and does not require preparation.
Breastfeeding helps in developing
mother–infant bonding.
Exclusive breastfeeding helps the
mother to recover from childbirth
early.
Exclusive breastfeeding protects
the mother from getting pregnant
again too soon.
It prevents postpartum depression.
Risks / Risk of acquiring HIV infection if Babies are at higher risk of
Demerits the baby is breastfed contracting diarrhoea, pneumonia
and other infections
The mother may be questioned
about not breastfeeding her baby.
Elimination of Vertical Transmission of Syphilis
Table 16.6 - Elimination of vertical transmission of Syphilis
Introduction • Syphilis is an STI caused by Treponema pallidum.
• It may be transmitted through the following routes:
- Unsafe sex with an infected person (oral/vaginal/anal sex)
- From an infected mother to her child during pregnancy and labour
- Transfusion of infected blood and blood products
• Syphilis is an easily preventable, diagnosable and curable disease.
Syphilis in • Syphilis can be transmitted from an infected pregnant woman to her
pregnancy child during pregnancy and labour.
• The infection is associated with various adverse birth outcomes,
including early foetal loss, stillbirths, neonatal deaths, low birth
weight, prematurity and transmission of infection to the infant (also
known as congenital syphilis).
• Congenital syphilis is a serious but preventable disease that can be
prevented through effective screening of pregnant women; timely and
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Elimination of Vertical Transmission of HIV and Syphilis (EVTHS)
appropriate treatment of infected women should be initiated without
delay.
Screening • Pregnant women should be screened for syphilis during their rst ANC
and visit (preferably in the rst trimester).
management • It can be screened using dual rapid diagnostic test (RDT) kits or rapid
of syphilis in plasma reagin (RPR)/VDRL kits.
pregnancy
• Re-testing criteria: If a woman is serologically non-reactive for
and
syphilis and/or HIV during pregnancy, the screening should be
treatment
repeated if she lives in areas with a high prevalence of syphilis among
monitoring
pregnant women (>1% seropositivity), where women are at risk of
getting infected with syphilis during pregnancy in the third trimester
(32–36 weeks) and during labour.
• Syphilis screening at screening sites (facility integrated ICTCs, VHND,
PMSMA, etc.) can be conducted using dual RDT kits or rapid plasma
reagin, while the screening at conrmatory sites (standalone ICTCs)
can be conducted using RPR/VDRL kits. When facility for RPR/VDRL
testing not available, pregnant woman may be referred to nearest SA-
ICTC or DSRC.
Linkages of • If any pregnant woman is found reactive for syphilis, then the ANM
syphilis should write on the MCP card for the pregnant women “Reactive for
reactive Syphilis” and refer the pregnant woman to the nearest PHC. She must
cases also share details with the linked In-charge PHC MO.
• Ensure atleast one dose of injection benzathine penicillin to all the
pregnant women screened reactive for syphilis at the nearest
treatment facility (including DSRC).
• Link all screened syphilis-reactive pregnant women to conrmatory
sites for conrmation. All women screened reactive with RPR/VDRL
should be provided with complete treatment with 3 doses of injection
benzathine penicillin at the nearest treatment facility (including
DSRC).
Screening and • The term ‘syphilis-exposed infants’(SEIs) is used to refer to infants
management born to mothers infected with syphilis until congenital syphilis
of SEIs infection can be reliably excluded or conrmed.
• Infants might be born without clinical signs of syphilis but go on to
develop late-stage manifestations of untreated congenital syphilis that
include developmental delays, neurologic manifestations and physical
signs of late congenital syphilis (like swelling of joints, skin lesions,
jaundice, anaemia, changes in long bones, etc.).
• All SEIs at birth should be referred to the nearest special newborn care
unit/neonatal intensive care unit/paediatric treatment facility at a
medical college/district hospital/sub-district hospital.
• The infants should be screened and managed by a paediatrician at the
facility using crystalline penicillin.
• The RPR titers of both mother and infant at birth should be compared
and the infant should be managed using the guidelines for scenario-
based case management.
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Hepatitis B
Hepatitis B is the inammation of the liver caused by Hepatitis B virus. The virus is most
commonly transmitted from mother to child during birth and delivery, through contact with
blood or other body uids during sex with an infected partner and unsafe injections or
exposures to sharp instruments.
a) Symptoms: May not show any symptoms in the infected person in the initial stages. The
symptoms include but are not limited to the following:
• Fatigue
• Poor appetite
• Stomach ache
• Nausea/vomiting
• Dark urine and jaundice-like symptoms.
b) Screening of Hepatitis B: The risk of Hepatitis B (HBV) infection may be higher in HIV-
infected adults, and therefore all people newly diagnosed with HIV should be screened for
HBsAg. HBV infection also negatively impacts the progression of HIV infection leading to
faster immune deterioration and higher mortality. Screening serological tests and
molecular tests are required to establish a diagnosis of hepatitis B (HBV) for evaluation for
further management.
Routine investigations like complete blood count, including platelets, and estimation of liver
enzymes alanine transaminase and aspartate aminotransferase, are essential to decide
whether a client is cirrhotic (complicated) or non-cirrhotic (uncomplicated). Apart from
these, renal function tests also must be done before treatment is initiated.
c) Treatment
Designated health facilities (treatment centres/model treatment centres)
• HBV-positive clients should be referred to the treatment centres/model treatment
centres under the NVHCP depending on their condition. The treatment centres are
located at district hospitals and designated sub-district hospitals, CHCs and PHCs,
while the model treatment centres are in designated medical colleges/tertiary care
hospitals.
• Once a client reaches the relevant centre, they should meet with the physician/medical
ofcer and they will be managed as per the NVHCP guidelines.
In case of clients diagnosed with HIV and HBV
• In case a client has co-infection of HIV and HBV, they should be referred to the ART
centre. Further, it will be the responsibility of the ART centre to link the client to a
model treatment centre under the NVHCP.
• Explain to the client about how co-infection of HIV with HBV may deteriorate their
health despite taking ART regularly and lead to rapid deterioration in liver function.
Also, inform the client that their ARV regimen may need modication in case of co-
infection.
• The counsellor also needs to give information about infection control practices to
prevent the spread of infection to other household members.
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Elimination of Vertical Transmission of HIV and Syphilis (EVTHS)
• Clients must be provided the NVHCP referral slip available at the ICTCs and ART
centres.
• Condentiality/shared condentiality of HIV status must be ensured at all levels by all
staff members.
• Ensure posters on the NVHCP are displayed at the NACP service delivery centres and
provide any other IEC material on HBV that is available for distribution to clients.
d) Vaccination for HBV: Hepatitis B has a vaccine and can be prevented by vaccination.
• All infants born to HBV-positive pregnant women need to be immunized within 24
hours of birth followed by routine vaccination under the immunization programme.
• It is recommended that all the TI staff should work closely with SACS and National
Hepatitis Control Program to get their staff and core groups vaccinated for Hepatitis B.
• Besides this, all infants born to hepatitis B-positive women need to be immunized
within 12 hours of birth (dose - 0) followed by 1, 2 and 6 months (dose – 10 µg IM) and
HBIG – 0.5 ml IM.
Key Messages
• Vertical transmission is the transmission of HIV, syphilis, Hepatitis B of a child by the
mother during pregnancy, delivery or breastfeeding.
• Elimination of vertical transmission of HIV, syphilis and Hepatitis B is focused upon,
leading to triple elimination.
• All women attending the ANC clinic should be offered HIV counselling and encouraged
for HIV testing.
• Care should be taken while disclosing HIV positive report. If the woman is HIV positive,
the counsellor should disclose the news with utmost care and support. The news may be
shocking and there might be a lot of concerns about the baby to be born. There might be
relationship and other issues that should be addressed.
- Discuss the importance of disclosure and partner testing. But, do not force or
pressurize.
- She should be guided for ART registration and preparedness counselling. Adherence
counselling should be provided as per the guidelines.
• Family counselling: In case of ANC, other family members too are involved in the care of
the woman, e.g., her mother, mother-in-law and others. In such cases, it might be
important to disclose the status to them as well but that decision should be taken by the
woman. If she needs any support, it should be provided. Family members also should be
counselled if required.
• Infant feeding options should be discussed with the woman during ANC period well in
advance. Explain the benets and risks of both options and let the woman take the
decision. It is not easy to make the decision because a lot of emotional and cultural issues
are attached to it. E.g. if a woman opts for replacement feeding, she may be pressured by
family members to breastfeed the baby. Culturally, there is a lot of importance to
breastfeeding and women who do not do it are stigmatized. If she opts for breastfeeding,
there will be always the concern of HIV transmission.
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HANDBOOK FOR HIV & STI COUNSELLORS
• Participation of spouse in care: Ensure the involvement of spouse in caring of the woman.
At most places, the participation of men in the care of women is less. Most of the time,
ANC women come to the centre with other women in the family. Encourage the
participation of spouses in the decision-making process.
• For ANC women: The woman should get proper rest and nutritious food. All medicines,
supplements and regular check-upsshould be done as per timelines.
- Insist on hospital delivery. Carry all documents while making a visit to the hospital.
Do the delivery at the same hospital where the client is registered. In case of a new
hospital, make sure to give all information to the doctors and show the documents.
- In the labour room, the infant should be given ARV prophylaxis. Labour room nurse
should support feeding as per the option exercised by the client. Counsellor should
document the details on the client’s papers.
- Further management of the client and the infant is to be done as per protocol.
- The client will need support and guidance from time to time while the child is growing
up. The ART team should ensure that the client gets all necessary support.
- Some women experience postpartum depression. Counsellor should assess the
symptoms and make referrals if needed. Consult with the gynaecologist too.
• Counselling messages for parents/caregivers for testing of the HIV-exposed infant/child
Counselling parents regarding the timing for HIV testing for their baby begins during
the antenatal period. This should be emphasized by the various staff at the health
facilities where pregnant women are being followed, including ART centres, health
centres, antenatal clinics and maternity wards. Counselling messages should include the
following:
- Importance of HIV testing and postnatal care for the infant/child
- Availability of tests that can diagnose HIV in the infant/child
- Availability of a comprehensive package of care and treatment for the HIV-exposed
infants and children
- Need for follow-up visits and regular monitoring
- Timing for testing and report collection
- Final testing would be at 18 months of age or 3 months after stopping breastfeeding,
whichever is later.
- Pre- and post-test counselling will be provided for mothers and caregivers by
counsellors, MOs and/or nurses at the EID testing sites.
• Counselling mothers regarding choosing feeding strategy
- Expectant mothers who test positive for HIV must be informed about the available
feeding options, including EBF or ERF during the ANC period well before delivery.
The healthcare team and counsellors must educate and guide the parents about the
benets and drawbacks of both options to enable them to make an informed decision.
Since each mother’s circumstances are unique, counselling and the nal decision on
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Elimination of Vertical Transmission of HIV and Syphilis (EVTHS)
feeding options must be tailored to their specic needs. The counsellor’s crucial role is
to support the family in successfully implementing their chosen feeding option.
- Counsellor should emphasize the importance of ART adherence especially if the
mother has opted for breastfeeding.
• Counselling messages related to EVTHS
Speak to the mothers during pregnancy and after delivery on the importance of the
following activities as part of the counselling sessions:
- Screening for TB, syphilis, Hepatitis B and other STIs
- Testing the partner for HIV
- Regular hospital visits
- Viral load testing
- ART adherence
- Practicing safe sex and viral suppression
- Appropriate ways to disclose HIV status to other children and caregivers in the family
- Institutional delivery
- Exclusive breastfeeding for the rst six months
- Introduction of appropriate complementary foods after 6 months
- ART given to the mother makes breastfeeding safe (Undetectable = Untransmissible)
- Mothers living with HIV should breastfeed till at least 12 months and may continue
breastfeeding till up to 24 months or beyond (like in the general population), while
being fully supported for ART adherence.
- Administration of ARV drugs to all HEIs immediately after delivery, within 72 hours
- Administration of CPT to all HEIs from the age of 6 weeks
- Vaccination as per the standard immunization schedule
- Dried blood spot testing for HEIs at 6 weeks, 6 months, 1 year and 18 months
- Final testing of HEIs at 18 months or three months after stoppage of breastfeeding
(whichever is later)
- Mothers must bring their children immediately to hospital, whenever they fall ill.
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HANDBOOK FOR HIV & STI COUNSELLORS
Family Planning Methods
17 for PLHIV
India took pioneering steps by launching its national family planning programme in 1952. The
programme’s primary objective was to regulate fertility and reduce birth rates to a level that
aligns with socio-economic development and environmental sustainability, as stated in the
Family Planning Insurance Manual of the National Health Mission.
According to the WHO “family planning enables individuals and couples to plan and achieve
their desired number of children while controlling the spacing and timing of their births. This
is achieved through the use of contraceptive methods and addressing involuntary infertility.
The ability of women to manage the timing and spacing of their pregnancies has a profound
impact on their overall health and well-being, as well as the outcomes of each pregnancy.
Source: (WHO, https://www.publichealth.com.ng/who-denition-of-family-planning/)
By framing family planning in a comprehensive manner, individuals and couples can make
informed decisions that align with their life circumstances, health and well-being, as well as
contribute to responsible population growth and sustainable development.
Importance of family planning
Figure 17.1- Importance of Family Planning
Age of mother <18 years or Bad consequences related to
Too early/too late
>35 years mother’s hearth
• Anaemia
• Increased chances of
- Infections
(i) Interval between two pregnancies
- Abortions
is less than 2 years
Too frequent - Haemorrhage
(ii) After miscarriage or abortion, next
- Obstructed labour
pregnancy within 6 months
- Pre-eclampsia/eclampsia
- Preterm birth
Woman is pregnant for the Bad consequences related to child
Too many
5th time or more health
• Low birth weight
• Increased chances of Infant
mortality
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Family Planning Methods for PLHIV
Various family planning methods
Figure 17.2 - Family planning methods
Various Commodities available in India PHC and Sub VHSND FLW
and who provides them at what level Above Centre
All Sterilization Services
PPIUCD (Only at Delivery Points)
IUCD
Injectable (Antara)
Condoms (Free)
Condoms (Paid)
Mala D/ Mala N
ECP (Ezy Pill)
Centchroman (Chhaya)
Table 17.1- Contraceptive methods and their use
Contraceptive Key Points about Contraceptive Methods
Methods and Their Use
Male condoms A condom, when used consistently and correctly during sexual activity, is
(Nirodh) a simple yet highly effective method for men. It acts as a barrier,
preventing sperm from reaching and fertilizing the egg by blocking
ejaculated semen from entering the vagina. In addition to contraception,
condoms also provide protection against sexually transmitted infections
(STIs), reproductive tract infections (RTIs) and HIV. They can also be
used in combination with other contraceptive methods for dual
protection.
Oral Two types:
contraceptive
1) Hormonal (combined oral contraceptive pills: COC i.e. Mala N and
pills
progestin-only pills)
2) Non-hormonal: Centchroman non-hormonal pill (Chhaya)
For women, taken to prevent pregnancy, no protection against STIs.
Intra-uterine An intra-uterine contraceptive device (IUCD) is a small, exible plastic
contraceptive frame containing coiled copper with two nylon strings at its lower end. It
device (IUCD) can be easily inserted in the uterus by a healthcare or trained service
provider even just after delivery for effective spacing. There are two types
of IUCDs available:
• IUCD 380 A that is effective for 10 years
• IUCD 375 that is effective for 5 years
Three types based on time of insertion: Interval IUCD, postpartum
IUCD and post-abortion IUCD
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HANDBOOK FOR HIV & STI COUNSELLORS
Contraceptive Key Points about Contraceptive Methods
Methods and Their Use
Injectable Medroxyprogesterone acetate (MPA) - Antara Programme:
contraceptive • A three-month injection which needs to be repeated every three
months
• Safe, highly effective, convenient method of contraception
• Can be taken intramuscularly or subcutaneously
• It does not affect breastmilk, hence can be injected to breastfeeding
mothers at 6 weeks.
• It is a reversible method.
Sterilization Either partner can choose this method when they decide that their family
is complete, and they do not wish to have any more children in the
future. Two types: (i) Female sterilization: One-time surgical
procedure where tubes carrying the eggs from the ovaries to the uterus
are blocked. (ii) Male sterilization: One-time surgical procedure where
the two vasa deferentia carrying the sperms to the urethra are blocked.
Emergency Sexually active individuals may encounter emergencies such as incorrect
Contraception condom use, condom breakage, missed contraceptive pills, IUCD
expulsion, coerced sex or situations where a contraceptive method is not
used during intercourse. In such circumstances, levonorgestrel tablets
(commonly known as Ezy Pill) containing progestin hormones can be
taken within three days (72 hours) following unprotected sex.
Table 17.2 - Types of contraception for different needs/reproductive intents
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Family Planning Methods for PLHIV
Family planning services for PLHIV
Couples have both the right and the responsibility to plan their families by taking necessary
steps to achieve the desired family size. PLHIV have similar fertility desires and intentions as
those who are not infected, and with advances in treatment, most WLHIV can realistically plan
to have and raise children to adulthood. Although HIV may have adverse effects on fertility,
recent studies suggest that ART may increase or restore fertility.
Ensuring that PLHIV have access to stigma-free family planning services to prevent
unintended pregnancies is one of the important services provided to the PLHIV. Counsellors
are expected to prepare a line list of eligible PLHIV in reproductive age groups based on
records available at the ART centre and counsel on pregnancy planning if desiring pregnancy
and provide preconception care.
a) Preconception Care (PCC)
Preconception care should be provided to all WLHIV who desire pregnancy as well as
negative partner of HIV-positive male who desires pregnancy. The viral suppression of the
HIV-infected partner before pregnancy is a key factor in addition to optimal health
conditions.
The goals of PCC for WLHIV are as follows:
• Prevent unintended pregnancy;
• Optimize maternal health prior to pregnancy;
• Improve maternal and foetal outcomes in pregnancy;
• Prevent perinatal HIV transmission;
• Prevent HIV transmission to an HIV-uninfected sexual partner when trying to conceive.
PCC counselling ensures the following:
1. Prepare line list of couple where one or both partners are infected with HIV and desire to
have child.
2. Ensure viral load suppression before planning pregnancies and optimal ART adherence.
3. Ensure optimal health of the couple. Anaemia and malnutrition may be treated by ART
medical ofcer as PLHIV nutritional requirements and drug-induced anaemia needs
special care.
4. Screening and management of STI/RTI of both the partners.
b) Birth Planning Counselling for PLHIV
The birth planning counselling should be tailored to the individual needs and preferences of
WLHIV and their partners, and should involve shared decision making. Counselling should
be offered at multiple points of contact with the health system, such as antenatal care
clinics, labour wards, postnatal wards, ART centres, etc.
Birth planning counselling for PLHIV should be provided in a respectful, non-judgemental and
condential manner. Reproductive rights of Women living with HIV include respecting
fertility, sexuality and contraceptive method choices, which do not force or coerce women into
abortion or sterilization.
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HANDBOOK FOR HIV & STI COUNSELLORS
Figure 17.3-Clients’ rights and voluntary decision of family planning
Client has right to
decide to adopt FP
Client has right to get adequate FP must be a voluntary Client has right to decide to
information on each method & informed decision stop or change a method
There are three key messages to be followed by couples to have healthy timing and spacing of
pregnancy:
• First pregnancy should be planned only after 20 years of age in order to avoid complications
in teenage pregnancy.
• After a live birth, another pregnancy should be planned at least after two years, with an
ideal spacing of 3–5 years.
• After a miscarriage or abortion, a new pregnancy should be planned only after six months
or later to avoid the occurrence of abortion again.
c) Counselling sero-discordant couples for family planning
Many sero-discordant couples may want to have a child. This may be a strongly felt need
even among couples who already have one or more children. One or both members of the
couple may experience a desire for parenthood even knowing that this carries the possibility
of HIV transmission.
The desire to be a parent is also often mixed with the fear of transmitting infection to the
child. Some experts have even suggested that the wish for parenthood may explain, to some
extent, why there is a high transmission rate between sero-discordant partners.
Factors that inuence the desire to have children:
• Availability of PPTCT and ART: PLHIV who have access to ART feel more condent
about parenthood. They feel more condent about the chances that their children may be
born without HIV, and that they will live long enough to parent them.
• Family support: If the sero-discordant couple feels stigmatized by family, or if they feel
that the family will not support the child after their death, they may not want to bear
children. When they feel the family will look after the children, they want to have children.
When you counsel a sero-discordant couple, you should probe for the family’s attitude.
• Stigma of infertility: Sometimes couples may report that they want to have children
because they believe the stigma of being infertile is worse than the stigma of being HIV
positive. This is more likely when the couple has not shared the HIV diagnosis with family
members.
• Completing the family: Some couples may want to have children in order to complete
their family. Some have stated that having a second or third child may provide the other
children with some companionship after they (the parents) have died. Some couples may
want to have children in order to cement their relationship.
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Family Planning Methods for PLHIV
PrEP for Safer Conception
HIV-discordant couples in which one partner is living with HIV and one partner is HIV-
uninfected, often desire pregnancy, despite risk of sexual HIV transmission during pregnancy
attempts. HIV prevention counselling for the desiring HIV-discordant couples will have to
discuss safer and more effective conception strategies. For HIV-discordant couples, an
integrated approach with PrEP use limited to the time prior to ART-induced HIV viral
suppression in the HIV-infected partner can virtually eliminate sexual HIV transmission and
can be used when pregnancy is desired.
Clinicians should educate HIV-discordant couples who wish to have a child about the potential
risks and benets of beginning or continuing PrEP during pregnancy so that an informed
decision can be made. Once the decision to take PrEP is made, the clinician must ensure that
• The HIV-positive partner is on ART and virally suppressed;
• PrEP is initiated at least 20 days ahead of unprotected sex.
The most fertile period may be advised to the couple for increasing chances of conception.
Counselling of pregnant women when one or both partners are HIV positive
Table 17.3 - Counselling guidance when one or both partners have HIV
Considerations Counselling Guidance
When both • Ensure both are on ART with sustained viral suppression before
partners have attempting conception. The risk of HIV superinfection or infection
HIV with a resistant virus is negligible when both partners are on ART
and have fully suppressed plasma viral loads.
• This underscores the importance of achieving and maintaining viral
suppression to ensure the health and well-being of both partners and
to minimize the risk of transmission during conception and
throughout their relationship.
• By following this approach, couples with HIV can condently pursue
their desire for parenthood while safeguarding their health and
reducing the risk of further transmission.
Couple who • Expert consultation is recommended to tailor guidance to an
wants to individual’s specic needs.
conceive when • People with HIV should achieve sustained viral suppression before
one or both attempting conception to maximize their health, prevent HIV sexual
partners have transmission and minimize the risk of HIV transmission to the
HIV infant, especially for pregnant individuals with HIV
• Ensure sustained clinical stability of the HIV-positive partner to
ensure their overall health during the conception process.
• Both partners should be screened and treated if any genital tract
infections are there, before conceiving. Treating such infections is
essential as genital tract inammation is associated with increased
genital shedding of HIV.
• When individuals have different HIV statuses, sexual intercourse
without a condom allows conception with effectively no risk of sexual
HIV transmission to the person without HIV if the person with HIV
is on ART and has achieved sustained viral suppression.
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HANDBOOK FOR HIV & STI COUNSELLORS
Additional guidance might be required in the following scenarios:
• If the person with HIV has not achieved sustained viral suppression or their HIV viral
suppression status is unknown, OR
• If concerns exist that the person with HIV might be inconsistently adherent to ART during
the peri-conceptional period.
If a sero-discordant couple desires pregnancy, PrEP can be one of the strategies for safer
conception. Clinicians should educate HIV-discordant couples who wish to have a child about
the potential risks and benets of all available alternatives for safer conception. If indicated,
referrals for assisted reproduction therapies can also be made. The clinicians should discuss
with them the available information related to the potential risks and benets of beginning or
continuing PrEP during pregnancy so that an informed decision can be made.
Table 17.4 - Counselling scenarios
Scenario Counselling
Before PrEP • Ensure HIV-positive partner is on ART and virally suppressed.
initiation, • Start PrEP at least 20 days before unprotected sex.
clinician must
ensure • Advise on the most fertile period for increasing chances of
conception.
Partners with • Partner without HIV can choose to take PrEP even if HIV-positive
different HIV partner is virally suppressed. This will provide an extra layer of
statuses protection as a prevention.
Condomless sex • Consider advising timing condomless sex to coincide with ovulation
timing (peak fertility) for safer conception and HIV risk reduction.
Home • Sero-discordant couples with an HIV-infected female partner may
insemination consider home insemination during the most fertile period of the
(HIV-infected menstrual cycle using a needleless syringe, while continuing
female partner) consistent condom use. Home insemination can be a safer alternative
by using to unprotected sexual intercourse for conception purposes, providing
needleless a way for sero-discordant couples to pursue pregnancy while still
syringe maintaining preventive measures against HIV transmission.
Around 63 thousand (36.72–104.06 thousand) new HI+V infections were estimated in 2021.
Almost 92% of total new infections were reported to be among the population aged 15 years or
older, including around 24.55 thousand (14.27–40.69 thousand) among women. Around 42
thousand PLHIV died of AIDS-related mortality in the same reference period.
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Family Planning Methods for PLHIV
Table 17.5 - Approaches to reduce risk of horizontal HIV transmission
Approaches to reduce risk of horizontal transmission for HIV-affected couples
who want to have children
Low technology High technology
Male HIV +ve • Screening and pre-treatment for STI • Sperm washing
Female HIV –ve • Delay until viral load controlled • IUI – Intra uterine
• Limited, timed, unprotected sexual insemination
encounters • ICSI – Intra cytoplasmic
• PrEP to negative partner sperm injection
Female HIV +ve • Screening and pre-treatment for STI • Articial insemination
Male HIV –ve • Delay until viral load controlled
• Limited, timed, unprotected sexual
encounters
• Male circumcision
• PrEP to negative partner
Key Messages
• Family planning for PLHIV involves preventing unintended pregnancy, optimizing
maternal health, improving pregnancy outcomes and preventing HIV transmission to
the partner or the child.
• Integrating family planning into HIV counselling involves asking clients about their
fertility intentions, contraceptive methods and HIV prevention concerns, and providing
them with information and support on their choices.
• Counsellors should prepare a line list of eligible couples (couples of childbearing age)
where one or both partners are infected with HIV and desire to have child. Family
planning counselling should be offered to the couples irrespective of the HIV status.
• Family planning counselling for PLHIV should be provided in a respectful, non-
judgemental and condential manner. Respect the reproductive rights of the couple. Do
not force to make use of contraception or abortion or sterilization. Couples should take
their own decision after counselling.
• Counsellor’s responsibilities include afrming the right of WLHIV and couples to make
informed decisions, providing preconception care, discussing dual protection and
disclosure, and following up on contraceptive use.
• Counselling sero-discordant couples for family planning involves providing information
and support on the factors, methods and risks of conceiving and preventing HIV
transmission.
• Sero-discordant couples should also consider screening and treatment for STIs, viral
load control, male circumcision and ART prophylaxis to prevent vertical transmission.
• Counsellor should respect the family planning need of PLHIV. Refer to gynaecologists
for the right choice of family planning methods for PLHIV.
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• Understand the challenges couples face while making pregnancy-related decisions.
When one or both persons in the couple are HIV positive, decision making for pregnancy
is not easy. Various health-related, psychosocial, cultural and nancial factors impact
the decision. A woman/couple may want to have a child for various reasons like natural
wish, cultural factors, fear of stigma of childlessness, children being perceived as old age
support etc. At the same time, they might consider this as a burden because of their own
health condition and nances. They may have concerns like who will look after their
child when they passaway, fear that their child will be HIV positive and so on.
• Facilitate decision-making process. Counsellors’ role is to understand this dilemma,
provide information on various options about conception and support the couple while
they are in the decision-making process. The couple’s decision also may not be
unanimous. So, facilitate to have a consensus between the couple.
• Initial dialogue-When the couple/woman expresses the wish to conceive, be empathetic
and listen carefully. Understand their point of view about the infection and life in
general. Assess whether they have an understanding of the risks involved while
planning for the pregnancy. Do not assume anything. Cross check if they have any
misconceptions or inadequate information and counsel accordingly. Explain the risk of
HIV and STI in case of unprotected sex. Discuss pros and cons of various options.
Discuss safe sex practices.
• Follow-up session - Ask about the decision taken. If the decision is to opt for pregnancy,
give information on all dos and don’ts. Offer various options with benets and risks
involved and ask them to select.
• Explain proper adherence to ART and its efciency in preventing horizontal
transmission. The concept of U=U (HIV undetectable = untransmittable) needs to be
explained along with its risks and exceptions.
• If the decision is “no”, provide information on safe sex and for the negative partner to
stay negative. Positive partner – ART adherence and viral load suppression.
• Provide detailed information on various contraception methods to all the couples and
support in choosing a suitable option.
Counsellors can present a range of contraceptive options to the couple. However, it is
important to emphasize that the guidance for the most suitable contraceptive method
should be provided by the clinician. So it is essential to refer the woman/ couple to a
clinician.
• Explain the difference between temporary and permanent methods. If the couple has
one or more living children, then a permanent sterilization method can be
recommended.
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Family Planning Methods for PLHIV
References:
• Preconception and Contraceptive Care for Women Living with HIV. Mary Jo Hoyt, Deborah S. Storm,
Erika Aaron, and Jean Anderson
• Commonly available family planning methods under NHM at various levels of health system:
https://nhm.gov.in/index1.php?lang=1&level=2&sublinkid=821&lid=222
• Sankalak 3rd Edition 2021
• Reference manual for integrating RMNCAH+N counselling: ENGLISH
RMNCAH+N_Manual_on_Counseling_2021.pdf
• WHO: https://www.publichealth.com.ng/who-denition-of-family-planning/
• Manual for Family Planning Insurance Scheme (nhm.gov.in)
• National Technical Guidelines for Pre-Exposure Prophylaxis, NACO
• Final Draft EVTHS Guidelines (Version 1) Chapter 3: Technical & Operational Guidelines for
EVTHS
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Counselling of Children
18 and Parent/Guardian
The estimated children living with HIV (CLHIV) in India are 69,808 (Sankalak,2022). Of these,
about 90% have been infected through mother-to-child transmission (MTCT) i.e., during
pregnancy/ childbirth/breastfeeding. The remaining 10% have acquired through other modes
like blood transfusion, sexual contact or sexual abuse. The information about the route of
transmission is signicant when addressing sexually active children as well as to understand
the effects of positive status on the physical and psychosocial growth of the children.
The child client and his/her parent/guardian must be supported through sensitive and caring
counselling.
Challenges Faced While Counselling Children
Table 18.1 - Challenges of Counselling children
Parent/Guardian- Child-related Home Environment-
related Challenges Challenges related Challenges
Frequent Dependency on adults Higher chance of sickness
sickness/mortality
Poor attention span, poor Economic constraints,
Frequent changes in physical growth
Stigma and discrimination
parent/guardian
Difculty in communication
Attitudes, beliefs and
Changing understanding of
habits
the child with age
Addressing Challenges in Counselling CLHIV
1. Both the child client and his/her parent/guardians need to be supported through sensitive
and caring counselling.
2. Counselling messages should be tailored as per child’s age, developmental status, ability to
understand HIV disease and treatment and his/her social circumstances.
3. Counselling messages should be adapted to changing needs as the child grows older and
progresses through various stages of child development.
4. Essential to identify the primary caregiver and a back-up secondary caregiver if the
primary caregiver is not available.
5. Challenges of coping with adherence to lifelong treatment; issues of disclosure,
condentiality, stigma and discrimination in their immediate environments, issues related
to education, career, relationships, etc., all need to be sensitively addressed at appropriate
times. These may vary from child to child.
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Counselling of Children and Parent/Guardian
Creating Child-friendly ART Centre
A child-friendly environment is necessary in the centre to support children and make them feel
comfortable. The atmosphere at the ART centre is crucial for strengthening the trust between
the ART team and the child, and to support adherence to treatment. This can change the
perception of the child from viewing the ART centre as a ‘hospital’ to a ‘friendly centre’ that can
help nd solutions to the issues he/she is facing.
Figure 18.1- Child Friendly ART centre
Ideas for a Child-friendly ART Centre
• Separate room for counselling of children is ideal. If it is not available, then plan a child-
friendly corner.
• The room should have small chairs, art materials, toys, drawing papers, crayons and art
materials.
• The wall should have a display of paintings done by CLHIV.
• Blackboard and chalk placed at the child’s eye level in a corner of the waiting area so that
they may express their creativity.
Child-Centred Counselling
Children have distinct physical, emotional, and social needs that demand a different approach
from adults. Although the core counselling skills apply to both groups, when working with
children, it is vital to use words they can understand and encourage them to share their
emotions. The messages related to various aspects of their illness are best conveyed using tools
like stories, drawings and games.
Talking to children effectively relies on their developmental stage and how well they can share
their feelings and concerns. Young children struggle with using words to describe their
thoughts or emotions. So, it is important to nd practical methods to connect with them and
help them express themselves. Holding their attention can be challenging. Therefore, using
tools like stories, drawings and games works best to convey messages about their illness.
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Table 18.2 - Child centered counselling
Principles of Child- Essential Description of Skills
centred Counselling Counselling Skills
Develop rapport, focus Rapport building Introduce yourself/your role to the
on child’s needs child. Clear fears, set context, assure
condentiality.
Tailor the messages Listening Pay attention to the child’s verbal and
according to physical, non-verbal communications, validate,
psychological support. This encourages them to share
development their stories and challenging
experiences. It also means being
supportive, refraining from arguing and
providing instant solutions as the child
unfolds his/her narrative.
Promote potential, build Recognizing and Validate feelings, experiences.
self-esteem acknowledging Empathize, understand. This helps
emotions children feel supported and
comfortable. This demonstrates your
understanding and empathy.
Respect identity, Acceptance and non- Refrain from judgement, provide space
emotions judgemental attitude for reection.
Creating a space where children can
analyse and contemplate their actions
is crucial. Such introspection forms the
foundation for them to make more
thoughtful decisions about their lives
and choices.The counsellor’s role is to
empower and facilitate the child’s
decision-making process.
Always involve the child Questioning Make use of more open-ended questions
and the child’s for detailed perspectives. Allow them to
parent/guardian in tell their stories in ways that are
counselling. descriptive, detailed and non-
Involve them in the threatening.
decision making.
Protecting the ‘best Paraphrasing Summarize accurately to validate their
interest’ of the child narratives and experiences.
Maintain
condentiality.
Ensure non-
discrimination
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Counselling of Children and Parent/Guardian
Disclosure of HIV Diagnosis to Children Living with HIV
Disclosure of HIV diagnosis to infected children is a challenge for both the parents/guardians
and the healthcare providers. A prevalent obstacle to disclosure arises from feelings of guilt
and discomfort among mothers/parents/guardians, coupled with apprehension about the
potential outcomes of revealing the truth. Frequently, parents/guardians are unsure how to
broach the subject with the child, often aiming to shield them from distressing information.
Another hurdle stems from the fear that the child might inadvertently disclose their HIV
status to others. In certain instances, the absence of a parent/guardian poses a challenge to the
disclosure process, as seen in the case of orphans.
Timing of Disclosure
Counsellors and doctors are often concerned about the right age for disclosure to the child. The
optimal approach is to initiate this conversation when children are between 5 and 7 years old,
gauging their comprehension and obtaining parental approval. This process can unfold
gradually, progressing until the child reaches 12–14 years of age.
Table 18.3 - Type and timing of disclosure
Type of Disclosure Time of Disclosure
Initiating disclosure (Age 4 to 6 years) When the child is curious about many issues and
concepts of illness and wellness can be
introduced
Partial disclosure (Age 7 to 11 years) When the child is aware that he/she or the
parent has a chronic illness and is taking daily
medications for it.
Full disclosure (Age 12 and above) When the child can understand full disclosure of
illness
How to Explain HIV and ART to Children
Disclosure must be done together with the child and the parent/guardians. Disclosure to a child
needs to be age appropriate and according to the level of understanding. Table18.2 gives an
example of utilizing the understanding about child’s growth in counselling using age-
appropriate counselling messages about HIV infection.
Table 18.2 - Age-appropriate counselling messages about HIV infection
3–6 years
6–9 years
9–12 years
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Preparing the parents/guardians for providing HIV disclosure
Parents/guardians play a vital role in the disclosure of a child’s HIV status, offering the most
appropriate and supportive environment for this important conversation. Encouraging and
assisting parents in this process is crucial, allowing them to choose the right time and place to
share this sensitive information with their child. Preparing parents to gently communicate the
news, address inquiries and guide the child in comprehending and managing the illness is
essential.
In certain cases, parents may seek the guidance of a counsellor or medical ofcer to facilitate
the disclosure. In such instances, it is advisable to arrange joint counselling sessions involving
both the child and the parent or guardian. The parents’ input regarding the child’s readiness
for disclosure counselling holds signicance and should be taken into consideration. The
counsellor can also provide their expert assessment of the child’s emotional readiness to receive
this life-changing news.
One common concern shared by parents, guardians and even counsellors is the fear that
children who are informed of their status might accidentally reveal this information to others,
potentially leading to stigma. There is also the apprehension that the child might experience
feelings of depression and even contemplate self-harm. To address these concerns, the
counselling team should propose a gradual disclosure approach based on the child’s ability to
grasp the implications of the diagnosis. Additionally, the team can normalize the situation by
drawing parallels between HIV and chronic illnesses like diabetes, underscoring the necessity
for consistent health-promoting behaviours.
A legitimate worry parents and guardians may have is the reluctance to divulge the child’s
HIV status to others. This apprehension could inadvertently affect the child’s treatment
journey. It might result in refusals to ll prescriptions locally, concealing or relabelling
medication containers to maintain secrecy within the family and missed doses when the parent
is unavailable. These potential challenges must be openly discussed during counselling
sessions, providing parents with a safe space to express their concerns and explore solutions.
Counselling the Child and Caregiver for Lifelong ART
Table 18.4 - Three Stages of counselling
Preparedness Adherence Follow-up
Counselling Counselling Counselling
It should start before Identifying barriers Providing ongoing
Key objectives
beginning of ART. and ensuring psychosocial support
adherence to
Disclosure of the HIV Monitoring of adherence
treatment.
status of the child
Monitor the growth of
Prepare child child
andparent/guardian
Nutrition counselling
for treatment
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Counselling of Children and Parent/Guardian
Preparedness Adherence Follow-up
Counselling Counselling Counselling
Educating and Educate on ART Address adherence
Counselling making ready both adherence. fatigue in CLHIV
child and the children and their Counselling for
parents/guardi parents/guardian for nutrition
ans lifelong therapy: this
groundwork is pivotal
for strong adherence
and successful
treatment results.
Explain ART and its
advantages/
limitations.
Evaluate child’s Provide reminder Assist with disclosure of
social environment. tools (alarms, HIV status.
Discuss lifelong calendars, SMS, rell Prepare child for
therapy. boxes and pill charts) disclosure.
Emphasizeon Build rapport with
adherence to child for reporting
treatment. about doses missed
Counselling Help them to deal Identify and address Prepare
parents/ with personal guilt barriers to parents/guardians for
guardian and worry. adherence. disclosure.
Support in accepting Nutrition counselling
the illness and its
implications before
initiating treatment.
Identify the main
caregiver(s).
Educate about ART Address concerns about
implications, disclosure.
adherence and drug
toxicities.
Sensitize about HIV Normalize HIV as
status disclosure to chronic illness.
child.
Medication Explain medicine Specify timing and Suggest disclosure in
information details (appearance, administration of stages.
dosage). medicines.
Discuss who will Address caregiver Address concerns about
administer the changes. secrecy.
medicines.
Educate about Address barriers in Address concerns about
possible side effects adherence. stigma.
and measures to
take.
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Treatment Preparedness Counselling
Preparedness counselling for children shares similarities with that for adults. The main
distinction is that since children rely on their parents/guardians for treatment, counselling for
children involves including the parents/guardian as well.
The 5 As method is a useful approach for preparing both the child and parents/guardian for
treatment.
1) ASSESS the child’s and parent’s/guardian’s comprehension of their HIV status, and
knowledge of its treatment, evaluate potential obstacles to adherence and the social support
systems.
2) ASSIST the child and parents/guardian in developing a treatment and adherence plan
3) ADVISE about how ART works and the importance of adherence. It is important to advise
the child and parents/guardian to aim for 100% adherence, ensuring not skipping even a
single dose or visit.
4) ARRANGE: the ART team can arrange for medical investigations and appropriate
referrals.
5) AGREE means that the patient and parents/guardian both understand, accept and agree to
the formulated treatment.
The counsellors should explain the What, When, How and Who of ART medicines as part of the
preparatory counselling.
Explain WHAT medicines will be given.
Specify WHEN the medicines should be given or taken.
Provide details on HOW the medicines will be given or taken.
Identify WHO will administer the medicines to the child.
Side effects: Prepare the parents/guardians for the possibility of minor side effects of ARV
drugs like nausea, headache and abdominal discomfort and explain to them about home-based
care for these common adverse events. Counsel that mild side effects will recede over time or
respond to changes in diet or method and timing of medication administration.
Treatment Adherence Counselling
Adherence to ART is essential to achieve viral suppression. Hence, it is essential to educate
both the CLHIV and the parents/guardian about adherence to ART.
Barriers to adherence: It is essential to monitor adherence during each visit and identify
and address any unidentied barriers to adherence. The four broad categories of potential
barriers to adherence in CLHIV are child-related, treatment related, provider-related and
environmental and social factors. This categorization helps the counsellor in addressing each
barrier.
Treatment-related adherence issues could occur due to long-distance travel to and from the
hospital, loss of daily wages for travel, frequent changes in ART staff, high pill burden, etc.
These issues can be addressed by the counsellor while designing the customized adherence
plan. Issues related to social factors may be stigma, discrimination at home and school, if living
in an orphanage or with relatives, and poor access to medical care facilities, etc. In issues
related to society, the ART team may have limited scope for intervention. However, CLHIV
should be helped to minimize the impact of the barrier on them and encouraged to continue
treatment.
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Table 18.5 - Child and Parent/ guardian related factors in treatment adherence
Child-related Factors Parents/Guardian-related Factors
Dependency on adults Knowledge and understanding of treatment and its
implications
Likes/dislikes for medicines Misconceptions regarding treatment and health beliefs
Emotional issues Relationship with the child, daily routineand nature of job
Other infections and medications Attitude towards adherence; repeated changes in
parent/guardians
Follow-up Counselling
Adherence fatigue
It is essential to monitor adherence during each visit and identify and address any unidentied
barriers to adherence. Monitor adherence fatigue in CLHIV and address the same.
Nutrition and Safe Food Handling
Dietary counselling is another important component of paediatric HIV-related counselling. It is
important to instruct the parent/guardian and the child to include a variety of nutritious food
items in the diet of CLHIV to eat small frequent meals and have plenty of uids.
Counselling for personal hygiene and measures for personal safety must also be given to the
child and the parents/guardian. This includes advice to always wash their hands with soap and
water, cover the nose and mouth while coughing, covering wounds and avoiding direct contact
with other people’s open wounds. Mosquito nets can be used to avoid infections such as dengue
or malaria. Garbage should be always kept in covered bins to avoid ies.
Immunization Advisory
The counsellor should encourage and ensure timely immunization of children with HIV.
Asymptomatic CLHIV with CD4 count above 15% can be safely immunized even with live
vaccines. The SMO/MO should assess the child for the safety of immunization with live
vaccines.
Child Abuse
Sexual abuse victims are among the most vulnerable members of our society, including
children and adolescents. We have a collective responsibility to listen to their experiences,
protect them from further harm and ensure they have ongoing access to specialist counselling
support.
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HANDBOOK FOR HIV & STI COUNSELLORS
Table 18.6 – Overview of Child abuse
Child Abuse Impact of How to Support Sexual Abuse
and Sexual Childhood Sexual Someone Who Has Trauma Recovery
Assault Abuse in Been Sexually Counselling
Overview Adulthood Assaulted
Sexual abuse can Long-lasting Listen, validate their Process what has
happen to problems in many feelings. happened.
anyone, any age. areas of adult life Reduce distressing
For legal after-effects.
purposes, all
children till the
age of 18 years
are covered
under this.
Often involves Damage to the sense Respect boundaries, Strengthen resilience,
close relations of self/negativeself- help with tasks. rebuild self-esteem.
and people in perception
position of
authority
Offender is often Interpersonal and Make sure they are Emphasize blame on
known to emotional difculties; aware that you are perpetrator, not victim.
victim(family Avoidance of there for them. Leave them alone if
members, foster intimacy; Numbness; requested.
parents, family Re-experiencing
friends);frequentl abusive patterns in
y repeated abuse adult relationships
Abuser uses Intense shame, Donot push them to Enhance coping, well-
promises, anger, depression, explain their being.
threats, bribes suicidal thoughts, experience.Leave
Guide on how to ensure
for control despair, isolation them alone if they so
safety.
request.
Disclosure can Fear of speaking up Help them with basic Refer the victim for
lead to disbelief, tasks. professional help.
trauma.
Vulnerable Counselling helps Be present, believe Assist in ling case
victims need accept it is not them. against perpetrators.
ongoing support victim’s fault
(POCSO Act, 2012).
Counsellors should get familiar with POCSO Act 2012 (Refer to Annexure). The act has been
enacted to protect children from offences of sexual assault, sexual harassment and
pornography and provide for the establishment of special courts for the trial of such offences
and related matters and incidents.
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Counselling of Children and Parent/Guardian
Key Messages
• Counselling skills required for counselling CLHIV are the same as for adults but the
child’s developmental stage should be considered while counselling.
• Counsellors should be able to effectively communicate with children using various
verbal and non-verbal methods and actions.
• CLHIV often have issues with self-esteem. Expressing acceptance is most important. It
helps in self-acceptance.
• Counselling messages should be adapted to changing needs as the child grows older and
progresses through various stages of child development.
• Children like being treated as ‘grown-ups’.
Refer following examples:
Age 3–6 years Age 6–9 years Age 9–12 years
Understand concepts such Peer recognition starts. Understand and are able
as size, shape, direction to follow sequential
• Ask them to name their
and time. directions.
various pills. Designate
• Use this to help them x them as friends who help • Explain them their
the time of their pills. them to stay t and treatment regimen.
healthy and be able to go
Enjoy doing most things • Reading and verbal
to school to meet other
independently. communications are very
friends.
well developed.
• You may ask caregivers to
• Ask them about their
place the tablet and water • Help them to maintain a
friends. This will help you
in the child’s hand rather record of their pill
identify any issues that
than feeding the tablet. consumption on a calendar
they face, like difculty
Explain how to swallow the or diary.
with friends, and
tablet to 5–6-year-old child.
avoidance from friends as • This age group has a lot of
• Explore whether children a result of stigma and the inuence of peers. So, talk
have an aversion to any emotional issues about their friends and
particular pill colour. associated with it. interest. It will help you to
understand the stigma and
Follow directions. • A good counsellor will
discrimination issues if
recall the names of the
• You can take them around any.
child’s friends because this
the ICTC and explain what
is one way of entering • Remember to ask them
happens there. You can
their world. She/he will about their physical
create a small demo (not
patiently listen to the milestones related to
real) for the actual testing
stories of “what Adi said” puberty.
process by asking them
and “what Kirti did.”
what a brave soldier would
do: e.g., not mind a little This is important for child-
pain which comes from centred counselling because
being pricked. This will it gives importance to those
help them in acceptance of things that are important for
the situation and normalize the child.
feelings associated with
HIV.
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HANDBOOK FOR HIV & STI COUNSELLORS
• Disclosure of HIV status to a child is a continuous and progressive process. It is
important that the disclosure be done by the caregiver, the role of the counsellor is to
support this process. If the caregiver really cannot do it, then the counsellor can help to
do it in the presence of the caregiver.
• Three types of disclosure: Initiating disclosure (Age 4–6 years) is done when the child
is curious about the illness. Partial disclosure (Age 7–11 years) is done when the child
is aware that the medicines are being taken for some chronic illness. Full disclosure
(Age 12 and above) is done when the child can understand and cope.
• Expression of emotions:
- Help the child express their emotions. Often children are told not to express emotions,
especially negative ones such as anger and sadness.
- Enabling the child to express emotions in a safe environment is an important task for
the counsellor.
- Normalize the feeling. Normalization helps people to feel that what they are
experiencing is acceptable.
- Explore the reason(s) for the feeling. Assist the child to manage the feelings.
- Assess adherence fatigue and counsel to overcome it. Some statements that a
counsellor may hear from the CLHIV are “I can’t take these medicines”; “I don’t like
the taste of these pills”; “My friends are not taking it, why should I?”; “My head is
paining” or “I feel like vomiting”.
• Discuss the parenting skills with parents/guardians. Many parents neglect the child’s
feelings, thoughts and opinions. It is important to understand children and guide them.
This will help them become independent and develop decision-making ability.
• Counsellors will have to understand the acts of the perpetrators that are considered as
sexual abuse under the POCSO Act 2012 and support the affected children.
References
• Reference Manual for Integrated RMNCAH+N, Ministry of Health and Family Welfare, Government
of India, September 2021
• Nutrition Guidelines for HIV-Exposed and Infected Children (0-14 Years Of Age)
• National Operational Guideline for ART Services, NACO, 2021
• National Guidelines for HIV Care and Treatment, NACO, 2021
• National HIV Counselling and Testing Services (HCTS) Guidelines, NACO, December 2016
• WHO (2010), 'IMAI one-day orientation on adolescents living with. HIV. Participants' manual and
facilitator guide'; accessed at http://whqlibdoc.who.int/publications/ 2010/9789241598972_eng.pdf
• The Protection of Children from Sexual Offences Act, 2012.
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19 with HIV (ALHIV) and Adolescents at Risk
Adolescents, aged 10–19, are a unique group transitioning from childhood to adulthood. This
phase encompasses physical, emotional and behavioural changes. Physically, they experience
the emergence of secondary sexual characteristics, rapid height growth, voice modulation and
sexual interest. Emotionally, surging sex hormones lead to mood swings, impulsivity, a sense of
invincibility and idealistic thinking. Behavioural shifts may involve self-consciousness,
sensitivity to bodily changes, a strong craving for peer approval, risk-taking tendencies,
identity confusion and vacillating between child and adult behaviours. Adolescents often
grapple with the ability to make and bear responsibility for their decisions.
Adolescents are at higher risk of HIV due to engaging in high-risk practices. Economic
hardship can drive adolescents into early employment, increasing street living, and exposure to
high-risk activities, alcohol and drugs. The increased awareness among paediatricians, early
diagnosis in infancy and the widespread availability of free ART have led to a growing number
of adolescents living with HIV.
Adolescents Living with HIV
Depending on the mode of acquisition of HIV, ALHIV may be classied into two distinct
populations:
1. Vertically infected adolescents: Those who have acquired HIV through vertical route:
The diagnosis of HIV infection in these children may be through the ‘early infant diagnosis’
protocol if maternal HIV exposure is known during pregnancy/delivery. Alternatively, their
diagnosis may occur later when symptoms manifest or through contact tracing if their
parents or siblings are found to be infected. Whether they are on antiretroviral therapy
(ART) by the time they enter adolescence varies.
2. Horizontally infected adolescents: Those who have acquired HIV infection horizontally
during childhood or adolescence through sexual transmission due to unprotected sex or
sexual abuse, or through injectable drug use, unsafe surgical procedures or injections or
blood transfusion. These two groups differ in some important characteristics.
Table 19.1 Characteristics of adolescents with HIV
Characteristics Vertically Infected Horizontally Infected
Adolescents Adolescents
Stage of HIV Likely in advanced stage of Usually in early stages of
infection infection infection
Occurrence of More likely Less likely
opportunistic
infections
Impact on growth Usually affected, especially if Lower impact on growth and
and development ART started late or not started development
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Characteristics Vertically Infected Horizontally Infected
Adolescents Adolescents
Mortality rate Higher Lower
Knowledge of HIV May not be fully disclosed or not Likely to know their HIV status
status disclosed at all if they have accessed HIV care
services
ART experience Likely to be highly ART- N/A (as they are usually in early
experienced with multiple stages)
changes in ARVs and multiple
mutations
HIV-related losses More likely N/A (as they are usually in early
stages)
Stigma experience Usually experience stigma early Usually face stigma later,
in life, at school, home and possibly exacerbated by stigma
healthcare related to drug use and sexuality
Detection age Diagnosed during childhood at Infection usually detected during
different ages, some may present adulthood
during adolescence
Medical problems Likely to have chronic medical N/A (as they are usually in early
and developmental problems and developmental stages)
delay delay
Challenges Faced by ALHIV
ALHIV face challenges of both adolescence and HIV infection. They feel the need to identify
themselves with peers and are often pre-occupied with self-image. This leads to risk-taking
behaviour.
Table 19.2 - Challenges faced by ALHIV
Challenges Faced by Vertically Challenges Faced by Horizontally
Infected Adolescents Infected Adolescents
• Poor/stunted physical growth due to • Hidden identities: Many conceal their
delay in ART initiation sexuality, occupation or gender identity from
• Delayed puberty family and peers.
• Impaired bone health • Difcult/hard to reach due to the
criminalization of behaviours such as drug use,
• Delayed cognitive and physical sex work and consensual same-sex relations,
development along with the fear of arrest and abuse
• Academic struggles, leading to a • Disclosure dilemma
high dropout rate
• Transgender youth and those with sexually
• Long-term morbidities involving transmitted infections (STIs) face difculties in
metabolic, renal, cardiovascular or navigating their HIV status.
central nervous system.
• Challenges in ART adherence and retention
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Counselling for Adolescents Living with HIV (ALHIV) and Adolescents at Risk
Challenges Faced by Vertically Challenges Faced by Horizontally
Infected Adolescents Infected Adolescents
• Psychiatric and behavioural • Delayed HIV detection in largely
problems asymptomatic adolescents and due to limited
• Lack of knowledge about their own youth-friendly voluntary testing facilities and
HIV status or that of their parents, the requirement of parental/caregiver consent
leading to incomplete or incorrect for HIV testing before the age of 18
information about the disease • Challenges to linkage to care due to high rate
• Transition challenges from adult- of loss to follow-up between diagnosis and ART
supervised care to self-led care initiation
• Adherence issues • Familial constraints due to disclosing their
HIV status, which can further delay their
• Treatment complications, failure, access to care
and/or side effects
• Lack of emotional and nancial support
• Stigma and discrimination
• Late entry into care with signicant immune
• Socio-economic challenges dysfunction, which can impact their long-term
• Mental health issues health outcomes
Common challenges faced by both groups:
• Increased likelihood of adverse family and social environment with poor support
• Difculty in accepting and learning to cope with their diagnosis and its impact on various
aspects of their life
• Increased mental stress and risk of acquiring deviant and aggressive behaviour
• Higher chance of hindered education and career-related challenges
• Difculty in coping with relationships, following protected sexual practices and a greater
risk of unwanted pregnancy
ALHIV and Mental Health
The relationship between HIV infection and mental health issues is bidirectional. ALHIV are
more susceptible to develop mental health problems due to social stressors. Conversely,
adolescents with pre-existing mental health problems are more prone to acquire HIV because
they are more likely to engage in risky behaviours like unprotected sex and substance abuse,
and they may also be vulnerable to sexual abuse.
Counselling for ALHIV
Adolescents living with HIV require ongoing counselling and support not only to accept their
diagnosis but also to navigate the challenges of living with HIV. Involving adolescents actively
in the counselling process is crucial. While parents or guardians may be involved, it is essential
to prioritize the adolescent’s needs. However, permission from the parent or guardian is
necessary before discussing certain issues with an adolescent under the age of 18.
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Key Counselling Areasfor ALHIV
Counselling needs of ALHIV can be grouped under three areas which are tabulated below.
Table 19.3 - Key counselling in ALHIV
Care and Treatment Sex and HIV Life Skills
Understanding HIV Involves discussion about Guidance in essential life
Importance of lifelong growing up and changing skills like effective
ART behaviour communication skills
Treatment adherence Maintaining healthy sexual Coping with stigma and
relationships discrimination
Disclosure of HIV
status Methods of preventing Decision making
pregnancy Planning for future
Healthy living with
HIV and nutritional
guidance
ALHIV need to have understanding about HIV and how it spreads. It is important to give
details about HIV infection and AIDS and discuss the need for lifelong therapy. Adolescents
need to know about drug side effects and the importance of adherence to drug regimens.
A strong rapport with the adolescent clients is essential, which helps counsellors to be
responsive towards the ever-changing concerns the adolescent may have as he/she goes
through this phase of life.
Table 19.4 - Key principles of communicating with adolescents
Principles Key Points
Understand Understand their interests, assure condentiality, ask about friends,
their interests acknowledge their identity, be open and non-judgemental
Address their Acknowledge their concerns and validate their feelings. One common
concerns concern voiced by most adolescents is “Nobody understands me”.
Constructively Adolescents may feel shy, helpless, anxious, scared, defensive, resistant,
respond to embarrassed or worried. The counsellor should explain to them that it is
their feelings normal to feel this way and overcome the barriers to communication.
Help with Build trust and rapport, address alcohol/substance use and depression,
adherence connect with peers facing similar issues and emphasize consistent
to ART medication.
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Table 19.5 - What to Do and What to Avoid When Communicating with Adolescents
Dos Avoid
• Be truthful about what you know and • Giving inaccurate information (to scare
what you do not know. them or make them “behave”)
• Be professional and technically • Threatening to break condentiality “for
competent. their own good”
• Use words and concepts that they can • Giving them only the information that
understand and relate toto assess if they you think they will understand
understand. • Using medical terms they will not
• Use pictures and ip charts to explain. understand
• Treat them with respect in terms of how • Talking down to them, shouting, getting
you speak and act. angry or blaming them
• Give all the information/choices and help • Telling them what to do because you
them decide what to do know best, and they “are young”
• Treat all adolescents equally. • Being judgemental about their behaviour,
• Be understanding and supportive even if showing disapproval or imposing your
you do not approve of their behaviour. own values
• Accept that they may choose to show their • Being critical of their appearance or
individuality in dress or language. behaviour, unless it relates to their
health or well-being
Source: WHO (2010), 'IMAI one-day orientation on adolescents living with. HIV. Participants' manual and facilitator
guide'; accessed at http://whqlibdoc.who.int/publications/ 2010/9789241598972_eng.pdf
Nutritional Counselling for ALHIV
Since adolescence is the phase of sudden and rapid growth, counselling on nutrition becomes
important. Assess and discuss the following points:
• Weigh adolescent clients at each visit and record their weight.
• If malnourished, discuss if nutritional problems exist: if so, the severity and probable causes.
• Assess eating habits, such as eating a lot of ‘junk food’ or skipping meals and the reason for
skipping meals.
• Encourage a well-balanced diet that includes a variety of fresh foods and that is based on
what is locally available and affordable.
• Discuss the ability of the client and his or her family to buy or grow enough healthy foods to
eat.
• Refer the clients for appropriate nutritional support programmes.
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Table 19.6 - 5As in ALHIV
A series of steps used in the integrated management of adult illness (IMAI) approach to chronic HIV
care with ART, to guide health workers at each consultation
Assess Goals for the consultation, physical and mental status, treatment adherence,
sexual activity and contraception use, pregnancy (for young women, risk
behaviours/factors, knowledge, beliefs and concerns about HIV, support
structures and disclosure
Advice Use plain, neutral, non-judgemental attitude, correct inaccurate knowledge,
advise on living with HIV (relationships, sex, substance use, discuss sexual
activity, condom use, contraception, couple counselling and HIV status
disclosure, peer support from other ALHIV, adherence advice, treatment options
and regimen. Consider developmental phase for ART prescription.
Agree Choose treatment and support location, decide whom to disclose status to, plan
for status disclosure, dene roles in care and treatment, agree on treatment
plan and goals. Decide on clear, measurable and limited goals.
Assist Provide written or pictorial plan summary, referrals to adolescent-friendly
services, links to support services, provide medications and treatments, condoms
and contraception, self-management tools and skills, address adherence
obstacles, predict and strategize barriers, psychological support if needed,
strengthen social connections and support.
Arrange Plan for time between visits, set next appointment date, arrange for group
counselling or support group referral.
Disclosure in ALHIV
Disclosing an adolescent’s HIV status is a crucial step, signicantly impacting adherence to
treatment and clinical outcomes. Adolescents require counselling and support to navigate
when, how and to whom to disclose their HIV status. This process encourages them to take
more responsibility for their health and increases their participation in care, ultimately
improving retention in care. Ongoing support is essential for both disclosing their own status
and learning about their parents’ status.
Counselling for disclosure should encompass a thorough discussion of the risks and benets
associated with disclosing their HIV status to others. Support should be readily available as
adolescents make decisions about when, how and to whom they will disclose their status.
It is paramount to ensure that the adolescent is emotionally prepared for the disclosure
process. Encouraging parents or caregivers to assume responsibility for disclosure can be a
more effective approach. The disclosure process should be tailored to align with each
adolescent’s developmental stage and understanding, taking their age into consideration.
Overcoming barriers to disclosure is crucial and should be undertaken with the active support
of caregivers.
Counsellors and healthcare staff should maintain accessibility and openness, ready to address
any questions or concerns that may arise during and after the disclosure. Disclosure is an
ongoing process, evolving as the adolescent’s understanding of the disease deepens.
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Counselling for Adolescents Living with HIV (ALHIV) and Adolescents at Risk
Linking with required services: Counselling centres cannot address all the needs of
adolescent clients. Hence there is a need to connect them with respective service facilities or
providers.
Facilities under National Health Mission
Adolescent-Friendly Health Clinics (AFHCS):
Rashtriya Kishor Swasthya Karyakram (RKSK) highlights the need for strengthening
Adolescent Friendly Health Clinics (AFHC) under its facility-based approach. This approach
was initiated in 2006 under RCH II in the form of Adolescent Reproductive Sexual Health
(ARSH) Clinic to provide counselling on sexual and reproductive health issues.
Now under RKSK, AFHC entails a whole gamut of clinical and counselling services on diverse
adolescent health issues ranging from sexual and reproductive health (SRH) to nutrition,
substance abuse, injuries and violence (including gender-based violence), non-communicable
diseases and mental health. AFHS are delivered through trained service providers: MO, ANM
and counsellors at AFHCs located at primary health centres (PHCs), community health centres
(CHCs),district hospitals (DHs) and medical colleges.
Facilities under NACP
ARTcentrefor pre-ARTregistration and/or treatment
STI clinic or STI care providers in case of STI/RTI symptoms
TI projects if the adolescentisan IDUor does sex work
Community care centres
Drop-in centres for ALHIV
Other Facilities and Providers
Designated Microscopy Centre for TB diagnosis
De-addiction centres
Legal help cells/advocates
Other agencies providing care and support services.
It is advisable to furnish adolescents and their parents/guardian with essential information
about the services available at the facility before referring them there. As previously
mentioned, adolescents may harbour reservations about accessing services alongside adults.
Therefore, it is important to proactively prepare the adolescent and their parents/guardian for
this arrangement. Clarify that directing them to another facility is not a form of abandonment;
rather, it is a proactive step taken to ensure they receive the specic help and support they
require.
Follow-Up for ALHIV
Follow-up counselling sessions offer an opportunity for the adolescent and parents/guardian to
express and share these concerns in a supportive environment.
Follow-up counselling includes:
Ensure the adolescent’s registration at the ART centre.
Facilitate disclosure of HIV status to the adolescent.
Facilitate reduction in identied risk behaviours of the adolescent.
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HANDBOOK FOR HIV & STI COUNSELLORS
Help the adolescent to deal with identied particular situations in his/her life such as
sickness in the family, stigma and trafcking.
The adolescent or parents/guardian may seek professional assistance to deal with particular
problems related to HIV in their life. This can again relate to stigma, problems with peers,
issues related with knowing one’s own HIV status and anxiety about life.
Table 19.7 - Addressing other issues with adolescents
Issues Suggested guidance
Stigma Discuss experiences of stigma, assist in overcoming effects of
stigma. Support parents/caregivers in handling situations and
disclosing status.
Work in dealing with ‘self-stigma’.
Difculty in Peers are important for adolescents. Due to HIV infection, they
identifying with may themselves stay apart from HIV-negative peers or experience
HIV-negative peers rejection from them. Encourage healthy relationships with HIV-
negative peers, educate them that HIV does not spread through
casual contact. Boost self-esteem. Work with peers during
outreach sessions to appreciate positive qualities in individuals.
Anxiety about Talk about delaying and safe sex practices, emphasize honesty in
sexual relationships relationships, discuss legal obligations to disclose to potential
and future planning partners; highlight importance of honesty and trust in
relationships.
Concerns about the Address care giving challenges for sick family members, provide
care of sick family emotional support, guidance and links to social support systems,
members assist in accessing medical services
Concerns about Address responsibilities and challenges of heading the family
heading family after parental death; offer follow-up support sessions, link to
relevant support networks and resources.
It is important to connect adolescents with one-stop centres and networks for PLHIV to access
the support they need during these challenging times.
Counsellors should get familiar with POCSO Act 2012. The Act has been enacted to protect
adolescents from offences of sexual assault, sexual harassment and pornography and provide
for the establishment of special courts for the trial of such offences and related matters and
incidents.
Key Messages
• ALHIV need long-term counselling and support not only to come to terms with their
diagnosis but also to discuss what it means to live with HIV, if and when to disclose their
status and how to envision their future.
• Counsellors should understand the developmental characteristics of the adolescents.
They are neither children nor adults. This is a period of physical growth. Sexual
characteristics develop. There are many psychological changes e.g., preoccupation with
body image, desire to establish own identity and freedom, distancing from parents, rapid
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mood changes, attraction towards the opposite sex, self-exploration, inuence of peer
group etc. These features put them at risk for HIV.
• Be empathetic and try to understand the issues from their point of view. Give them the
condence that you understand them.
• Involve them in the counselling process. Discuss separately with them. Do not talk only
with parents.
• Treat them as adults (though legally they are not adults, they do not like to be treated
like children).
• Do not preach to them. Instead, have a discussion with them on various issues and ask
for their opinion.
• Respect their point of view. Show trust.
• Adolescents have peer inuence on them and they may not be getting along with parents.
Handle the situation carefully. Do not take sides, stay neutral. Explain both sides to both
of them and ask what will be benecial for the ALHIV.
• Adolescents may not want their family to be involved in counselling, especially when
sensitive matters are discussed. But the family may insist on being part of counselling. In
such cases, conduct separate as well as joint sessions and have a discussion on various
points including points of disagreement.
• Maintain condentiality. If the counsellor feels the need to inform certain things to
parents, ask the consent of the client.
• Normalization can be used to reassure clients that the feelings they experience(e.g. guilt,
anger) are common or normal reactions.
• Normalize feelings of shyness, anxiety and embarrassment. Explain that it is normal to
feel this way. The feelings of shame and guilt are associated with HIV infection. Address
these feelings.
• The options decided on by the adolescents may not always be right and benet them.
Help them to understand the risks and benets of each solution.
• Self Esteem: This is a very crucial area for focused in counselling. Adolescents’ self-image
is based on acceptance by the peers. ALHIV face many issues like self-stigma, negative
attitude towards self due to the difference between self and others. Discuss self-
acceptance.
• Encourage them to explore their own good qualities. Encourage them to mix with peers.
If they stay aloof, they will not experience belongingness with the peer group.
• Discuss how they can deal with the stigma. They should also work on the self-stigma
with the help of the counsellor.
• Discuss self-care. This is one strategy to deal with low self-esteem.
• Communication: Key principles of communicating with adolescents are understanding
their interests, addressing their concerns, constructively responding to their feelings and
helping them with adherence to ART.
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HANDBOOK FOR HIV & STI COUNSELLORS
• Ensure that you are not communicating in a way that reminds them of a dominating
parent.
• Ask direct questions.
• Avoid judgemental and evaluative statements.
• Assess mental health issues: Mental health issues are very common among adolescents
and they remain neglected most of the time. If necessary, make psychiatric referral.
• Provide anticipatory guidance while making referrals: For instance, prepare for what
might happen at the facilities they are referred to: e.g., “It may be crowded. You may
have to wait a long. Better to go in the morning/noon.”; “The people over there might ask
you some questions. They may ask for your reports and I card. So, please carry it with
you.”
• Counsellors will have to understand the acts of the perpetrators that are considered as
sexual abuse under the POCSO Act 2012 and support affected adolescents.
References
Reference Manual for Integrated RMNCAH+N, Ministry of Health and Family Welfare, Government of
India, September 2021
Nutrition Guidelines for HIV-Exposed and Infected Children (0-14 Years of Age)
National Operational Guideline for ART Services, NACO, 2021
National Guidelines for HIV Care and Treatment, NACO, 2021
National HIV Counselling and Testing Services (HCTS) Guidelines, NACO, December 2016
WHO (2010), 'IMAI one-day orientation on adolescents living with. HIV. Participants' manual and
facilitator guide'; accessed at http://whqlibdoc.who.int/publications/ 2010/9789241598972_eng.pdf
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20 Newer Interventions in NACP-V
A number of initiatives have been launched by NACO recently like Sampoorna Suraksha
Strategy (SSS), One Stop Centre (OSC), Community Systems Strengthening (CSS) and virtual
interventions to reach the population at risk that is not covered under Targeted Interventions
(TI) or other prevention programmes.
Sampoorna Suraksha Strategy (SSS)
As per the HIV Estimations 2021 report, annual new HIV infections declined in India by 46%
between 2010 and 2021. While this is signicantly higher than the global average of 32%, it is
evident that there is a need to further arrest the spread of HIV to reach the programme
targets.
While the programme has made a huge leap in preventing HIV among key populations (KP)
through its TI programme, new infections among ‘at risk’ individuals who do not identify
themselves as part of any high-risk group (HRG) are target beneciaries who are still being
missed out.
Sampoorna Suraksha is a strategy aimed at reaching out to those not self-identifying as HRGs
but are at risk, and providing them with a clinical, need-based and comprehensive package of
supportive services that help them stay negative and healthy.
Objectives of Sampoorna Suraksha Strategy:
Identify individuals who are at risk HIV-negative clients.
Ensure evidence-based comprehensive prevention service package customized to
geographies and vulnerable populations to maintain their HIV-and STI-negative status.
Sustain focus on all at-risk HIV-negative clients.
Drive the development and roll-out of new generation communication strategies tailored to
the current context.
What is a Sampoorna Suraksha Kendra?
SSS is being implemented as an evidenced-based ‘Immersion Learning Model’ to identify the
best path forward and adapt strategies, by leveraging feedback, eld experiences and
learnings.
The SSS is being implemented through existing identied NACP facilities i.e., ICTCs or
DSRCs functional at the districts by remodelling into SSKs.
The national programme has selected 150 districts in 20 states for the implementation of
SSS in the country till 2024 based on a detailed data analysis.
The SSKs will deliver a comprehensive service package under one roof and address the 360-
degree health needs of the beneciaries.
The service package is designed to include a holistic set of services customized as per clients’
needs, with strong linkages and referrals to other services and social security schemes, and
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HANDBOOK FOR HIV & STI COUNSELLORS
rigorous client outreach and follow-up by using different modalities that may include virtual
platforms through various apps and other strategies.
Target population
The population ‘At Risk’ for HIV and STIs is dened as “any individual who is at risk of
acquiring HIV or STI due to risky behaviours of self or partner(s)”. This includes the core
population, the bridge population, their spouses/partners and other populations who are
engaging in risky behaviours. ‘At risk’populations to be covered through SSS are the following:
Self-initiated clients at ICTC with risky behaviour;
Social and sexual networks of self-initiated clients/individuals;
Youth and adolescents;
Individuals having casual sexual relation with regular/non-regular partner/s;
STI/RTI clients visiting DSRC/STI Clinicswith STI complaints;
HIV-negative but at-risk clients identied through virtual outreach, NACO Helpline 1097
etc.;
Regular and non-regular partner/s/spouse of HRG (FSW, MSM, TG/TS) who are not
associated/covered with TIs, LWS and OSC;
Needle/Syringes-sharing partners (IDU/FIDU) and their sexual partners (who are not
associated with TIs/ LWS/OSC);
HIV-negative partners of discordant couples.
Figure 20.1 – “At Risk” Population Chart
Risk Assessment Questionnaire
The risk assessment can also be leveraged to assess whether the client is atrisk or not.
Further, at-risk clients can be categorized into low, moderate and high-risk in the manner
given below. These categorizations will help in prioritization and facilitating follow-up of
priority clients.
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Newer Interventions in NACP-V
Interpretation of Risk Assessment Questionnaire
Table 20.1 – Risk assessment questionnaire
Question No. Response Interpretation
1. Do you have the Used, Shared, No, Refuse to If (a) “Shared” or (b) “Used AND
habit of answer Shared”>> High risk;
using/sharing If “Used”>> Moderate risk;
injecting drugs? If “Refuse to answer”>> Low risk;
If “No”>> Not at risk.
2. What kind of sexual Male, Female, TG, No sexual If client is Male AND sexual partner is
partner(s) do you partner, Male>> High risk;
have? Refuse to answer If client is Male AND sexual partner is
TG>> High risk;
If client is TG AND sexual partner is
Male>> High risk;
If client is TG AND sexual partner is
TG>> High risk;
For other scenarios >> Not at risk;
If refuse to answer>> Low risk.
3. Do you have any Yes/No/Refuse to answer If “Yes”>> High risk;
sexual relationship If “Refuse to answer”>> Low risk;
beyond your If “No” >>Not at risk.
spouse/partner?
4. Have you bought sex Yes/No/Refuse to answer
in the past from a
man, woman or TG
using money, goods,
favours or benets?
5. Have you provided Yes/No/Refuse to answer
sex in the past in
exchange for money,
goods, favours or
benets?
If “Yes”>> Moderate risk (AND in case
6. Any STI symptoms Yes/No/Refuse to answer
of “Yes” in any of these questions
in the last three
(Q No. 2 to 5) >> High risk;
months?
If “Refuse to answer”>> Low risk;
If “No” >>Not at risk.
7. Is your spouse or Yes/No/Refuse to answer If “Yes” >> High risk;
partner a PLHIV? If “Refuse to answer” >> Moderate
risk;
If “No” >> Not at risk.
If “Yes” OR “Refuse to answer” in Q6
AND
Basis combination of questions “Yes” OR “Refuse to answer” in any of
these questions (Q2/Q3/Q4/Q5/Q7) >>
High risk.
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HANDBOOK FOR HIV & STI COUNSELLORS
Comprehensive Service Package under SSS
Essential Services: These are essential services that are to be provided across all SSKs and
their linked centres uniformly.
Figure 20.2 - Essential services under SSS
Desirable Services (Non-exhaustive): These are heterogeneous services
tailored to client-based needs at each SSK.
Figure 20.3 – Desirable services at SSK
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Newer Interventions in NACP-V
Commodities to be available at SSK
Table 20.2 – Commodities available at SSK
Kits/Drugs/Commodities Purpose
HIV/Syphilis Dual RDT kits For testing at SSK
Needle/Syringe For dispensation to relevant clients through
ORWs or from SSK
HIV WBFP kits and HIV For screening at eld and conrmatory tests
Conrmatory Test kits (A1/A2/A3)
Buprenorphine
STI/RTI Colour-Coded kits
SRH Commodities (Condoms/Lubes etc.) For dispensation to clients at SSK
PEP
RPR kits For syphilis testing at SSK
Injectable Benzathine Penicillin G For treatment at SSK through DSRC
HIV self-test kit Proposed (when approved)
PrEP Proposed (when approved)
Hepatitis screening test kits Proposed (when approved)
One Stop Centre
Over the last decade, evidence shows the changing landscape of risk due to sexual and injecting
behaviours among the HRGs, bridge populations and special groups. To effectively respond to
the evolving epidemic and to saturate the coverage of KPs, revamping efforts are needed to
reach out to hitherto unreached HRGs living outside the TI geographic areas. So, the TI
revamped strategies are recommended.
One Stop Centre – An Integrated Service Delivery Model at Community Settings
One Stop Centre (OSC) is designed as a person-centred and resource-effective approach to
deliver integrated HIV preventioncare cascade services in settings with low-level and
concentrated HIV epidemics to the hard-to-reach segment of the at-risk population who are
still out of national HIV control response due to high stigma, discrimination and lack of
awareness i.e Transgender persons, People who Inject Drugs and Bridge Populations (
including clients of sex workers, truckers and allied population).
OSCs provide comprehensive services based on the risk assessment, HIV screening,
subsequent linkages for HIV/STI preventive and treatment services along with required
social support to improve general health and wellbeing of the clients by helping them reduce
the harm associated with risk behaviours.
The specic objectives of establishing OSCs are as follows:
Promote screening and linkage for HIV and other essential health services.
Promote screening and referral to requisite holistic care services.
Ensure completion of referrals/linkages among different service providers.
Increase access to HIV, other essential health services and social welfare services.
Increase awareness and reduce stigma and discrimination.
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Comprehensive Service Delivery Package
The project is mandated to establish integrated service delivery models through OSCs for
medical and behavioural aspects of HIV and social protection services. The proposed
package of services for each typology is as follows:
Figure 20.4 – Current package of services in OSC
Figure 20.5 – Direct and referral based services
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Newer Interventions in NACP-V
Commodity and Consumables for OSCs
OSCs are a resource-effective way to implement HIV prevention and care programmes in
settings with a concentrated burden of hidden and hard-to-reach populations. They are also a
cost-effective method of reaching people who are most at risk in more generalized epidemics.
OSC Service Delivery Model
Figure 20.6 – OSC service delivery model
Community System Strengthening
NACP-V institutionalizes community engagement and meaningful participation at the most
granular level in the form of community system strengthening (CSS). This is expected to lead
to improved health outcomes under the NACP, specically through strengthened TI
programmes and greater involvement of communities in decision making, and nally
developing structured systems of community-led monitoring (CLM).
CSS is an approach that promotes the development and reinforcement of informed, capable,
coordinated and sustainable structures, mechanisms, processes and actions through which the
KPs, their organizations and groups interact, coordinate and deliver their responses to the
challenges and needs affecting their communities. It increases both the reach and
sustainability of programmes.
CSS aims to achieve the goals of the NACP through the following objectives:
Support an enabling environment;
Demand generation for prevention and increasing testing;
Care and support for those on ART including social protection, treatment literacy,
adherence;
Community monitoring and ensuring effective and quality programme delivery.
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HANDBOOK FOR HIV & STI COUNSELLORS
CSS Implementation Framework
Figure 20.7 – CSS Implementation Framework
The National Youth Policy of India (2014) denes youth in the country as people belonging to
the age group of 15–29 years.
Community structures at the national, state and district levels
Initiative Summary
Community CRG is a formal structure anchored in the national response at the
Resource Group district, state and national levels to identify, understand,
(CRG) resolve and address the community’s concerns with their
meaningful representation (HRGs - FSW, MSM, H/TG, PWID,
PLHIV and Youth communities).
It facilitates and augments community participation in
planning, implementation and supportive supervision.
It establishes formal structures for meaningful engagement
and involvement of KPs, PLHIV and youth community
members.
It promotes meaningful engagement and involvement of KPs,
PLHIV andyouth community members.
It ensures timely identication and redressal of issues of
stigma and discrimination.
Community Community champions are KPs with inuence in local area. They
Championship address the needs of KPs, stigma and discrimination, are trained in
Initiative advocacy, mobilization, leadership, information dissemination, are
expected to empower local communities and become a resource.
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Newer Interventions in NACP-V
Initiative Summary
Strengthening Community mobilization for effective HIV prevention,
Community formal/informal networks for partnerships, collaborative solutions
Engagement through stakeholder engagement, communities voice concerns via
CLM.
Community-led Specic objectives include collecting regular feedback from the KPs
Monitoring (CLM) and PLHIV on improvement of service delivery. This feedback will
help in increasing ownership as well as ensuring services access
among the communities. Feedback from community is collected
systematically via scorecards, discussions, data analysis, solutions
generated with community and providers. Involvement of
community in making and implementing action plans.
Virtual Interventions
With internet users in India expected to surpass 658 million by 2022, online platforms are
changinghow Indians communicate, seek information and identify sex partners. Higher risk
groups for HIV, particularly men who have sex with men, transgender individuals and sex
workers, are increasingly using virtual channels to nd sex partners as well as to build and
maintain communities. In recent times, sex work patterns have also undergone a change owing
to technology and social media. Mobile phones act as a tool for networking and soliciting.
Hence the programme has initiated various efforts to close the existing gaps due to newer risk
behaviours like soliciting partners through virtual platforms, through new spaces like spa and
massage parlours, etc.It has emerged as a programmatic focus under NACP V.
Virtual Strategy Advancement in India
For engaging with the virtual population, it is essential to expand approaches to reach all
population groups at risk for HIV, especially groups involved in high-risk behaviours. The
possibility of remote care through virtual strategies can overcome barriers of social
stigmatization that impede these groups from accessing conventional in-person HIV services.
Many organizations in India have responded to the increase in digital communication and
information sharing through novel digital interventions for HIV care and prevention.
The NACP V will work to incorporate online communication-based strategies, considering
evolutions in the technology industry and digital platforms in India as well as strive to
understand the size of target virtual population; explore differences among users in
demographics, preferences and context to facilitate tailored virtual approaches; design effective
online messages to generate awareness about HIV prevention, care and service options; and
link virtual populations to comprehensive HIV services tailored to the needs of communities.
(Refer annexure for the details of virtual interventions being implemented across the country).
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HANDBOOK FOR HIV & STI COUNSELLORS
Key Messages
• Various initiatives like Sampoorna Suraksha Kendra, One Stop Centre, Community
System Strengthening and Virtual Interventionhave been initiated under NACP V to
reach the population at risk that is not covered under TI or other prevention
programmes.
• Counsellors’ role is to identify and link the ‘at risk’ (non-TI) population with these
initiatives.
• Community members can play an important role for effective linkages.
• Rapport establishment and communication skills should be used effectively for linkages.
It is important to connect with the client‘as a person’and not just as ‘client came for HIV
services’.So, discuss other concerns as well with the client along with HIV-related issues.
E.g., you may talk with an adolescent about their family issues, their interests. Many
festivals are celebrated in the community. Discuss that. Explore your own ways to
connect with the communities.
• Counselling and education of the target audience on prevention measures, testing and
treatment of HIV, STIs and related co-infections.
• Undertake risk assessment of the target audience and offering of suitable follow-up
services.
• Promoting comprehensive prevention models (Condom, Contraception, Pre-Exposure
Prophylaxis, Post-Exposure Prophylaxis etc.)
• Undertake HIV and Syphilis screening services in facility and eld settings.
• Counsel people found reactive/positive for HIV, STIs and related co-infections,
counselling for ART, opportunistic infections management, management of NCD,
lifestyle modication, positive prevention, index testing, psychosocial support, family
counselling, suitable linkage and referrals etc.
• Provide an enabling environment to ght against stigma and discrimination.
• Undertake family planning counselling and follow-up referral and linkages among
eligible HIV-positive clients.
• Counsel adolescents and youths for sexual and reproductive health.
• Counsel and follow-up services for ‘at-risk’ non-reactive/negative clients.
• Follow-up for HIV and STIs reactive/positive people through eld visit/outreach ensuring
uptake of suitable services like conrmatory testing, registration to treatment facilities
and adherence counselling.
• Coordinate with various outreach workers/eld functionaries/ANM/ASHA
workers/Anganwadi workers etc. in context of HIV/STI-reactive/positive individuals
ensuring uptake of suitable services.
• Perform the role of nodal point for Sampoorna Suraksha Strategy.
• Counsel on harm-reduction services for people who inject drugs (PWIDs).
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Newer Interventions in NACP-V
• Ensure the suitable use and maintenance ofkits/commodities/consumables/equipment
provided under NACP including the cold-chain maintenance of kits/drugs as per
guidelines.
• Undertake data recording and reporting as required.
• Criteria for at-risk HIV-negative clients:
In order to ensure that the target population is continuously engaged with the SSK and
is prioritized, a graduation criterion has been devised. Upon meeting such criteria, the
client can be graduated from the system, or in other words, may not be followed up
actively. However, such clients should be provided services/commodities if they
voluntarily ask for the same. Additionally, the client may visit the SSK on yearly or half-
yearly basis as advised by the counsellor and/or subject to the risk perceived by the
client in future.
References:
White Paper on Strategies for Engaging with HIV at-risk populations in Virtual Spaces
Technical Brief on Changing trends in sex work, IDENTIFYING CHANGING TRENDS IN THE
SEX WORK DYNAMICS AMONG FEMALE SEX WORKERS (FSWS) IN INDIA- Bal Rakshase,
Priyanka Dixit, P. Saravanamurthy, Vinita Verma, Shobini Rajan
Available at:
https://naco.gov.in/sites/default/les/Technical%20Brief%20on%20Changing%20trends%20in%20s
ex%20work.pdf
White Paper on Comprehensive Health-Related Services for Transgender Persons., 2023, NACO, New
Delhi
The Guidance Document on Integrated Package of Services for People Who Use Drugs in 2023, NACO,
New Delhi
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Annexure: Examples of Virtual Strategies for HIV Care in India
Featured Virtual Strategies for HIV Care in India
Intervention Intervention About the Intervention
Name/ Name/
Organization/ Organization/
Population Population
Group Group
Virtual DIC, Risk awareness, Virtual drop-in centre for KPs in Delhi to identify
Delhi SACS, prevention, and link the virtual network-based HRGs with
FSW/MSM/TG testing, service service provisions.
linkage
An interactive web portal managed by the community
and TI team allows KPs to log in with their ID and
password and seek services/book appointments to
seek HIV services as per their choiceand time in
Delhi.
• Web Page
• Virtual Mapping
• Training of the TI staff
• Online Outreach
• Service provision
• Monitoring &Evaluation (M&E)
MDACS/HST, Risk awareness, Enhanced Peer Outreach
ITECH-CDC, prevention, • To reach the unreached
Young MSM testing, service • Through social media platforms
linkage
For individuals above 18 years who have accessed
social media platform for sex with a man in last 3
months; had sex with a male in the last one month;
not associated with any TI
Maharashtra Knowledge, WhatsApp groups for awareness generation;
SACS, HRGs awareness, committee awareness generation activities –feedback
(FSW) feedback, from HRGs. Also, hotspots/health facilities’ Google
planning Map for ease of planning by eld workers
Love Zodiac – Risk awareness, Risk proling quiz on safe sex, relationship health,
Twistle prevention and social stigma and HIV testing promoted via targeted
treatment advertising on social media. Clients can then optin
support 45-days educational SMS.
Game Set Match Prevention, Incentive-based model rewards dating app users to
–One Key Care testing, stigma play short games promoting HIV prevention
Ventures reduction behaviours and stigma reduction.
IRA - Jubi.AI Knowledge, Powered by articial intelligence, IRA is a one-to-one
awareness, conversational platform where users can talk to a
service linkage chatbot offering information and emotional support
in response to HIV/AIDS queries.
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Newer Interventions in NACP-V
Featured Virtual Strategies for HIV Care in India
Intervention Intervention About the Intervention
Name/ Name/
Organization/ Organization/
Population Population
Group Group
Ujwala project - Prevention, To improve uptake of HIV services among FSW in
Alliance India, testing, urban areas in India, Ujwala sends informational
FSW treatment and videos over smartphone apps with links to a
care support helpline.
Yes4Me – Risk assessment, Yes4Me uses advertising and outreach workers on
USAID, General prevention, social media and dating apps to engage users. They
and KPs testing and are directed to a website with a risk assessment and
service linkage appointment booking for HIV services.
Safe Masti – Awareness, Promotion of visuals and videos raising HIV/STI
Elton John AIDS prevention, awareness over social media using inuencers, links
Foundation, stigma reduction to HIV testing sites, chat-based counselling
Young MSM
Dr Safe Hands, Awareness, Dr Safe Hands is a website promoted through social
General and KPs testing, media offering information, telemedicine counselling,
treatment, booking support for HIV/STI testing and treatment,
counselling, as well as free home sample pick-up.
retention
Virtual Outreach, Reaching MSM & TG population through virtual
Outreach, awareness interventions for harm-reduction services and linkage
Nagaland, messaging on to HIV testing, prevention and treatment services
ITECH-CDC, HIV/AIDS, STIs through various social media platforms including
MSM and TG and safe Blued, Grindr and Facebook.
practices, linkage
to harm
reduction
services, HIV
testing and
treatment
services,
distribution of
commodities
229
230
21 Mobile Outreach Services
Mobile and outreach activities are critical in order to ensure that need-based services are
delivered. In 2007, access to counselling and testing services expanded to provide HIV
Counselling and Testing (HCT) outreach services and Mobile ICTCs. Subsequently, mobile
facility-integrated counselling and testing centres (FICTCs) were also introduced to expand
HIV screening services.
At present, a mobile ICTC consisting of a team of paramedical healthcare providers (an ANM/
counsellor and LT) is used to set up a temporary clinic with exible working hours in hard-to-
reach areas, where services include regular health check-ups, syndromic treatment for
STI/RTIs, antenatal care, immunization, as well as HIV counselling and testing services
(Operational Guidelines for Integrated Counselling and Testing Centres , 2007). Introduction
of NACP V and launch of newer strategies such as client prioritization, rationalization of
conrmatory facilities, introduction of Sampoorna Suraksha Kendras, and integration with
other health programmes such as National TB Elimination Programme (NTEP) and National
Viral Hepatitis Control Programme (NVHCP) demand change in strategies related to outreach
services.
Objectives of Mobile Outreach Services
To increase access to NACP and other related health services for the at-risk/vulnerable/high-
risk or unreached populations in under served areas to minimize the gap of 95-95-95 by 2025 to
end HIV AIDS as a public health threat by 2030.
Intended Beneciaries/Priority Populations for Mobile Outreach Services
• Difcult-to-reach populations, HRGs, at-risk populations;
• Inmates of prisons and other closed settings (OCS);
• Population that is unable to access regular, stand-alone HIV/STI services or displaced due
to natural/manmade disasters;
• Populations in vulnerable areas who are at risk of transmission of HIV/STI/Hepatitis
B/Hepatitis C/TB infections.
Type of Services Provided
Comprehensive prevention and treatment services: Risk reduction counselling and
risk assessment, distribution of needle syringes, lubricant jelly and condoms, camp-based
induction and dispensation of OST medication to stable clients and follow-up counselling,
comorbidity (STI, hepatitis, TB, substance use) screening, referral and treatment,
awareness generation/IEC activities;
Differential HIV screening/testing: Disclosure counselling, index testing, social and
sexual network mapping and testing, HIV conrmation of pending HIV-reactive cases;
HIV and STI treatment services: ART pill dispensation and rell, adherence counselling,
follow-up of missed cases (MIS) and LFU, STI/RTI testing, diagnosis and treatment, partner
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HANDBOOK FOR HIV & STI COUNSELLORS
counselling and testing for HIV/STI, other need-based services such as viral load or CD4
sample collection and transportation and DBS samples for EID.
Other health services: Screening and referral for TB, hepatitis B and C, diabetes,
hypertension and other non-communicable diseases.
Selection of Geographies for Mobile Outreach Services:
SACS should select the districts for implementation based on the below suggested criteria:
1. Districts or areas with high gaps in achievement of the rst 95;
2. Districts or areas with high numbers diagnosed, and documented clustering of uncovered
at-risk, bridge and HRG populations, unreached pregnant women;
3. Districts or areas with high HIV prevalence or identication of new HIV infections, high
STI/RTI or high AIDS-related deaths;
4. Districts or areas with vast geographies and hilly terrain, scattered location of health
facilities, limited public transportation and with scarce HIV-related service provision
including CD4 and viral load testing;
5. Districts or areas with high load of pending HIV conrmation, high rate of MIS/LFUs or
linkage loss;
6. Padas/villages/blocks within districts where HIV screening at Health and Wellness Centres
(HWC)/other NHM facilities are not initiated or are limited.
SACS may additionally deploy the outreach camp based on epidemiological intelligence and
interactions with at-risk clients/PLHIV and other key stakeholders.
Strategy of Outreach Activities:
The various strategies that could be used for mobile outreach services include the following:
i. Static camp-based approach: HIV-related services and outreach activity can be
delivered through use of SACS/state-hired or owned vehicles (bus, van or even a two-
wheeler), which can move from place to place, or by organizing outreach camps to provide
the required services to those at-risk or HIV-positive individuals who have difculty in
accessing facility-based services. The counsellors (SA-ICTC, ART, OST, SSK), laboratory
technicians and additional workforce including outreach workers or staff nurse of nearby
ART, OST, SSK, CSCs, TI NGO can provide various HIV and STI services according to the
roster prepared and approved by the district nodal ofcer (DISHA ofcial, DACO), Chief
District Health Ofcer (CDHO) or Chief District Medical Ofcer (CDMO) and competent
SACS authority, as deemed t.
ii. Alignment of mobile vans/bike outreach plan with the following activities for
better integration with health systems:
Coordination with other campaigns: Coordination with integrated health campaigns/
ISHTH campaign/IEC campaigns/observance of any special day/ health programmes
conducted by District Health Society;
Collaboration with other stakeholders: The route map should be aligned with NHM’s
Medical Mobile Units (MMU). Coordination meeting should be held with the Block
Medical Ofcer to discuss the utilization of services and seek further support.
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Mobile Outreach Services
iii. Extended outreach component under the Integrated Health Campaigns of health
systems:
The staff engaged in conducting the camp will coordinate and carry-out extended outreach
(EOR) at the hotspots or sites where the HRGs are available and feel comfortable. This
will include index testing with HIV/STI screening.
Social networking strategy (SNS) will be implemented to reach at-risk or high-risk
behaviour populations who are hidden with HCT services. SNS utilizes peers to reach
their network members and motivate them to undergo HCT. The peer educators and
outreach workers under the TI-NGO will play an important part in this strategy.
Suggested Models for Operationalization of Mobile Outreach Services
1. Operation of mobile vans on outsourcing basis: Mobile vans and human resources are
provided on outsource basis. Drugs and supplies are provided by SACS/DISHA.
2. State-owned mobile vans: Mobile vans and human resources are deployed by SACS. Drugs
and supplies are provided by SACS/DISHA.
3. Mobile bikes with driver: Procured/hired by the SACS for undertaking camps in remote and
hilly terrains where reach by mobile vans is not possible.
a. Human resources required:
The human resources requirements are classied as essential and desirable.
Essential: Driver/rider, counsellor, laboratorytechnician (if facilities for conrmation are
available in camp)
Desirable: Medical doctor, nurse, ORW
These human resources are from within the existing programme facilities and there are no
new recruitments, or they are mobilized from health system. In addition, in the districts where
there are existing TIs or LWS, the staff of the TI/LWS will provide necessary support to the
mobile intervention team for mobilizing KPs and making necessary arrangements as required.
Operationalization of Mobile Outreach Services
Figure 21.1 - Mobile outreach services
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HANDBOOK FOR HIV & STI COUNSELLORS
KEY CONSIDERATIONS FOR PLANNING MOBILE OUTREACH SERVICES
I. Preparatory Planning and Initiation Phase
Approvals and coordination: The SACS in coordination with the DISHA unit will be
responsible for operationalization of Mobile Outreach Services, supervision and monitoring
of these units. The Mobile Outreach plan may be prepared by mobile van counsellor or
DISHA ofcials (who will act as a nodal ofcer).Only after approval can the roster be
implemented.
Day-wise and week-wise plans will be prepared for each unit of mobile camp. For each
day, there should be a facilitator preferably from the nearest health facility/public health
administrator. The format of road map is below in Table 21.1.
The necessary coordination and approval of the DTO/DHO/CMHO is to be undertaken to
ensure that the camps are convened smoothly. The necessary approvals of the prison and
other closed settings are to be undertaken.
Infection prevention measures and biomedical waste disposal guidelines must be
followed.
Table 21.1 - Format for Road Map of Mobile Outreach Unit
Name of the State Unique ID of Mobile Unit:
S. Weeks District Date Facilitator Location/ Location/ Location/ Location/
No. Area/Site 1 Area/Site 2 Area/Site 3 Area/Site 4
1 Week-1
2
3
4
5
6 Week-2
7
8
9
10
11 Week-3
12
13
14
15
16 Week-4
17
18
19
20
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Mobile Outreach Services
Community Engagement and Collaboration: NACP counsellors under the leadership of
DISHA will arrange initial meetings with local government authorities, local community
leaders and HIV-positive networks to engage communities and carry out community
mobilization as needed.
Conduct IEC activity: IEC or advocacy activities will be conducted prior to organizing the
camps. This will help in spreading information and awareness about camps well in advance
and will help in mobilizing people when the camps are organized. Community sensitization
activities will be conducted for members of the general population as well as HRGs. Support
from community champions will be taken for reaching out to key populations. The mobile unit
will be painted and decorated with key messages on health including HIV to ensure stigma-free
services.
ii. Implementation of Outreach Camps at Service Delivery Points
• A district route map and service delivery points will be prepared based on a mapping of
HRG/at-risk populations, pending reactive cases for HIV conrmation, OST patients,
PLHIV not linked to ART services etc.
• The visit date, service time and the possible parking points for the vehicle need to be
shared with the local health team (ANM, ASHA) in advance.
• If possible, the services in rural areas could be conducted in any adequate building with
one or two rooms and toilets, such as an Anganwadi centre or Panchayat Bhavan or
primary school. Adequate arrangements for waiting area should be made in
coordination with the Gram Panchayat/VHSNC.
iii. Equipment and Inventory Management
• The expected number of beneciaries or clients in the camp should be identied and
counsellors should prepare a list of the equipment based on diagnostics and treatment
services provided.
• The list of drugs and consumables required along with required quantity will be
prepared and shared with DISHA. The supply shall be provided from the nearest NACP
facility or from district stores. The drugs and consumables required for integrated
health camps will be mobilized in planned coordination with the health systems like
NTEP, NVHCP and NCD at the state and district levels.
• Regular inventory should be maintained in the physical format and shared from time to
time and as per national guidelines.
iv. Effective Referral Mechanism
In order to keep identied at-risk negative clients negative, an effective referral with
appropriate services will play a very crucial role. Counsellors should understand the
requirement of the at-risk clients and refer them for the required service/s.
The conrmed HIV-positive cases will be linked with the nearby ART centre for initiation
of treatment. The staff will ensure effective referral and linkages for diagnosis and
management of TB, Hepatitis B/C and non-communicable diseases during the camp. The
line list should be maintained for effective referrals, linkages and follow-up.
v. Reporting and Documentation
Reporting will be done in NACO’s existing SOCH as a separate facility. Monthly and
quarterly reports will be prepared and shared with DISHA. A logbook should be
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HANDBOOK FOR HIV & STI COUNSELLORS
maintained by the mobile camp driver and supervised by DISHA and be available for
verication. The mobile camp shall adhere to all the provisions of Motor Vehicle Acts and
other applicable acts in this regard.
vi. Post Camp Follow-up
Post camp follow-up will help counsellors and/or other personnel to ascertain that the
clients have availed the services for which they were referred.
Monitoring and Supportive Supervision
The IMS data management system of NACP must be regularly updated every time after
the completion of the camp. The data below should be updated with DISHA and SACS
every month:
• Number of mobile units in the district (sanctioned andoperational);
• Units managed by outsourced or owned by state (disaggregate);
• Number of trips/day in a month;
• Number of villages/habitations visited with route map;
• Number of patients servedper trip and per month;
• Number of individuals screened for HIV, syphilis and other diseases (TB/ Hepatitis B &
C, blood sugar levels, BP etc.) and identied positives/reactive;
• Number of patients screened for STI, screened reactive and number of patients treated
for STI;
• Number of patients who receive follow-up care like adherence counselling, follow-up for
sputum test etc.
• Number of patients provided ART rell, OST rells;
• Number of patients referred to other health facilities for any services;
• Details of commodities distributed under prevention services.
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Mobile Outreach Services
Key Messages
• Field activities are to support the client in order to ensure that need-based services are
delivered.
• Based on the client’s needs and programmatic needs, eld activities are to be planned
and prioritized.
• For the counsellors, eld activities indicate going out of the facility/institution to meet
clients at their homes or common places for various follow-ups to ensure service uptake.
• Counsellor posted at the Mobile Outreach Van shall be responsible for ensuring referral
and follow-ups of the clients.
• Attending coordination meetings, meetings with SACS ofcials or nodal medical ofcers,
coordination with other departments regarding service referralsand linkages or
performing any administrative activities are not considered as eld activities.
• Types of services provided by mobile ICTCs include comprehensive prevention and
treatment services, differential HIV screening/testing services, HIV and STI treatment
services and other health services.
• Various strategies that can be used for outreach activities includestatic camp-based
approaches, coordination with other campaigns and stakeholders for better integration
with health systems.
• The DISHA unit will be responsible for operationalization, supervision and monitoring
of Mobile Outreach Services.
References
• Operational Guidelines for Integrated Counseling and Testing Centres, 2007
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HANDBOOK FOR HIV & STI COUNSELLORS
Linkages and Referrals for PLHIVs
22 and At-Risk Negative Clients
In HIV and AIDS programme, it is important to establish linkages with both NACP
programme and other health, social welfare programmes, connect with local leaders/groups,
organizations for referrals and linkages both with various government and civil society service
providers.
Linkages and Referrals with Health Services
Mechanisms for establishing linkages and referral systems are necessary to meet the
immediate and long-term needs of PLHIV and at-risk negative clients of SSKs. Each NACP
facility must establish the following programmatic linkages with other health services, social
welfare and protection services within the institute as well as within district. The counsellor
must also be aware of the services available at each of these units and guide clients
appropriately. Following are the referral and linkage services required for the clients accessing
various health facilities:
• Referrals/linkages is to be done with appropriate prevention, care and treatment services.’
• Referrals/linkages of the clients to be done to other social welfare and social protection
services.
• Counsellors at SA-ICTCs and ART centre also should collect information on the services
available for the mental health issues for HRGs, at-risk population and PLHIVs. If and
when counsellors feels that the clients require enhanced and/or special mental health
services, they should be able to refer such clients for the special services.
• Referrals to DSRC for screening for presence of STI signs and symptoms and early
diagnosis and treatment of STI and syphilis. If tested negative, link to SSK for prevention
services;
• Referrals to NGOs/CBOs for psychosocial support, support groups, legal support, socio-
economic support and nutritional support;
• The CSC serves as a comprehensive unit for treatment support, retention, adherence,
positive living and referral linkages to need-based services and strengthening enabling
environment for PLHIV.
• For comprehensive care, PLHIV need access to various departments/services within the
health facility depending upon disease stage and occurrence of opportunistic infections to
the departments of medicine, microbiology, obstetrics & gynaecology, paediatrics,
dermatology/venereology, chest diseases, non-communicable diseases (NCD), screening for
Hepatitis B and C free of cost under the National Viral Control Programme (NVHCP) or
other OPDs.
• To provide nutrition counselling and psychosocial support to HIV-infected pregnant women,
Linkages should be made with ANMs, ASHAs, community outreach workers district-level
networks to advise them on the right foods to take and go to Anganwadi centres for
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Linkages and Referrals for PLHIVs and At-Risk Negative Clients
nutritional support, and to the district-level network of Positive People for peer counselling
and psychosocial support.
• Due to lifelong ART, PLHIV need to undergo several follow-up investigations for monitoring
purpose and for the early diagnosis of comorbid conditions (blood and urine tests, molecular
tests for TB, radiological investigations etc.).
• Patients with suspected treatment failure, severe adverse effects and complicated clinical
cases of drugs are referred for review by the panel of experts called State AIDS Clinical
Expert Panel (SACEP) at Centre of Excellence/ART plus centres for further evaluation and
timely switch/substitution to appropriate ART.
• For non-PLHIVs, at-risk negative population, SSK counsellors are required to identify the
comprehensive service needs from such clients to provide them the referrals and link them
to the other health services as per need so that such clients remain associated with the
programme and receive services from SSK as per the guidelines.
Figure 22.1 - Referrals and linkages under NACP
Table 22.1 - Referrals and Linkages to Social Protect Schemes
Need for • The medical and social reality of HIV/AIDS pushes people and households
Social into poverty in part by reducing household labour capacity and by
Protection increasing medical expenses.
for PLHIV • HIV-related stigma and discrimination marginalize PLHIV, and
households affected by the HIV epidemic and exclude them from essential
services.
• The impact is felt on income, employment, consumption expenditure
(especially nutrition, education and healthcare) and savings.
• PLHIV face various vulnerabilities such as job insecurity, loss of livelihood,
poor access to healthcare facilities, low access to nutritional support, loss of
education for children, issues of identity and lack of support for orphan and
semi-orphan children, losing a house and/or family if WLHIV.
• Self and social stigma and discrimination diminish the social support
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HANDBOOK FOR HIV & STI COUNSELLORS
system. The burden of increased illness, loss of jobs and income, rising
medical expenses, depletion of savings and other resources, food insecurity,
psychological stress and social exclusion further worsens the socio-
economic condition of PLHIV.
• It has been recognized that PLHIV, CABA, their families and MARPs have
needs beyond HIV prevention and treatment services. In these
circumstances, social protection (including legal aid) is imperative.
Social • Social protection in the context of HIV may be understood as a set of
protection policies, schemes and entitlements or legislations that help those infected
in the or affected by HIV and the most-at-risk populations to mitigate the impact
context of of HIV, reduce further vulnerability and lead life with dignity.
HIV • The strategy behind social protection is to reduce the impact of HIV by
ensuring social entitlements and benets of various welfare schemes to
PLHIV, CABA, their families and MARPs. It reduces the burden on
households as well as vulnerabilities of people to infection.
Social • The Indian government, at all levels, announces welfare schemes for a
welfare cross section of the society from time to time. These schemes could be either
schemes central, state specic or a collaboration between the centre and the states.
An easy and single point of access to information about several welfare
schemes and their various aspects (eligibility, types of benets, other
scheme details) are given here: https://www.india.gov.in/my-
government/schemes.
• The schemes are also compiled and presented by NACO and there are
schemes that are different for different states. A compendium of schemes
available during 2017 can be seen here (these schemes may have been
modied and new schemes may have been added by the governments
concerned):
http://naco.gov.in/sites/default/les/Social%20Protection%20Compendiu
m%20%20Version%202%20.pdf.
• The Government of India jointly with the state governments implements
several welfare schemes for the poor and deprived to provide them with
direct benets. PLHIV, CABA, MARPs and tribals living in geographically
remote areas, people from disadvantaged castes and the economically
vulnerable category and people who do not have a substantial source of
income are dependent on these schemes to support their livelihood. Hence,
the basic objective of the welfare scheme is to support and improve the
standard of living of the above-mentioned groups of people and provide
them with equal opportunities.
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Linkages and Referrals for PLHIVs and At-Risk Negative Clients
Table 22.2 - Some centrally sponsored welfare schemes
Name of the schemes Implementing agency/department
Job card under the Mahatma Gandhi National Ministry of Rural Development
Rural Employment Scheme (MGNREGS)
Pradhan Mantri Awas Yojana (PMAY) Ministry of Housing and Urban Affairs
Pradhan Mantri Ujjwala Yojana (PMUY) LPG connection for women
Pre- and post-matric scholarships for OBC and SC Ministry of Social Justice and
students Empowerment
Entrepreneurial schemes for OBC women Ministry of Social Justice and
Empowerment
Pradhan Mantri Suraksha Bima Yojana (PMSBY) Ministry of Finance
Pradhan Mantri Jan Arogya Yojana (PMJAY) National Health Protection Mission
under Ayushman Bharat
Rashtriya Swasthya Bima Yojana (RSBY) Ministry of Labour and Employment
Support for Marginalized Individuals for Ministry of Social Justice and
Livelihood and Enterprise (SMILE) Empowerment
HIV/AIDS Act 2017 NACO, Ministry of Health & Family
Welfare
Additionally, individuals can be directed to the State/District Legal Services Authorities and
the State Ombuds person for HIV/AIDS for legal assistance with matters related to
discrimination against PLHIV.
Key Messages
• One of the functions of the HIV counselling services is to link clients with various
services under NACP and other health services. Only counselling will not help to
mitigate the response of HIV and so connections with health services and social
protection schemes are important.
• PLHIV and their families face poverty, stigma and exclusion due to HIV and need social
protection to cope and live with dignity. Social protection for HIV includes policies,
schemes and legislations that help mitigate the impact of HIV and reduce vulnerability.
• Mechanisms for establishing linkages and referral systems are necessary to meet
immediate and long-term needs of PLHIV.
• Counsellors should be aware of the services available at each facility and guide clients
appropriately to access them. Counsellors should also coordinate with other service
providers and follow up on the referrals and linkages.
• Various services under NACP aim to provide comprehensive and holistic care for
PLHIV and their partners, including prevention, diagnosis, treatment, counselling,
support and legal aid.
• In addition to the linkages with services under NACP, it is important to establish
linkages with other health services e.g., services under National Health Mission.
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HANDBOOK FOR HIV & STI COUNSELLORS
• The Indian government offers various welfare schemes for the poor and deprived,
including PLHIV, CABA, MARPs and tribals, to support their livelihood and rights.
These schemes provide direct benets such as food, education, healthcare, disability
assistance and skill development, and are implemented by different ministries and
departments at the central and state levels, such as rural development, social justice,
tribal affairs, agriculture, etc.
• Counsellors are expected to make a list of various schemes in their own
district/corporation area with details of the scheme, the eligibility norms, documents
required, contact details and other information, if any. They should develop a booklet
that has state-specic schemes that help PLHIV access them.
• Counsellors should establish rapport with the respective persons of various
departments/NGOs who are implementing the schemes.
• Counsellors should link clients with various such services and schemes. Give a referral
slip if convenient. However, if there is any fear of stigma, make the referral in the most
convenient manner; e.g., instead of giving a referral slip, you may want to speak to the
respective person. Maintain a register for referrals and linkages.
• Provide anticipatory guidance to the client before sending them to another service
provider: e.g., advise them about the documents to carry, where to go, whom to meet
and other information.
• If there are challenges in referrals and linkages, nd out the reasons and address them.
Contact respective stakeholders like collector ofce/corporation ofce/NGO for further
guidance.
• Counsellors should encourage clients to keep the documents like Aadhar card, pan card,
bank account details, ration card, income proof, photograph etc., ready, which will help
them avail various schemes. Help of local authorities may be availed for this.
• Counsellors may invite government ofcials, NGO representatives in the community
camps/ events to guide people about the schemes and preparing the documents. This
may help in strengthening the bond between the ofcials and community members.
References:
• Integrated training module for ICTC, ART, and STI Counsellors, NACO, Nov 2014
• National Operational Guideline for ART Services, NACO, 2021
• National Guidelines for HIV Care and Treatment, NACO, 2021
• Operational Guidelines 2nd cut for Sampoorna Suraksha Strategy, August 2023
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Linkages and Referrals for PLHIVs and At-Risk Negative Clients
Annexure: Worksheet for Mapping the Social Welfare and Social Protection Schemes in the
State/District of the Participants
Age Aadhaar Voter Ration Bank Legal Liveli- Educa- Pension Health Transport Housing
group card ID card card account aid hood tion (old Insurance support schemes
(years) Nutrition support support age, Health
support MNERGA widow, services
ART)
0–15
16–18
18+
(Female)
18+
(Male)
More
than 60
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HANDBOOK FOR HIV & STI COUNSELLORS
Breaking Silos – Counselling
23 Needs and Terms of Reference
of the NACP Counsellors
Counselling services are an essential component for achieving the objectives of NACP V
(2021–2206).
Counselling is a type of therapy that helps individuals work through personal, mental health
and emotional issues.
As counselling can be benecial for people of all ages and backgrounds, some common reasons
why people seek counselling are as follows:
a. Struggling with anxiety or depression;
b. Coping with the aftermath of trauma or abuse;
c. Dealing with relationship problems or conicts;
d. Adjusting to major life changes or transitions;
e. Struggling with addiction or substance abuse;
f. Coping with grief or loss;
g. Managing stress or stress-related health problems;
h. Working through issues related to self-esteem or self-worth.
In the context of HIV/AIDS, counselling remains one of the key pillars of HIV services. HIV
counselling and testing is a package service that supports people to make informed decisions
regarding their HIV status and to make informed choices about their future practices and
behaviours. The purpose of counselling is to create awareness and prepare a person for both a
seropositive and seronegative status,and also to address the issues of anxiety, denial, anger
and guilt, which a person is likely to go through upon knowing their seropositive status.
Key objectives and points for consideration across various counselling phases:
Counselling Objectives and Key Points
Phase
Pre-test • Assess the risk behaviour
counselling • Give information on HIV, syphilis and other STIs, routes of
transmission.
• Give information about tests and the possible results.
• Prepare and encourage clients for testing.
• Give information on safe sex practices.
• Prepare for HIV-negative and HIV-positive test results.
• Linkages with necessary services
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Breaking Silos – Counselling Needs and Terms of Reference of the NACP Counsellors
Counselling Objectives and Key Points
Phase
Post-test • Prepare clients for test results.
counselling • If positive, help in coping up with results, educate the client about the
condition, available treatment(ART), other assessments (TB,STI, etc.)
and supportive services.
• Counsel for positive and healthy lifestyle.
• Encourage partner testing.
• If negative, educate them about the risk behaviour, possible sources of
HIV/STI infection and preventive measures.
• Encourage partner testing.
• Linkages with necessary services
For HIV- • Inform about options, care, support and treatment services and
positive clients provide referrals.
• The client must be aware of safer sex practices and the risks
associated with unprotected sex.
• Promote safer sex practices and encourage disclosure of serostatus.
• Encourage partner testing.
For HIV- • Provide information and materials for remaining HIV negative.
negative • Refer high-risk clients to the relevant care and support services (like
clients injecting drug users can be referred to harm reduction services or drug
treatment facilities).
Breaking Silos and Building Synergies
One of the guiding principles of NACP-V is breaking the silos and building synergies. NACP-V
recognizes opportunities available within the programme as well as in the other national
health programmes to catalyse progress on stated goals.
Break the silos, build synergies promotes coordinated actions through single-window delivery
systems along with functional and measurable referral and linkages, within NACP and across
national health programmes and related sectors for an efcient service delivery. This will take
into account the local contexts to ensure a suitable, functional and sustainable model.It is
expected that this approach will help the clients improve their quality of life, which will help in
reducing their vulnerability.
The Sampoorna Suraksha Strategy (SSS) is the rst step towards breaking the silos and
building synergies. It aims to provide a comprehensive package of services to the at-risk HIV-
negative population as per their needs to keep them HIV-free, thus boosting the national level
progress on HIV prevention.
The eight NACP facilities, which include ICTCs, TI projects, ART centres, DSRCs, OST
centres, Sampoorna Suraksha Kendras (SSKs), One Stop Centres (OSCs) and the 1097
helpline, offer HIV/AIDS/STI services. For the clients who attend these institutions, these
facilities offer services like HIV/STI/RTI prevention, testing, treatment, care, referrals and
linkages.
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The community-level services by the TI and LWS projects to the high-risk groups and
bridge populations include HIV/AIDS/STI/RTI awareness and education, commodities
distribution, screening and referrals.
Facility-based prevention services are provided at OST, ICTCs, OSCs and SSKs for high-
risk groups as well as for at-risk clients.
Facility-based treatment services are provided at the ART centres and DSRCs to those who
have STI and tested reactive for HIV respectively.
The following diagram depicts how the NACP services are interconnected in terms of services
provided to the clients visiting any of the centres. Most frequently, a client who visits one of the
services needs to be repeatedly referred to a variety of additional facilities. Counsellors must be
knowledgeable about the services offered at different NACP sites in order to full this
requirement. For example, a person visiting an OST directly for drug-related issues or DSRC
with any of the symptoms of STI/RTI should be referred to TI/LWS for comprehensive package
of preventive services coupled with risk-reduction counselling; the client should also be referred
for HIV screening/testing services and if the client tests positive, then they are further referred
to care and treatment services. During all these processes, it is quite possible and normal that
a client keeps coming to the OST or DSRC as well. So, all in all, a counsellor will have to
understand this inter-dependency among various services in order to effectively cater to the
needs of the clients.
Figure 23.1 – Services and linkages in NACP
The counsellors’ terms of reference (ToR) have been revised to break the silos and to create
synergy in the counselling support provided under NACP. The revised ToR for all counsellors
working in various NACP facilities has come into effect from 11 November 2022.
Revised ToR for Counsellors (w.e.f. November 2022)
(i) Essential qualication:
Graduate degree holder in psychology/social work/sociology/ anthropology/human
development/nursing with at least three years of experience in counselling/educating
under a national health programme
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Breaking Silos – Counselling Needs and Terms of Reference of the NACP Counsellors
OR
Post-graduate degree holder in psychology/social work/ sociology/ anthropology/ human
development/nursing.
If the candidate is a PLHIV: Graduate degree holder in psychology/social
work/sociology/ anthropology/human development/nursing with at least one year of
experience in counselling/educating under a national health programme.
Desirable: Experience of working under an NACP facility or community settings.
(ii) Knowledge and skill set needed:
• The candidate should be computer literate with working knowledge of MS Ofce, usage
of internet and electronic mail.
• The candidate should be familiar with government health policies and related
programmes.
• The candidate should be able to work in teams and have exible ways of working as
per the need of the programme.
(iii) Roles and responsibilities of a counsellor: Acounsellor will be performing the
following jobs, in facilities (including prisons) and in outreach/community settings
through eld visits in a condential and ethical manner, as per the modalities prescribed
in the national guidelines and periodic instructions issued under the NACP:
1. Counselling and educating the target audience on preventive measures, testing and
treatment of HIV, STIs and related co-infections through one-to-one or group counselling,
using suitable media (posters, ip books, yers, leaets, audio-visual material, tele-
counselling, virtual platform, etc.);
2. Undertaking risk assessment of the target audience and offering of suitable follow-up
services as per the risk level of the clients;
3. Promoting comprehensive prevention models (condoms, contraception, PEP, PrEP etc.),
including condom demonstrations (using a penis model), for prevention of new HIV
infections.
4. Undertaking HIV and syphilis screening in facility and eld settings;
5. Undertaking counselling of people found reactive/positive for HIV, other STIs and related
co-infections, including but not limited to, ARV medicines, preparedness counselling,
adherence counselling, opportunistic infections management, management of non-
communicable diseases, lifestyle modications, positive prevention, disclosures, index
testing, psychosocial support, family counselling, suitable linkage and referrals, including
to the 1097 helpline, social protection schemes, legal aid, rehabilitation and other relevant
services.
6. Promoting benets of DTG-based regimen or current ART regimen preferred in the
programme;
7. Contributing to the creation of an enabling environment to ght stigma and
discrimination;
8. Undertaking family planning counselling and follow-up of referral and linkages among
eligible HIV-positive clients;
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HANDBOOK FOR HIV & STI COUNSELLORS
9. Undertaking counselling of adolescents and youth for SRH, including that for prevention,
testing and treatment of HIV, other STIs and related co-infections;
10. Undertaking counselling and follow-up of services for at-risk non-reactive/negative clients,
including but not limited to comprehensive prevention models, periodic screening for HIV
and other STIs, and suitable linkage and referrals, including to the 1097 helpline, as per
national guidelines;
11. Conducting follow-up for STI/HIV-reactive/positive people through eld visits/outreach
ensuring uptake of suitable services like conrmatory testing, registration with treatment
facilities and adherence counselling;
12. Conducting follow-up for STI/HIV-reactive/positive children through eld visits/outreach
ensuring uptake of suitable services like conrmatory testing, viral load tests, registration
with treatment facilities and adherence counselling;
13. Conducting follow-up for STI/HIV-reactive/positive children through eld visits/outreach
for ARVs/prophylaxis/suitable treatment administration;
14. Coordinating with various outreach workers/eld functionaries/ANMs/ASHA
workers/Anganwadi workers etc. in the context of STI/HIV-reactive/positive individuals
ensuring uptake of suitable services like conrmatory testing, registration with treatment
facilities and adherence counselling;
15. Promoting institutional delivery among HIV-positive pregnant women;
16. Counselling on exclusive breastfeeding/replacement feeding and counselling the mother
for complete EID;
17. Performing the role of a nodal point for the SSS as suitable for the given locality;
18. Counselling on harm-reduction services for PWID, including on OST, viral load testing
and viral suppression;
19. Administration of OST drugs to PWID as suitable;
20. Ensuring the suitable use and maintenance of kits/commodities/consumables/equipment
provided under the NACP, including the cold-chain maintenance of kits/drugs as per
guidelines;
21. Undertaking data recording and reporting, including data entry in IT-enabled platforms,
for the services offered as per the system prescribed under the national guidelines;
22. Undertaking specic activities for programme monitoring, surveillance and research as
per the instructions issued periodically;
23. Participating in reviews, trainings and capacity-building activities etc., as per the
instructions issued periodically;
24. Undertaking any other related activities under the NACP as per the instructions issued
periodically.
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Breaking Silos – Counselling Needs and Terms of Reference of the NACP Counsellors
Key Messages
• HIV counselling plays a major role in achieving the objectives of NACP V,95:95:95 goal,
universal access to quality STI/RTI services to vulnerable/at-risk populations and
attaining the elimination of vertical transmission of syphilis.
• HIV counselling and testing is a package service that supports people to make informed
decisions regarding knowing their HIV status and to make informed choices about their
future practices and behaviours.
• One of the guiding principles of NACP-V (2021–2026) is breaking the silos and building
synergies.
• Break the silos, build the synergies and promote coordinated actions, through single-
window delivery systems is the principle of NACP V. This will be achieved through
referrals and linkages within NACP and across national health programmes and
related sectors.
• This will help ensure single-window service delivery to the PLHIVs as well as at-risk
population, which will help improve their quality of life.
• The Sampoorna Suraksha Strategy (SSS) is the rst step towards breaking the silos
and building synergies. It aims to provide a comprehensive package of services to the
at-risk HIV-negative population as per their needs to keep them HIV-free.
• In order to provide quality services to the clients in a holistic manner, the counsellors’
ToR has been revised to break the silos and to create synergy in the counselling support
provided under the NACP.
• As per the revised ToR, counsellors’ role will not be restricted to one centre. They will
have to play diverse roles like counselling at the centre for various services under
NACP, referrals and linkages, outreach activities, follow-up and various other
activities.
• To perform these roles, counsellors will have to keep themselves updated with
knowledge, attitude and skills required for the respective tasks.
References:
• Strategy document titled National AIDS and STD Control Programme Phase-V (2021-2026).
• Revised integrated Terms of Reference (ToR) for the Counsellors under National AIDS Control
Programme (NACP) Phase -V, Dated 09/11/2022
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HANDBOOK FOR HIV & STI COUNSELLORS
Data Safety and Management
24 at Facilities under NACP
The National AIDS Control Programme (NACP) generates considerable amount of data on
HIV/AIDS from service facilities across the country through the Information Management
Systems, Research Projects, HIV Sentinel Surveillance etc. NACO encourages the use of this
data for evidence-based programme planning, research etc., at all levels under the programme.
NACO also encourage students to use NACP data for their thesis/dissertation work.
In addition to this, a large number of organizations are involved in ghting against HIV/AIDS
across the country and many of them are supporting SACS/NACP facilities in various
activities; so there is a need for availability of data to all those who are involved in the
programme.
According to section 11 of the HIV and AIDS (Prevention and Control) Act, 2017, it is
mandatory for every facility to keep records of HIV-related information. The details of HIV-
infected and affected population should be maintained with data protection measures. All the
data should be kept condential.
“HIV-related information” means any information relating to the HIV status of a person
and includes
information relating to the undertaking performing the HIV test or result of an HIV test;
information relating to the care, support or treatment of that person;
information which may identify that person; and
any other information concerning that person, which is collected, received, accessed or
recorded in connection with an HIV test, HIV treatment or HIV-related research or the HIV
status of that person.
“Protected person” means a person who is
i. HIV positive; or
ii. ordinarily living, residing or cohabiting with a person who is HIVpositive; or
iii. ordinarily lived, resided or cohabited with a person who was HIVpositive.
Data Protection Measures at the Facility Level
A) Composition of Data Management Committee (DMC)
A DMC should be formed at each facility. The concerned DMC is responsible for ensuring data
security and also to review and provide appropriate recommendation regarding data security
measures. Wherever a facility does not have DMC, the head of the facility should be entrusted
with the responsibility and function of DMC. Details of composition as well as roles and
responsibilities at the NACP facility level are as follows:
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Data Safety and Management at Facilities under NACP
Table 24.1 – Composition of DMC at NACP facility
Composition of DMC At NACP Facility
Chairperson Senior and relevant ofcer of the facility
Members The committee will have 2 members, one of the members should be a
representative from the protected persons and the other from the same
facility who deals with the data
Terms of Reference
• Review of implementation of data protection measures at the facility
• Review of data access and data security at the facility
• To provide inputs on the disposal of physical les/computer equipment containing HIV-
related information at the facility
• To consider all adverse events related to NACP data reported to the committee
• Any other matter related to NACP data management
B) Steps for data management at NACO, SACS and NACP facility
It is mandatory for every facility that keeps the records of HIV-related information of protected
persons to adopt data protection measures. Data protection measures here include the
following steps:
• Protecting information from disclosure of HIV-related information: Condentiality
and privacy is to be maintained while collecting HIV-related information. For each facility
desirous of collecting HIV-related information, authorized persons or staff should sign an
undertaking for data condentiality.
• Access to HIV-related information: Access should be granted only to the authorized
persons/ staff after they sign a formal undertaking for condentiality.
• Provision for security systems for HIV-related information:
i. There should be secured almirahs or cabinet for physical records like registers, reports
etc., which should be carefully locked when not being used.
ii. Facilities should ensure that computer systems having HIV-related information are
protected by using appropriate and up-to-date anti-virus and rewall technologies and
these should be kept up-to-date to meet emerging threats.
iii. Personal computers, mobile phones,tablets or any other hardware with HIV-related
information should be password protected and should be logged off or ‘locked’ when not
being used.
iv. Passwords for hardware, software, databases, etc., should be of sufcient strength.
Facilities must ensure that passwords are changed on a regular basis.
v. A strong password must
- be at least 8 characters in length;
- contain both upper and lowercase alphabetic characters (e.g. A-Z, a-z);
- have at least one numerical character (e.g. 0–9);
- have at least one special character (e.g. ~!@#$%^&*()_-+=).
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HANDBOOK FOR HIV & STI COUNSELLORS
vi. Any software or applications for maintaining the HIV-related information of protected
persons in the facility should be explicitly approved by the competent authority of the
respective institution.
• Disposal of HIV-related information: Facility should have standard operating procedures
(SOPs) in place regarding the disposal of physical and electronic records/les containing
HIV-related information of protected persons.
• Accountability and liability for security of HIV-related information should be with DMCs or
the head of the concerned facility where DMC is not constituted.
C) NACP data sharing through shared condentiality: NACP data is only to be shared by
NACO and SACS as per the SOP for NACP data sharing available onthe NACO website.
D) Exemption through shared condentiality
• By a healthcare provider to another healthcare provider who is involved in the
screening/testing, linkage, care, treatment, support or counselling of HIV and other related
disease of such person, when such disclosure is necessary to provide appropriate healthcare
to that person;
• By an order of a court that the disclosure of such information is necessary in the interest of
justice for the determination of issues and in the matter before it;
• In suits or legal proceedings between persons, where the disclosure of such information is
necessary in ling suits or legal proceedings or for instructing their counsel;
• To the ofcials of the central government or the state government/SACS for the purposes of
monitoring, evaluation and related activities;
• If it relates to statistical or other information of a person that could not reasonably be
expected to lead to the identication of that person.
In all other scenarios, no paper or electronic records containing the HIV-related information of
protected persons shall be shared or transferred to other facilities or persons without the written
informed consent of the concerned person or his or her representative.
Data sharing and monitoring of shared data at facility level
Consistently monitor data access and security, and in case of any concerns or data breach,
proactively report them to the DMC or the head of the institution.
The sharing of data between different facilities or organizations must strictly adhere to
authorized channels. It is of utmost importance to ensure that shared data is exclusively
utilized for healthcare and monitoring purposes and is not disseminated to any unauthorized
individuals or organizations.
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Data Safety and Management at Facilities under NACP
Table 24.2 - Dos and Don’ts for NACP Data Management at NACP Facilities
Dos Don’t
• Grant access to authorized personnel. • Allow unauthorized personnel to access
data/records.
• Maintain condentiality during data
collection. • Neglect secure storage and protection
measures such as leaving paper/ les
• Implement password protection for
accessible to unauthorized individuals.
devices.
• Use weak passwords that do not meet the
• Secure physical records in locked
criteria.
cabinets.
• Use software/device for NACP data
• Log off and lock devices when not in use.
storage without proper approval.
• Follow SOP for safe physical/electronic
• Dispose of data without following the
le disposal.
established procedures.
• Regularly review data access/security;
• Share data through unauthorized
promptly inform the Data Management
channels.
Committee/Head of Institution of any
issues. • Neglect to monitor data access regularly.
• Share NACP data through authorized
channels.
Table 24.3 - Dos and Don’ts for NACP Data Sharing at NACP facilities
Dos Don’t
• Share data for appropriate healthcare • Share NACP data without proper
between healthcare providers. approval of NACO/ SACS.
• Share with central government, state • Share paper/electronic HIV-related data
government/SACS for monitoring and with personal information without
evaluation. informed consent, except for healthcare
and monitoring purposes.
• Ensure shared data is not further shared
with other organizations/individuals.
• Maintain responsibility for data security
and proper use.
Role of Counsellor in NACP Data Safety and Management
As counsellors working in the programme, the following is the list of registers, records and
reporting formats to be maintained by the counsellors:
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HANDBOOK FOR HIV & STI COUNSELLORS
Table 24.4 – List of registers and records to be maintained by counsellors
Registers • Counselling register for general individuals
• Counselling register for pregnant women
• Outreach activity register
Forms • Linkage form in triplicate
• Indent form
• RNTCP form for referral for diagnosis
Reports • SOCH monthly report
Cards • PLHIV card for general individuals
• PPTCT beneciary card
• EID card
• Discordant couple card
• Follow-up HIV testing card
Importance of Client Records
• Client records are intended to ensure continuity and quality of service delivery.
• Benets of maintaining client records include the availability of information to different
counsellors and healthcare workers within the team to ensure emotional support and
follow-up management.
Importance of Analysis and Reporting
• Necessary to enter client and clinic data into a system so as to ensure proper analysis and
reporting.
• Reporting reects the overall service provided by the counsellor/s during a specied period.
• Reporting helps to make decisions on the effectiveness and efcacy of services provided.
Barriers to Data Recording Practices
• Individual barriers
- Leave data eld blank in the data collection form
• Occupational barriers
- Non-availability of forms
- Power breakdown etc.
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Data Safety and Management at Facilities under NACP
Key Messages
• The HIV and AIDS Act, 2017 directs every facility to keep records of HIV-infected and
affected population and ensure that the data is protected and condentiality is
maintained.
• According to the section 11 of the HIV and AIDS (Prevention and Control) Act 2017, it is
mandatory for every facility to keep records of HIV-related information.
• Data Management Committee (DMC) should be formed at each facility responsible for
ensuring data security.
• Consistently monitor data access and security, and in case of any concerns or data
breach, proactively report them to the DMC or the head of the institution.
• Client records are intended to ensure continuity and quality of service delivery.
• Counsellors should maintain accurate data. The data can help them to understand the
progress being made towards the programme objectives; it helps in modifying
interventions if progress is not seen. It helps in evidence-based planning and to assess
progress.
• At local, state and national levels, it is useful to get information on various trends and
see the impact of the interventions.
• Patient recordshelp in the assessment of the progress made. If a new team member has
joined the healthcare team, it helps the person to understand the case history of the
patient.
• It is the responsibility of everyone working in NACPto ensure data security.
255
256
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Separate paging is given to this Part in order that it may be filed as a separate compilation.
MINISTRY OF LAW AND JUSTICE
(Legislative Department)
New Delhi, the 21st April, 2017/Vaisakha 1, 1939 (Saka)
The following Act of Parliament received the assent of the President on the
20th April, 2017, and is hereby published for general information:—
THE HUMAN IMMUNODEFICIENCY VIRUS AND ACQUIRED
IMMUNE DEFICIENCY SYNDROME (PREVENTION AND
CONTROL) ACT, 2017
NO. 16 OF 2017
[20th April, 2017.]
An Act to provide for the prevention and control of the spread of Human
Immunodeficiency Virus and Acquired Immune Deficiency Syndrome and
for the protection of human rights of persons affected by the said virus and
syndrome and for matters connected therewith or incidental thereto.
WHEREAS the spread of Human Immunodeficiency Virus and Acquired Immune
Deficiency Syndrome is a matter of grave concern to all and there is an urgent need for the
prevention and control of said virus and syndrome;
AND WHEREAS there is a need to protect and secure the human rights of persons who
are HIV-positive, affected by Human Immunodeficiency Virus and Acquired Immune
Deficiency Syndrome and vulnerable to the said virus and syndrome;
AND WHEREAS there is a necessity for effective care, support and treatment for Human
Immunodeficiency Virus and Acquired Immune Deficiency Syndrome;
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2 THE GAZETTE OF INDIA EXTRAORDINARY [PART II—
AND WHEREAS there is a need to protect the rights of healthcare providers and other
persons in relation to Human Immunodeficiency Virus and Acquired Immune Deficiency
Syndrome;
AND WHEREAS the General Assembly of the United Nations, recalling and reaffirming
its previous commitments on Human Immunodeficiency Virus and Acquired Immune
Deficiency Syndrome, has adopted the Declaration of Commitment on Human
Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (2001) to address the
problems of Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome in
all its aspects and to secure a global commitment to enhancing coordination and
intensification of national, regional and international efforts to combat it in a comprehensive
manner;
AND WHEREAS the Republic of India, being a signatory to the aforesaid Declaration, it
is expedient to give effect to the said Declaration.
BE it enacted by Parliament in the Sixty-eighth Year of the Republic of India as
follows:––
CHAPTER I
PRELIMINARY
Short title, 1. (1) This Act may be called the Human Immunodeficiency Virus and Acquired
extent and Immune Deficiency Syndrome (Prevention and Control) Act, 2017.
commencement.
(2) It extends to the whole of India.
(3) It shall come into force on such date as the Central Government may, by notification
in the Official Gazette, appoint.
Definitions. 2. In this Act, unless the context otherwise requires,—
(a) “AIDS” means Acquired Immune Deficiency Syndrome, a condition
characterised by a combination of signs and symptoms, caused by Human
Immunodeficiency Virus, which attacks and weakens the body’s immune system making
the HIV-positive person susceptible to life threatening conditions or other conditions,
as may be specified from time to time;
(b) “capacity to consent” means ability of an individual, determined on an
objective basis, to understand and appreciate the nature and consequences of a
proposed action and to make an informed decision concerning such action;
(c) “child affected by HIV” means a person below the age of eighteen years,
who is HIV-positive or whose parent or guardian (with whom such child normally
resides) is HIV-positive or has lost a parent or guardian (with whom such child resided)
due to AIDS or lives in a household fostering children orphaned by AIDS;
(d) “discrimination” means any act or omission which directly or indirectly,
expressly or by effect, immediately or over a period of time,—
(i) imposes any burden, obligation, liability, disability or disadvantage on
any person or category of persons, based on one or more HIV-related grounds;
or
(ii) denies or withholds any benefit, opportunity or advantage from any
person or category of persons, based on one or more HIV-related grounds,
and the expression “discriminate” to be construed accordingly.
Explanation 1.—For the purposes of this clause, HIV-related grounds include—
(i) being an HIV-positive person;
(ii) ordinarily living, residing or cohabiting with a person who is
HIV-positive person;
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SEC. 1] THE GAZETTE OF INDIA EXTRAORDINARY 3
(iii) ordinarily lived, resided or cohabited with a person who was
HIV-positive.
Explanation 2.—For the removal of doubts, it is hereby clarified that
adoption of medically advised safeguards and precautions to minimise the risk
of infection shall not amount to discrimination;
(e) “domestic relationship” means a relationship as defined under clause (f) of
43 of 2005. section 2 of the Protection of Women from Domestic Violence Act, 2005;
(f) “establishment” means a body corporate or co-operative society or any
organisation or institution or two or more persons jointly carrying out a systematic
activity for a period of twelve months or more at one or more places for consideration
or otherwise, for the production, supply or distribution of goods or services;
(g) “guidelines” means any statement or any other document issued by the
Central Government indicating policy or procedure or course of action relating to HIV
and AIDS to be followed by the Central Government, State Governments, governmental
and non-governmental organisations and establishments and individuals dealing with
prevention, control and treatment of HIV or AIDS;
(h) “healthcare provider” means any individual whose vocation or profession is
directly or indirectly related to the maintenance of the health of another individual and
includes any physician, nurse, paramedic, psychologist, counsellor or other individual
providing medical, nursing, psychological or other healthcare services including HIV
prevention and treatment services;
(i) “HIV” means Human Immunodeficiency Virus;
(j) “HIV-affected person” means an individual who is HIV-positive or whose
partner (with whom such individual normally resides) is HIV-positive or has lost a
partner (with whom such individual resided) due to AIDS;
(k) “HIV-positive person” means a person whose HIV test has been confirmed
positive;
(l) “HIV-related information” means any information relating to the HIV status of
a person and includes—
(i) information relating to the undertaking performing the HIV test or result
of an HIV test;
(ii) information relating to the care, support or treatment of that person;
(iii) information which may identify that person; and
(iv) any other information concerning that person, which is collected,
received, accessed or recorded in connection with an HIV test, HIV treatment or
HIV-related research or the HIV status of that person;
(m) “HIV test” means a test to determine the presence of an antibody or antigen
of HIV;
(n) “informed consent” means consent given by any individual or his
representative specific to a proposed intervention without any coercion, undue
influence, fraud, mistake or misrepresentation and such consent obtained after informing
such individual or his representative, as the case may be, such information, as specified
in the guidelines, relating to risks and benefits of, and alternatives to, the proposed
intervention in such language and in such manner as understood by that individual or
his representative, as the case may be;
(o) “notification” means a notification published in the Official Gazette;
(p) “partner” means a spouse, de facto spouse or a person with whom another
person has relationship in the nature of marriage;
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4 THE GAZETTE OF INDIA EXTRAORDINARY [PART II—
(q) “person” includes an individual, a Hindu Undivided Family, a company, a
firm, an association of persons or a body of individuals, whether incorporated or not,
in India or outside India, any corporation established by or under any Central or State
Act or any company including a Government company incorporated under the
Companies Act, 1956, any Limited Liability Partnership under the Limited Liability 1 of 1956.
Partnership Act, 2008, any body corporate incorporated by or under the laws of a 6 of 2009.
country outside India, a co-operative society registered under any law relating to
co-operative societies, a local authority, and every other artificial juridical person;
(r) “prescribed” means prescribed by rules made by the Central Government or
the State Government, as the case may be;
(s) “protected person” means a person who is—
(i) HIV-Positive; or
(ii) ordinarily living, residing or cohabiting with a person who is
HIV-positive person; or
(iii) ordinarily lived, resided or cohabited with a person who was
HIV- positive;
(t) “reasonable accommodation” means minor adjustments to a job or work that
enables an HIV-positive person who is otherwise qualified to enjoy equal benefits or
to perform the essential functions of the job or work, as the case may be;
(u) “relative”, with reference to the protected person, means—
(i) spouse of the protected person;
(ii) parents of the protected person;
(iii) brother or sister of the protected person;
(iv) brother or sister of the spouse of the protected person;
(v) brother or sister of either of the parents of the protected person;
(vi) in the absence of any of the relatives mentioned at sub-clauses (i)
to (v), any lineal ascendant or descendant of the protected person;
(vii) in the absence of any of the relatives mentioned at sub-clauses (i)
to (vi), any lineal ascendant or descendant of the spouse of the protected person;
(v) “significant-risk” means—
(a) the presence of significant-risk body substances;
(b) a circumstance which constitutes significant-risk for transmitting or
contracting HIV infection; or
(c) the presence of an infectious source and an uninfected person.
Explanation.—For the purpose of this clause,—
(i) “significant-risk body substances” are blood, blood products, semen,
vaginal secretions, breast milk, tissue and the body fluids, namely, cerebrospinal,
amniotic, peritoneal, synovial, pericardial and pleural;
(ii)‘‘circumstances which constitute significant-risk for transmitting or
contracting HIV infection” are—
(A) sexual intercourse including vaginal, anal or oral sexual
intercourse which exposes an uninfected person to blood, blood products,
semen or vaginal secretions of an HIV-positive person;
(B) sharing of needles and other paraphernalia used for preparing
and injecting drugs between HIV-positive persons and uninfected persons;
260
SEC. 1] THE GAZETTE OF INDIA EXTRAORDINARY 5
(C) the gestation, giving birth or breast feeding of an infant when
the mother is an HIV-positive person;
(D) transfusion of blood, blood products, and transplantation of
organs or other tissues from an HIV-positive person to an uninfected
person, provided such blood, blood products, organs or other tissues
have not been tested conclusively for the antibody or antigen of HIV and
have not been rendered non-infective by heat or chemical treatment; and
(E) other circumstances during which a significant-risk body
substance, other than breast milk, of an HIV-positive person contacts or
may contact mucous membranes including eyes, nose or mouth, non-
intact skin including open wounds, skin with a dermatitis condition or
abraded areas or the vascular system of an uninfected person, and
including such circumstances not limited to needle-stick or puncture
wound injuries and direct saturation or permeation of these body surfaces
by the significant-risk body substances:
Provided that “significant-risk” shall not include—
(i) exposure to urine, faeces, sputum, nasal secretions, saliva,
sweat, tears or vomit that does not contain blood that is visible to
the naked eye;
(ii) human bites where there is no direct blood to blood, or no
blood to mucous membrane contact;
(iii) exposure of intact skin to blood or any other blood
substance; and
(iv) occupational centres where individuals use scientifically
accepted Universal Precautions, prohibitive techniques and
preventive practices in circumstances which would otherwise pose
a significant-risk and such techniques are not breached and remain
intact;
(w) “State AIDS Control Society” means the nodal agency of the State
Government responsible for implementing programmes in the field of HIV and AIDS;
(x) “State Government”, in relation to a Union territory, means the Administrator
of that Union territory appointed by the President under article 239 of the Constitution;
and
(y) “Universal Precautions” means control measures that prevent exposure to
or reduce, the risk of transmission of pathogenic agents (including HIV) and includes
education, training, personal protective equipment such as gloves, gowns and masks,
hand washing, and employing safe work practices.
CHAPTER II
PROHIBITION OF CERTAIN ACTS
3. No person shall discriminate against the protected person on any ground including Prohibition of
any of the following, namely:— discrimination.
(a) the denial of, or termination from, employment or occupation, unless, in the
case of termination, the person, who is otherwise qualified, is furnished with—
(i) a copy of the written assessment of a qualified and independent
healthcare provider competent to do so that such protected person poses a
significant risk of transmission of HIV to other person in the workplace, or is
unfit to perform the duties of the job; and
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6 THE GAZETTE OF INDIA EXTRAORDINARY [PART II—
(ii) a copy of a written statement by the employer stating the nature and
extent of administrative or financial hardship for not providing him reasonable
accommodation;
(b) the unfair treatment in, or in relation to, employment or occupation;
(c) the denial or discontinuation of, or, unfair treatment in, healthcare services;
(d) the denial or discontinuation of, or unfair treatment in, educational,
establishments and services thereof;
(e) the denial or discontinuation of, or unfair treatment with regard to, access to,
or provision or enjoyment or use of any goods, accommodation, service, facility,
benefit, privilege or opportunity dedicated to the use of the general public or customarily
available to the public, whether or not for a fee, including shops, public restaurants,
hotels and places of public entertainment or the use of wells, tanks, bathing ghats,
roads, burial grounds or funeral ceremonies and places of public resort;
(f) the denial, or, discontinuation of, or unfair treatment with regard to, the right
of movement;
(g) the denial or discontinuation of, or, unfair treatment with regard to, the right
to reside, purchase, rent, or otherwise occupy, any property;
(h) the denial or discontinuation of, or, unfair treatment in, the opportunity to
stand for, or, hold public or private office;
(i) the denial of access to, removal from, or unfair treatment in, Government or
private establishment in whose care or custody a person may be;
(j) the denial of, or unfair treatment in, the provision of insurance unless supported
by actuarial studies;
(k) the isolation or segregation of a protected person;
(l) HIV testing as a pre-requisite for obtaining employment, or accessing
healthcare services or education or, for the continuation of the same or, for accessing
or using any other service or facility:
Provided that, in case of failure to furnish the written assessment under sub-
clause (i) of clause (a), it shall be presumed that there is no significant-risk and that the
person is fit to perform the duties of the job, as the case may be, and in case of the
failure to furnish the written statement under sub-clause (ii) of that clause, it shall be
presumed that there is no such undue administrative or financial hardship.
Prohibition 4. No person shall, by words, either spoken or written, publish, propagate, advocate or
of certain communicate by signs or by visible representation or otherwise the feelings of hatred against
acts. any protected persons or group of protected person in general or specifically or disseminate,
broadcast or display any information, advertisement or notice, which may reasonably be
construed to demonstrate an intention to propagate hatred or which is likely to expose
protected persons to hatred, discrimination or physical violence.
CHAPTER III
INFORMED CONSENT
Informed 5. (1) Subject to the provisions of this Act,—
consent for
undertaking (a) no HIV test shall be undertaken or performed upon any person; or
HIV test or
treatment.
(b) no protected person shall be subject to medical treatment, medical
interventions or research,
except with the informed consent of such person or his representative and in such manner,
as may be specified in the guidelines.
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SEC. 1] THE GAZETTE OF INDIA EXTRAORDINARY 7
(2) The informed consent for HIV test shall include pre-test and post-test counselling
to the person being tested or such person’s representative in the manner as may be specified
in the guidelines.
6. The informed consent for conducting an HIV test shall not be required— Informed
consent not
(a) where a court determines, by an order that the carrying out of the HIV test of required for
any person either as part of a medical examination or otherwise, is necessary for the conducting
HIV tests in
determination of issues in the matter before it; certain cases.
(b) for procuring, processing, distribution or use of a human body or any part
thereof including tissues, blood, semen or other body fluids for use in medical research
or therapy:
Provided that where the test results are requested by a donor prior to donation,
the donor shall be referred to counselling and testing centre and such donor shall not
be entitled to the results of the test unless he has received post-test counselling from
such centre;
(c) for epidemiological or surveillance purposes where the HIV test is anonymous
and is not for the purpose of determining the HIV status of a person:
Provided that persons who are subjects of such epidemiological or surveillance
studies shall be informed of the purposes of such studies; and
(d) for screening purposes in any licensed blood bank.
7. No HIV test shall be conducted or performed by any testing or diagnostic centre or Guidelines for
pathology laboratory or blood bank, unless such centre or laboratory or blood bank follows testing
centres, etc.
the guidelines laid down for such test.
CHAPTER IV
DISCLOSURE OF HIV STATUS
8. (1) Notwithstanding anything contained in any other law for the time being in Disclosure of
force,— HIV status.
(i) no person shall be compelled to disclose his HIV status except by an order of
the court that the disclosure of such information is necessary in the interest of justice
for the determination of issues in the matter before it;
(ii) no person shall disclose or be compelled to disclose the HIV status or any
other private information of other person imparted in confidence or in a relationship of
a fiduciary nature, except with the informed consent of that other person or a
representative of such another person obtained in the manner as specified in
section 5, as the case may be, and the fact of such consent has been recorded in
writing by the person making such disclosure:
Provided that, in case of a relationship of a fiduciary nature, informed consent
shall be recorded in writing.
(2) The informed consent for disclosure of HIV-related information under clause (ii)
of sub-section (1) is not required where the disclosure is made—
(a) by a healthcare provider to another healthcare provider who is involved in
the care, treatment or counselling of such person, when such disclosure is necessary
to provide care or treatment to that person;
(b) by an order of a court that the disclosure of such information is necessary
in the interest of justice for the determination of issues and in the matter
before it;
(c) in suits or legal proceedings between persons, where the disclosure of such
information is necessary in filing suits or legal proceedings or for instructing their counsel;
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8 THE GAZETTE OF INDIA EXTRAORDINARY [PART II—
(d) as required under the provisions of section 9;
(e) if it relates to statistical or other information of a person that could not
reasonably be expected to lead to the identification of that person; and
(f) to the officers of the Central Government or the State Government or State
AIDS Control Society of the concerned State Government, as the case may be, for the
purposes of monitoring, evaluation or supervision.
Disclosure of 9. (1) No healthcare provider, except a physician or a counsellor, shall disclose the
HIV-positive HIV-positive status of a person to his or her partner.
status to
partner of (2) A healthcare provider, who is a physician or counsellor, may disclose the HIV-
HIV-positive positive status of a person under his direct care to his or her partner, if such healthcare
person.
provider—
(a) reasonably believes that the partner is at the significant risk of transmission
of HIV from such person; and
(b) such HIV-positive person has been counselled to inform such partner; and
(c) is satisfied that the HIV-positive person will not inform such partner; and
(d) has informed the HIV-positive person of the intention to disclose the HIV-
positive status to such partner:
Provided that disclosure under this sub-section to the partner shall be made in person
after counselling:
Provided further that such healthcare provider shall have no obligation to identify or
locate the partner of an HIV-positive person:
Provided also that such healthcare provider shall not inform the partner of a woman
where there is a reasonable apprehension that such information may result in violence,
abandonment or actions which may have a severe negative effect on the physical or mental
health or safety of such woman, her children, her relatives or someone who is close to her.
(3) The healthcare provider under sub-section (1) shall not be liable for any criminal or
civil action for any disclosure or non-disclosure of confidential HIV-related information
made to a partner under this section.
Duty to 10. Every person, who is HIV-positive and has been counselled in accordance with
prevent the guidelines issued or is aware of the nature of HIV and its transmission, shall take all
transmission
of HIV. reasonable precautions to prevent the transmission of HIV to other persons which may
include adopting strategies for the reduction of risk or informing in advance his HIV status
before any sexual contact with any person or with whom needles are shared with:
Provided that the provisions of this section shall not be applicable to prevent
transmission through a sexual contact in the case of a woman, where there is a reasonable
apprehension that such information may result in violence, abandonment or actions which
may have a severe negative effect on the physical or mental health or safety of such woman,
her children, her relatives or someone who is close to her.
CHAPTER V
OBLIGATION OF ESTABLISHMENTS
Confidentiality 11. Every establishment keeping the records of HIV-related information of protected
of data. persons shall adopt data protection measures in accordance with the guidelines to ensure
that such information is protected from disclosure.
Explanation.— For the purpose of this section, data protection measures shall include
procedures for protecting information from disclosure, procedures for accessing information,
provision for security systems to protect the information stored in any form and mechanisms
to ensure accountability and liability of persons in the establishment.
264
SEC. 1] THE GAZETTE OF INDIA EXTRAORDINARY 9
12. The Central Government shall notify model HIV and AIDS policy for HIV and
establishments, in such manner, as may be prescribed. AIDS policy
for
CHAPTER VI establishments.
ANTI-RETROVIRAL THERAPY AND OPPORTUNISTIC INFECTION MANAGEMENT FOR PEOPLE
LIVING WITH HIV
13. The Central Government and every State Government, as the case may be, shall Central
take all such measures as it deems necessary and expedient for the prevention of spread of Government
and State
HIV or AIDS, in accordance with the guidelines. Government
to take
measures.
14. (1) The measures to be taken by the Central Government or the State Government Anti-
under section 13 shall include the measures for providing, as far as possible, diagnostic retroviral
Therapy and
facilities relating to HIV or AIDS, Anti-retroviral Therapy and Opportunistic Infection Opportunistic
Management to people living with HIV or AIDS. Infection
Management
(2) The Central Government shall issue necessary guidelines in respect of protocols by Central
for HIV and AIDS relating to diagnostic facilities, Anti-retroviral Therapy and Opportunistic Government
Infection Management which shall be applicable to all persons and shall ensure their wide and State
Government.
dissemination.
CHAPTER VII
WELFARE MEASURES BY THE CENTRAL GOVERNMENT AND STATE GOVERNMENT
15. (1) The Central Government and every State Government shall take measures to Welfare
facilitate better access to welfare schemes to persons infected or affected by HIV or AIDS. measures by
Central
(2) Without prejudice to the provisions of sub-section (1), the Central Government Government
and State Governments shall frame schemes to address the needs of all protected persons. and State
Government.
16. (1) The Central Government or the State Government, as the case may be, shall Protection of
take appropriate steps to protect the property of children affected by HIV or AIDS for the property of
children
protection of property of child affected by HIV or AIDS. affected by
(2) The parents or guardians of children affected by HIV and AIDS, or any person HIV or AIDS.
acting for protecting their interest, or a child affected by HIV and AIDS may approach the
Child Welfare Committee for the safe keeping and deposit of documents related to the
property rights of such child or to make complaints relating to such child being dispossessed
or actual dispossession or trespass into such child’s house.
Explanation.—For the purpose of this section, “Child Welfare Committee” means a
Committee set-up under section 29 of the Juvenile Justice (Care and Protection of Children)
56 of 2000. Act, 2000.
17. The Central Government and the State Government shall formulate HIV and AIDS Promotion of
related information, education and communication programmes which are age-appropriate, HIV and AIDS
related
gender-sensitive, non-stigmatising and non-discriminatory. information,
education and
communication
programmes.
18. (1) The Central Government shall lay down guidelines for care, support and treatment Women and
of children infected with HIV or AIDS. children
infected with
(2) Without prejudice to the generality of the provisions of sub-section (1) and HIV or AIDS.
notwithstanding anything contained in any other law for the time being in force, the Central
Government, or the State Government as the case may be, shall take measures to counsel
and provide information regarding the outcome of pregnancy and HIV-related treatment to
the HIV infected women.
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10 THE GAZETTE OF INDIA EXTRAORDINARY [PART II—
(3) No HIV positive woman, who is pregnant, shall be subjected to sterilisation or
abortion without obtaining her informed consent.
CHAPTER VIII
SAFE WORKING ENVIRONMENT
Obligation of 19. Every establishment, engaged in the healthcare services and every such other
establishments establishment where there is a significant risk of occupational exposure to HIV, shall, for the
to provide
purpose of ensuring safe working environment,—
safe working
environment. (i) provide, in accordance with the guidelines,—
(a) Universal Precautions to all persons working in such establishment
who may be occupationally exposed to HIV; and
(b) training for the use of such Universal Precautions;
(c) Post Exposure Prophylaxis to all persons working in such establishment
who may be occupationally exposed to HIV or AIDS; and
(ii) inform and educate all persons working in the establishment of the availability
of Universal Precautions and Post Exposure Prophylaxis.
General 20. (1) The provisions of this Chapter shall be applicable to all establishments consisting
responsibility of one hundred or more persons, whether as an employee or officer or member or director or
of
establishments. trustee or manager, as the case may be:
Provided that in the case of healthcare establishments, the provisions of this
sub-section shall have the effect as if for the words “one hundred or more”, the words
“twenty or more” had been substituted.
(2) Every person, who is in charge of an establishment, referred to in sub-section (1),
for the conduct of the activities of such establishment, shall ensure compliance of the
provisions of this Act.
Grievance 21. Every establishment referred to in sub-section (1) of section 20 shall designate
redressal such person, as it deems fit, as the Complaints Officer who shall dispose of complaints of
mechanism.
violations of the provisions of this Act in the establishment, in such manner and within such
time as may be prescribed.
CHAPTER IX
PROMOTION OF STRATEGIES FOR REDUCTION OF RISK
Strategies for 22. Notwithstanding anything contained in any other law for the time being in force
reduction of any strategy or mechanism or technique adopted or implemented for reducing the risk of HIV
risk.
transmission, or any act pursuant thereto, as carried out by persons, establishments or
organisations in the manner as may be specified in the guidelines issued by the Central
Government shall not be restricted or prohibited in any manner, and shall not amount to a
criminal offence or attract civil liability.
Explanation.—For the purpose of this section, strategies for reducing risk of HIV
transmission means promoting actions or practices that minimise a person’s risk of exposure
to HIV or mitigate the adverse impacts related to HIV or AIDS including—
(i) the provisions of information, education and counselling services relating to
prevention of HIV and safe practices;
(ii) the provisions and use of safer sex tools, including condoms;
(iii) drug substitution and drug maintenance; and
(iv) provision of comprehensive injection safety requirements.
266
SEC. 1] THE GAZETTE OF INDIA EXTRAORDINARY 11
Illustrations
(a) A supplies condoms to B who is a sex worker or to C, who is a client of B.
Neither A nor B nor C can be held criminally or civilly liable for such actions or be
prohibited, impeded, restricted or prevented from implementing or using the strategy.
(b) M carries on an intervention project on HIV or AIDS and sexual health
information, education and counselling for men, who have sex with men, provides
safer sex information, material and condoms to N, who has sex with other men. Neither
M nor N can be held criminally or civilly liable for such actions or be prohibited,
impeded, restricted or prevented from implementing or using the intervention.
(c) X, who undertakes an intervention providing registered needle exchange
programme services to injecting drug users, supplies a clean needle to Y, an injecting
drug user who exchanges the same for a used needle. Neither X nor Y can be held
criminally or civilly liable for such actions or be prohibited, impeded, restricted or
prevented from implementing or using the intervention.
(d) D, who carries on an intervention programme providing Opioid Substitution
Treatment (OST), administers OST to E, an injecting drug user. Neither D nor E can be
held criminally or civilly liable for such actions or be prohibited, impeded, restricted or
prevented from implementing or using the intervention.
CHAPTER X
APPOINTMENT OF OMBUDSMAN
23. (1) Every State Government shall appoint one or more Ombudsman,— Appointment
of
(a) possessing such qualification and experience as may be prescribed, or Ombudsman.
(b) designate any of its officers not below such rank, as may be prescribed, by
that Government,
to exercise such powers and discharge such functions, as may be conferred on Ombudsman
under this Act.
(2) The terms and condition of the service of an Ombudsman appointed under
clause (a) of sub-section (1) shall be such as may be prescribed by the State Government.
(3)The Ombudsman appointed under sub-section (1) shall have such jurisdiction in
respect of such area or areas as the State Government may, by notification, specify.
24. (1) The Ombudsman shall, upon a complaint made by any person, inquire into the Powers of
Ombudsman.
violations of the provisions of this Act, in relation to acts of discrimination mentioned in
section 3 and providing of healthcare services by any person, in such manner as may be
prescribed by the State Government.
(2) The Ombudsman may require any person to furnish information on such points or
matters, as he considers necessary, for inquiring into the matter and any person so required
shall be deemed to be legally bound to furnish such information and failure to do so shall be
45 of 1860. punishable under sections 176 and 177 of the Indian Penal Code.
(3) The Ombudsman shall maintain records in such manner as may be prescribed by
the State Government.
25. The complaints may be made to the Ombudsman under sub-section (1) of section 24 Procedure of
complaint.
in such manner, as may be prescribed, by the State Government.
26. The Ombudsman shall, within a period of thirty days of the receipt of the complaint Orders of
under sub-section (1) of section 24, and after giving an opportunity of being heard to the Ombudsman.
parties, pass such order, as he deems fit, giving reasons therefor:
Provided that in cases of medical emergency of HIV positive persons, the Ombudsman
shall pass such order as soon as possible, preferably within twenty-four hours of the receipt
of the complaint.
267
12 THE GAZETTE OF INDIA EXTRAORDINARY [PART II—
Authorities to 27. All authorities including the civil authorities functioning in the area for which the
assist Ombudsman has been appointed under section 23 shall assist in execution of orders passed
Ombudsman.
by the Ombudsman.
Report to 28. The Ombudsman shall, after every six months, report to the State Government, the
State number and nature of complaints received, the action taken and orders passed in relation to
Government.
such complaints and such report shall be published on the website of the Ombudsman and
a copy thereof be forwarded to the Central Government.
CHAPTER XI
SPECIAL PROVISIONS
Right of 29. Every protected person shall have the right to reside in the shared
residence. household, the right not to be excluded from the shared household or any part of it and
the right to enjoy and use the facilities of such shared household in a non-discriminatory
manner.
Explanation.—For the purposes of this section, the expression “shared household”
means a household where a person lives or at any stage has lived in a domestic relationship
either singly or along with another person and includes such a household, whether owned or
tenanted, either jointly or singly, any such household in respect of which either person or
both, jointly or singly, have any right, title, interest or equity or a household which may
belong to a joint family of which either person is a member, irrespective of whether either
person has any right, title or interest in the shared household.
HIV-related 30. The Central Government shall specify guidelines for the provision of HIV-related
information, information, education and communication before marriage and ensure their wide
education and
dissemination.
communication
before
marriage.
Persons in care 31. (1) Every person who is in the care or custody of the State shall have the right to
or custody of HIV prevention, counselling, testing and treatment services in accordance with the guidelines
State.
issued in this regard.
(2) For the purposes of this section, persons in the care or custody of the State include
persons convicted of a crime and serving a sentence, persons awaiting trial, person detained
under preventive detention laws, persons under the care or custody of the State under the
Juvenile Justice (Care and Protection of Children) Act, 2000, the Immoral Traffic (Prevention) 56 of 2000.
Act, 1956 or any other law and persons in the care or custody of State run homes and 104 of 1956.
shelters.
Recognition 32. Notwithstanding anything contained in any law for the time being in force, a
of person below the age of eighteen but not below twelve years, who has sufficient maturity of
guardianship
understanding and who is managing the affairs of his family affected by HIV and AIDS, shall
of older
sibling. be competent to act as guardian of other sibling below the age of eighteen years for the
following purposes, namely:—
(a) admission to educational establishments;
(b) care and protection;
(c) treatment;
(d) operating bank accounts;
(e) managing property; and
(f) any other purpose that may be required to discharge his duties as a guardian.
Explanation.—For the purposes of this section, a family affected by HIV or AIDS
means where both parents and the legal guardian is incapacitated due to HIV-related illness
or AIDS or the legal guardian and parents are unable to discharge their duties in relation to
such children.
268
SEC. 1] THE GAZETTE OF INDIA EXTRAORDINARY 13
33. (1) Notwithstanding anything contained in any law for the time being in force, a Living wills
parent or legal guardian of a child affected by HIV and AIDS may appoint, by making a will, for
guardianship
an adult person who is a relative or friend, or a person below the age of eighteen years who and
is the managing member of the family affected by HIV and AIDS, as referred to in section 33, testamentary
to act as legal guardian immediately upon incapacity or death of such parent or legal guardian, guardianship.
as the case may be.
(2) Nothing in this section shall divest a parent or legal guardian of their rights, and the
guardianship referred to in sub-section (1) shall cease to operate upon by the parent or legal
guardian regaining their capacity.
(3) Any parent or legal guardian of children affected by HIV and AIDS may make a will
appointing a guardian for care and protection of such children and for the property that such
children would inherit or which is bequeathed through the will made by such parent or legal
guardian.
CHAPTER XII
SPECIAL PROCEDURE IN COURT
34. (1) In any legal proceeding in which a protected person is a party or such person Suppression
is an applicant, the court, on an application by such person or any other person on his behalf of identity.
may pass, in the interest of justice, any or all of the following orders, namely:—
(a) that the proceeding or any part thereof be conducted by suppressing the
identity of the applicant by substituting the name of such person with a pseudonym in
the records of the proceedings in such manner as may be prescribed;
(b) that the proceeding or any part thereof may be conducted in camera;
(c) restraining any person from publishing in any manner any matter leading to
the disclosure of the name or status or identity of the applicant.
(2) In any legal proceeding concerning or relating to an HIV-positive person, the court
shall take up and dispose of the proceeding on priority basis.
35. In any maintenance application filed by or on behalf of a protected person under Maintenance
any law for the time being in force, the court shall consider the application for interim applications.
maintenance and, in passing any order of maintenance, shall take into account the medical
expenses and other HIV-related costs that may be incurred by the applicant.
36. In passing any order relating to sentencing, the HIV-positive status of the persons Sentencing.
in respect of whom such an order is passed shall be a relevant factor to be considered by the
court to determine the custodial place where such person shall be transferred to, based on
the availability of proper healthcare services at such place.
CHAPTER XIII
PENALTIES
37. Notwithstanding any action that may be taken under any other law for the time Penalty for
being in force, whoever contravenes the provisions of section 4 shall be punished with contravention.
imprisonment for a term which shall not be less than three months but which may extend to
two years and with fine which may extend to one lakh rupees, or with both.
38. Whoever fails to comply with any order given by an Ombudsman within such time Penalty for
as may be specified in such order, under section 26, shall be liable to pay a fine which may failure to
extend to ten thousand rupees and in case the failure continues, with an additional fine comply with
orders of
which may extend to five thousand rupees for every day during which such failure continues. Ombudsman.
39. Notwithstanding any action that may be taken under any law for the time being in Penalty for
force, whoever discloses information regarding the HIV status of a protected person which breach of
is obtained by him in the course of, or in relation to, any proceedings before any court, shall confidentiality
in legal
proceedings.
269
14 THE GAZETTE OF INDIA EXTRAORDINARY [PART II—
be punishable with fine which may extend to one lakh rupees unless such disclosure is
pursuant to any order or direction of a court.
Prohibition of 40. No person shall subject any other person or persons to any detriment on the
victimisation. ground that such person or persons have taken any of the following actions, namely:—
(a) made complaint under this Act;
(b) brought proceedings under this Act against any person;
(c) furnished any information or produced any document to a person exercising
or performing any power or function under this Act; or
(d) appeared as a witness in a proceeding under this Act.
Court to try 41. No court other than the court of a Judicial Magistrate First Class shall take
offences. cognizance of an offence under this Act.
Offences to be 42. Notwithstanding anything contained in the Code of Criminal Procedure, 1973, 2 of 1974.
cognizable and offences under this Act shall be cognizable and bailable.
bailable.
CHAPTER XIV
MISCELLANEOUS
Act to have 43. The provisions of this Act shall have effect notwithstanding anything inconsistent
overriding therewith contained in any other law for the time in force or in any instrument having effect
effect.
by virtue of any law other than this Act.
Protection of 44. No suit, prosecution or other legal proceeding shall lie against the Central
action taken Government, the State Government, the Central Government or AIDS Control Society of the
in good faith. State Government Ombudsman or any member thereof or any officer or other employee or
person acting under the direction either of the Central Government, the State Government,
the Central Government, or Ombudsman in respect of anything which is in good faith done or
intended to be done in pursuance of this Act or any rules or guidelines made thereunder or
in respect of the publication by or under the authority of the Central Government, the State
Government, the Central Government or AIDS Control Society of the State Government
Ombudsman.
Delegation of 45. The Central Government and State Government, as the case may be, may, by
powers. general or special order, direct that any power exercisable by it under this Act shall, in such
circumstances and under such conditions, if any, as may be mentioned in the order, be
exercisable also by an officer subordinate to that Government or the local authority.
Guidelines. 46. (1) The Central Government may, by notification, make guidelines consistent with
this Act and any rules thereunder, generally to carry out the provisions of this Act.
(2) In particular and without prejudice to the generality of the foregoing power, such
guidelines may provide for all or any of the following matters, namely:—
(a) information relating to risk and benefits or alternatives to the proposed
intervention under clause (n) of section 2;
(b) the manner of obtaining the informed consent under sub-section (1) and the
manner of pre test and post test counselling under sub-section (2) of section 5;
(c) guidelines to be followed by a testing or diagnostic centre or pathology
laboratory or blood bank for HIV test under section 7;
(d) the manner of taking data protection measures under section 11;
(e) guidelines in respect of protocols for HIV/AIDS relating to Anti-retroviral
Therapy and Opportunistic Infections Management under sub-section (2) of
section 14;
270
SEC. 1] THE GAZETTE OF INDIA EXTRAORDINARY 15
(f) care, support and treatment of children infected with HIV or AIDS under
sub-section (1) of section 18;
(g) guidelines for Universal Precautions and post exposure prophylaxis under
section 19;
(h) manner of carrying out the strategy or mechanism or technique for reduction
of risk of HIV transmission under section 22;
(i) manner of implementation of a drugs substitution, drug maintenance and
needle and syringe exchange programme under section 22;
(j) provision of HIV-related information, education and communication before
marriage under section 30;
(k) manner of HIV or AIDS prevention, counselling, testing and treatment of
persons in custody under section 31;
(l) any other matter which ought to be specified in guidelines for the purposes
of this Act.
47. (1) The Central Government may, by notification, make rules to carry out the Power of
provisions of this Act. Central
Government
(2) In particular, and without prejudice to the generality of the foregoing provision, to make rules.
such rules may provide for all or any of the following matters, namely:—
(a) manner of notifying model HIV or AIDS policy for the establishments under
section 12;
(b) any other matter which may be or ought to be prescribed by the Central
Government.
48. Every rule made under this Act shall be laid, as soon as may be after it is made, Laying of
before each House of Parliament, while it is in session, for a total period of thirty days which rules before
both Houses
may be comprised in one session or in two or more successive sessions, and if, before the
of
expiry of the session immediately following the session or the successive session aforesaid, Parliament.
both Houses agree in making any modification in the rule or both Houses agree that the rule
should not be made, the rule shall thereafter have effect only in such modified form or be of
no effect, as the case may be; so, however, that any such modification or annulment shall be
without prejudice to the validity of anything previously done under that rule.
49. (1) The State Government may, by notification, make rules for carrying out the Power of
provisions of this Act. State
Government
(2) In particular, and without prejudice to the generality of the foregoing power, such to make rules
rules may provide for all or any of the following matters, namely:— and laying
thereof.
(a) measures to provide diagnostic facilities relating to HIV or AIDS, Anti-
retroviral Therapy and Opportunistic Infection Management to people living with HIV
or AIDS and for the prevention of spread of HIV or AIDS in accordance with the
guidelines under section 14;
(b) qualification and experience for the appointment of a person as an Ombudsman
under clause (a) or rank of officer of the State Government to be designated as
Ombudsman under clause (b) of sub-section (1) of section 23;
(c) terms and conditions of services of Ombudsman under sub-section (2) of
section 23;
(d) manner of inquiring into complaints by the Ombudsman under sub-section (1)
and maintaining of records by him under sub-section (3) of section 24;
(e) manner of making the complaints to the Ombudsman under section 25; and
(f) manner of recording pseudonym in legal proceedings under clause (a) of
sub-section (1) of section 34.
271
16 THE GAZETTE OF INDIA EXTRAORDINARY [PART II— SEC. 1]
(3) Every rule made by the State Government under this Act shall be laid, as soon as
may be, after it is made before the Legislature of that State.
Power to 50. (1) If any difficulty arises in giving effect to the provisions of this Act, the Central
remove Government may, by order published in the Official Gazette, make such provisions, not
difficulties.
inconsistent with the provisions of this Act, as may appear to be necessary for removing the
difficulty:
Provided that no order shall be made under this section after the expiry of the period of
two years from the date of commencement of this Act.
(2) Every order made under this section shall be laid, as soon as may be after it is made,
before each House of Parliament.
————
DR. G. NARAYANA RAJU
Secretary to the Govt. of India.
————
CORRIGENDUM
THE GOODS AND SERVICES TAX (COMPENSATION TO STATES) ACT, 2017
NO. 15 OF 2017
In the Goods and Services Tax (Compensation to States) Act, 2017 (15 of 2017) published
in the Gazette of India, Extraordinary, Part II, Section I, dated 12th April, 2017, issue No. 15, at
page 3, in line 20, for “onstitution”, read “Constitution”.
UPLOADED BY THE GENERAL MANAGER, GOVERNMENT OF INDIA PRESS, MINTO ROAD, NEW DELHI–110002
AND PUBLISHED BY THE CONTROLLER OF PUBLICATIONS, DELHI–110054.
GMGIPMRND—561GI(S3)—21-04-2017.
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jftLVªh laö Mhö ,yö&33004@99 REGD. NO. D. L.-33004/99
vlk/kj.k
EXTRAORDINARY
Hkkx II—[k.M 3—mi&[k.M (i)
PART II—Section 3—Sub-section (i)
izkf/dkj ls izdkf'kr
PUBLISHED BY AUTHORITY
la- 653] ubZ fnYyh] lkseokj] flrEcj 17] 2018@Hkkæ 26] 1940
No. 653] NEW DELHI, MONDAY, SEPTEMBER 17, 2018/BHADRA 26, 1940
वा
वाय और प रवार क याण
याण मंालय
( राी
ीय
य ए स िनयंण संगठन)
अिधसूचना
नई दली, 17 िसत बर, 2018
सा.. का
सा का.. िन 888((अ).—के ीय सरकार मानव रोग म अ पता िवषाणु और अजत रोग म अ पता संल ण
िन.. 888
(िनवारण और िनयं ण) अिधिनयम, 2017 (2017 का 16) क# धारा 47 &ारा 'द) शि+य, का 'योग करते -ए,
िन/निलिखत िनयम बनाती है, अथा1त:् -
अयाय- I
ारंिभक
1. संित नाम और ारं भ.—(1) इन िनयम का संित नाम मानव रोगम अपता िवषाणु और अ जत रोगम
अपता संलण (िनवारण और िनयं ण) िनयम, 2018 है।
(2) ये राजप से "काशन क$ तारीख से "वृ( ह गे।
2. प रभाषाएं—
(1) इन िनयम म+ जब तक संदभ/ के अनुसार अ0यथा अपेित न हो,
(क) ‘‘अिधिनयम’’ से मानव रोगम अपता िवषाणु और अ जत रोगम अपता संलण (िनवारण और
िनयं ण) िनयम, 2017 (2017 का 16) अिभ"ेत है;
(ख) ‘‘समुिचत "ािधकारी’’ से अिभ"ेत है;
5503 GI/2018 (1)
294
2 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)]
(i) क+5ीय सरकार के मामले म+ रा67ीय ए9स िनयं ण संगठन; और
(ii) रा;य सरकार के मामले म+ रा;य ए9स िनयं ण सोसाइटी;
(ग) ‘‘उ>च भार िजले’’ से अिभ"ेत उस िजले से है जहां –
(i) "हरी िनगरानी म+ "सवपूव/ पAरचया/ म+ एक "ितशत से अिधक का "चलन हो; या
(ii) "हरी िनगरानी म+ उ>च-जोिखम जनसंBया म+ पांच "ितशत से अिधक का "चलन हो; या
(iii) एक$कृत काउं िसCलग और समय-समय पर क+5ीय सरकार के अधीन समुिचत "ािधकारी Dारा अिधसूिचत
Eकए गए परीण क+ 5 म+ आम मरीज म+ एचआईवी पािजAटव रा67ीय औसत से अिधक हो।
(2) इसम+ उपयोग Eकए गए शHद और अिभIयिJय िज0ह+ इन िनयम म+ पAरभािषत नहK Eकया गया है परं तु
अिधिनयम म+ पAरभािषत Eकया गया है, का अथ/ वही होगा जो अिधिनयम म+ िनLद6ट Eकया गया है।
अ याय – II
थापन!
थापन! के िलए एचआईवी और ए'स नीित को अिधसूिचत +कए जाने क- िविध
3. क+5ीय सरकार के अधीन समुिचत "ािधकारी MथापनाN के िलए मॉडल एचआईवी और ए9स नीित को
अिधसूिचत करने से पूव/ इस नीित के संबंध म+-
(क) एचआईवी पािजAटव IयिJय के "ितिनिधय सिहत सभी पणधारक ;
(ख) एचवाईवी "भािवत IयिJय और संरित Eकए गए IयिJय ;
(ग) MवाMQय देखरे ख "दाता;
(घ) िशा, MवाMQय पAरचया/ सेवाएं उपलHध कर रही MथापनाN, िवशेषR और एचआईवी तथा ए9स के े म+
काय/ रहे संगठन , िनयोजक , 7ेड यूिनयन एवं अ0य सुसंगत पणधारक के साथ परामश/ करे गा।
4. क+5ीय सरकार के अधीन समुिचत "ािधकारी राजप म+ MथापनाN के िलए मॉडल एचआईवी और ए9स
नीित अिधसूिचत करे गा।
5. क+5ीय सरकार के अधीन समुिचत "ािधकारी िनयम 3 और 4 के अनुसार MथापनाN के िलए समय-समय
पर मॉडल एचआईवी और ए9स नीित क$ पुन वलोकन करे गा तथा उसे अSतन करे गा।
6. (1) MवाMQय देखरे ख सेवाN के उपबंध का अनुपालन कर रही Mथापन तथा एचआईवी के Iयावसाियक
खुलासे क$ अTयिधक जोिखम वाली दूसरी "Tयेक Mथापन म+ मॉडल एचआईवी और ए9स नीित लागू करने
से काय/ करने म+ तथा अिधिनयम के उपबंध के अनुUप परीण, उपचार और अनुसंधान के िलए संसिू चत
सहमित के िलए सुरित वातावरण उपलHध होगा।
(2) Eकसी Mथापना पर लागू मॉडल एचआईवी और ए9स नीित, िजसम+ 100 अथवा उससे अिधक IयिJ सिVमिलत
ह , चाहे कोई कम/चारी अथवा अिधकारी या िनदेशक अथवा 0यासी या "बंधक है, जैसा भी मामला हो, Dारा
अिधिनयम के उपबंध और इन िनयम के अनुUप एक िशकायत समाधान तं क$ IयवMथा क$ जाएगी।
पर0तु MवाMQय देखरे ख Mथापन के मामले म+ Mथान पर और इस उप-िनयम के उपबंध इस "कार लागू ह गे जैसे Eक
“सौ अथवा अिधक” शHद के Mथान पर “बीस अथवा अिधक” शHद को रख Eदया गया हो; और
295
¹Hkkx IIµ[k.M 3(i)º Hkkjr dk jkti=k % vlk/kj.k 3
7. (1) के05ीय सरकार के अधीन समुिचत "ािधकारी Dारा समय-समय पर लागू संशोिधत और अSतन मॉडल
एचआईवी और ए9स नीित को इसक$ अिधसूचना होने पर "Tयेक Mथापना Dारा अंग ीकार Eकया जाएगा।
(2) Mथापन म+ काय/रत सभी IयिJय को एचआईवी और ए9स नीित के िवषय क$ जानकारी Mथापना के "भारी
IयिJ अथवा उTतरदायी IयिJ Dारा दी जाएगी।
(3) "भारी IयिJ अथवा Mथापन हेतु उTतरदायी IयिJ एचआईवी और ए9स नीित के पाठ को अंWेजी म+ अथवा
काय/रत अिधकांश IयिJय Dारा समझी जाने वाली भाषा म+ अथवा "वेश Dार पर अथवा उसके समीप, जहां से
काय/रत अिधकांश IयिJ आते-जाते हY, पर इस उZे[य हेतु लगाए गए िवशेष बोड\ पर "मुखता के साथ "द शत
करे गा।
(4) Mथापन एचआईवी और ए9स नीित को समझने और इसके E]या0वयन के िलए काय/ करने वाले IयिJय के
िलए वा षक "िशण स का आयोजन करे गी।
8. (1) िनयम 7 के उप-िनयम (3) म+ िविनLद6ट सूचना उस रीित म+ कथन करे गा, िजसम+ एचआईवी और ए9स
नीित क$ "ितयां "ात क$ जाएंगी और Mथापन म+ काय/रत अथवा सेवाN हेत ु आने वाले IयिJ ऐसी नीित क$
िन:शुक "ितिलिप पाने के हकदार ह गे।
(2) Mथापन क$ एचआईवी और ए9स नीित क$ "ितयां उनके Dारा पिHलक डोमेन म+ उपलHध कराई जाएंगी,
िजनके िलए नीित उपलHध कराई गई है, िजसम+ उनक$ वेबसाइट, यEद कोई हो, और नाममा मूय पर हाड/कॉपी
उपलHध कराना सिVमिलत है।
(3) "Tयेक रा;य का समुिचत "ािधकारी सभी शैिणक MथापनाN के "मुख को एचआईवी तथा ए9स नीित क$
"ित उपलHध कराएंगे, जो इन Mथापन म+ "वेश पाने वाले िवSा थय को अथवा उनके माता-िपता अथवा
अिभभावक को इन नीितय क$ एक "ित िन:शुक उपलHध कराएगा।
अ याय – III
थापना.
थापना. हेतु िशकायत िनवारण णाली
9. (1) सौ या इससे अिधक कम/चाAरय वाले "Tयेक Mथापन, िजसम+ कम/चारी अथवा अिधकारी अथवा िनदेशक
अथवा 0यासी अथवा "बंधक, जैसा भी मामला हो, इस अिधिनयम के लागू होने के 180 Eदन के अंदर Eकसी वAर6ठ
पंिJ के IयिJ को, Dारा जैसा वह उिचत समझे, िशकायत अिधकारी के Uप म+ िनयुaत Eकया जाएगा, जो इन
िनयम के अनुपालन म+ Mथापना म+ अिधिनयम के उपबंध के उलंघन क$ िशकायत का समाधान करे गा।
पर0तु सौ या इससे अिधक कम/चाAरय वाले Mथापन क$ "Tयेक शाखा, िजसम+ कम/चारी अथवा अिधकारी अथवा
िनदेशक अथवा 0यासी अथवा "बंधक, जैसा भी मामला हो, इस अिधिनयम के लागू होने के 180 Eदन के अंदर
Eकसी वAर6ठ पंिJ के IयिJ को, Dारा जैसा वह उिचत समझे, िशकायत अिधकारी के Uप म+ िनयुaत Eकया जाएगा,
जो इन िनयम के अनुपालन म+ Mथापन म+ अिधिनयम के उपबंध के उलंघन क$ िशकायत का समाधान करे गा।
पर0तु आगे यह Eक MवाM Qय देखरे ख Mथापन के मामले म+, इस िनयम के उपबंध इस तरह से लागू ह गे जैसे
“सौ अथवा इससे अिधक” शHद के Mथान पर “बीस अथवा इससे अिधक” शHद को रखा गया है।
(2) Mथापन Dारा िनयुिJ के 30 Eदन के अंदर, रोकथाम क$ सूचना, देखरे ख, सहयोग तथा एचआईवी संबंिधत
उपचार, मानव लYिगकता, यौन अिभमुखता तथा Cलग िनधा/रण, नशीले पदाथ/ का "योग, सेaस वक/, एचआईवी
संभािवत IयिJय , कलंक तथा भेदभाव, एचआईवी पीि़डत के साथ घिन6ठता बनाने के िसfांत, जोिखम कम
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4 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)]
करने के उपाय आEद सिहत इस अिधिनयम के उपबंध पर िशकायत अिधकाAरय को "िशण Eदया जाएगा।
"िशण के दौरान िशकायत अिधकारी को संरित IयिJय तथा एचआईवी संभािवत IयिJय सिहत िवशेषR
क$ सहायता "दान क$ जाएगी।
10. (1) कोई भी IयिJ Mथापन म+ अिधिनयम के किथत उलंघन क$ जानकारी िमलने के उपरांत तीन माह के
भीतर िशकायत अिधकारी को िशकायत कर सकता है:
पर0तु िशकायत अिधकारी, िलिखत म+ कारण अिभलेख करते gए और तीन मास के िलए िशकायत करने क$
समय-सीमा बढ़ा सकता है, यEद वह संतु6ट है Eक िशकायतकता/ कुछ पAरिMथितय के कारण िनधा/Aरत समय म+
िशकायत नहK कर सका।
(2) "Tयेक िशकायत, इन िनयम के साथ उपबf "Uप म+, िलिखत म+, क$ जाएगी:
पर0तु यह Eक जहां िलिखत म+ िशकायत नहK क$ जा सकती है, िशकायत अिधकारी, िशकायतकता/ को सभी
"कार क$ युिJयुaत सहायता "दान करे गा िजससे Eक िशकायत िलिखत म+ क$ जा सके।
(3) िशकायत अिधकारी IयिJगत Uप म+, अथवा डाक Dारा अथवा फोन से अथवा इलैa7ॉिनक Uप म+ िशकायत
"ात कर सकता है:
पर0तु यह Eक Mथापन िशकायत अिधकारी िनयुaत Eकए जाने क$ 30 Eदन क$ अविध के भीतर सम पत
वेबसाइट, वेबपेज के माjयम से इलैa7ॉिनक Uप म+ िशकायत क$ "ािk अथवा िशकायत अिधकारी को िशकायत+
भेजने के िलए सरकारी ई-मेल का पते "दान करने क$ रीित तय करे गी।
(4) िशकायत अिधकारी, िशकायत क$ "ािk पर, िशकायतकता/ को पावती देगा और मा उस उZे[य के िलए रखे
गए रिजMटर म+ िशकायत दज/ करे गा।
(5) रिजMटर म+ िशकायत क$ "ािk का समय और क$ गई कार/ वाई क$ रिजMटर म+ "िवि6ट क$ जाएगी।
(6) रिजMटर म+ "Tयेक िशकायत को ]िमक संBया दी जाएगी।
(7) िशकायत अिधकारी अिधिनयम क$ अधीन क$ गई िशकायत पर उZे[यपरक और Mवतं रीित से काय/ करे गा।
(8) िशकायत अिधकारी िशकायत पर तTपरता से और Eकसी भी िMथित म+ सात काय/ Eदवस के भीतर िनण/य लेगा:
पर0तु यह Eक आपात मामले म+ अथवा MवाMQय देखरे ख के Mथापन के मामले म+ जहां यह उपबंध म+ भेदभाव
या Eफर MवाM Qय देखरे ख सेवाN के पgँच अथवा सवा/भौिमक सावधािनय के उपबंध से संबंिधत िशकायत है,
िशकायत अिधकारी उसी Eदन, िजस Eदन उसे िशकायत "ात होती है, िनण/य लेगा।
11. (1) िशकायत अिधकारी यEद संतु6ट है Eक अिधिनयम का उलंघन gआ है जैसा Eक िशकायत म+ आरोप लगाया
गया है-
(क) "थमत:, Mथापना को उलंघन सुधार के उपाए करने का िनदेश देगा;
(ख) दूसरे , िजस IयिJ ने उलंघन Eकया है उसे परामश/ देगा और ऐसे IयिJ को एचआईवी और ए9स,
अिधिनयम के उपबंध और िनयम तथा Eदशा-िनदmश , िवशेषकर कलंक और भेदभाव से संबंिधत "िशण
Eदया जाएगा जो एक सताह क$ अविध का होगा और सामािजक सेवा हेतु िनधा/Aरत अविध तय क$
जाएगी िजसम+ एचआईवी और एaवायड/ इVयून ोडेEफिसएंसी वायरस, संरित IयिJ नेटवक/ हेतु काय/रत
297
¹Hkkx IIµ[k.M 3(i)º Hkkjr dk jkti=k % vlk/kj.k 5
गैर-सरकारी संगठन के साथ काय/ करना सिVमिलत होगा, अथवा रा;य सरकार के अधीन समुिचत
"ािधकारी Dारा िनगरानी रखी जाएगी और हो सकता है Eक उलंघनकता/ का पय/वेण करने वाले को भी
ऐसा "िशण लेना हो।
(2) उसी IयिJ Dारा पुन:अिधिनयम का उलंघ न करने पर िशकायत अिधकारी, Mथापन को िविध अनुसार उसके
िवnf अनुशांसिनक कार/ वाई करने क$ िसफाAरश कर सकता है।
(3) िशकायत अिधकारी, िशकायत के संबध
ं म+ क$ गई कार/ वाई क$ िशकायतकता/ को जानकारी देगा और यEद
िशकायतकता/ क$ गई कार/ वाई से असंतु6ट हो तो उसको अिधकार होगा Eक वह ओVब9समैन के पास जाए अथवा
कोई अ0य उपयुaत िविध कार/ वाई करे ।
(4) िशकायत अिधकारी, िशकायत पर िनण/य के उपरांत िनण/य क$ तारीख से 10 Eदन क$ अविध म+ Mथापना को
तथा िशकायत से संबf पकार को िनण/य के संबंध म+ िलिखत म+ कारण सूिचत करे गा।
12. (1) िशकायत अिधकारी सुिनि[चत करे गा Eक िशकायत, इसक$ "कार संBया और क$ गई कार/ वाई क$ Aरपोट/
के05ीय सरकार के अधीन उपयुaत "ािधकारी को अिधिनयम क$ धारा 11 और इसके अधीन िनयम 13 के अंतग/त,
हर छ: माह म+ दी जाए।
(2) िशकायत अिधकारी इस अिधिनयम के िनयम 13 और धारा 11 के उपबंध के अjययधीन, यह सुिनिoत करे गा
Eक िशकायत, िशकायत क$ "कृित, िशकायत क$ संBया और क$ गई कार/ वाई वा षक आधार पर संMथान क$ वा षक
Aरपोट/ म+ अथवा संMथान क$ वेब साइट पर "कािशत हो।
13. (1) िशकायत अिधकारी, संरित IयिJ जो Eकसी िशकायत का िहMसा है, के अनुरोध पर िनVनिलिखत रीित
से उaत संरित IयिJ क$ पहचान के संरण को सुिनिoत करे गा, अथा/त्:
(क) िशकायत अिधकारी ऐसे दMतावेज क$ एक "ित फाइल करे गा िजसम+ ऐसे संरित IयिJ का नाम,
पहचान और पहचान योqय Hयौरा Eदया गया हो, और इसे बंद िलफाफे म+ िशकायत अिधकारी क$ सुरित
अिभरा म+ रखा जाएगा;
(ख) उसके सम आई िशकायत म+ संिलत संरित IयिJ को छr नाम "दान करे गा;
(ग) िशकायत अिधकारी के सम आई िशकायत म+ संिलत संरित IयिJ क$ पहचान और उसके पहचान
योqय Hयौर को िनयम 10 के उप-िनयम 4 के तहत िशकायत के रिजMटर सिहत िशकायत के संबंध म+
िशकायत अिधकारी और संMथान Dारा सृिजत सभी दMतावेज और Aरकॉड\ म+ छr नाम से "द शत Eकया
जाएगा;
(घ) िशकायत अिधकारी के सम आई िशकायत म+ संिलत संरित IयिJ क$ पहचान और पहचान योq य
Hयौर को Eकसी भी IयिJ या सहायक और M टाफ सिहत उनके "ितिनिधय Dारा "कट नहK Eकया
जाएगा।
(2) कोई भी IयिJ िशकायत अिधकारी के सम आई िशकायत के संबंध म+ कोई भी मामला तब तक मुE5त या
"कािशत नहK कराएगा जब तक Eक िशकायत म+ संिलत संरित IयिJय क$ पहचान सुरित न क$ गई हो।
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6 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)]
(3) िशकायत अिधकारी इस अिधिनयम क$ धारा 11 के उपबंध के अनुसार आंकड़ के संरण के उपाय का
अनुपालन करे गा।
14. "Tयेक Mथापन िजसे िशकायत अिधकारी िनयुaत करने क$ आव[य कता है वह-
(क) अपने कम/चाAरय को इस अिधिनयम के उपबंध के "ित संवेदनशील बनाने के िलए वा षक आधार पर
काय/शालाएं और जागUकता काय/कम तथा िशकायत अिधकारी के िलए अिभमुखी काय/]म काय/]म संचािलत
करे गा;
(ख) िशकायत पर िनण/य लेने के िलए िशकायत अिधकारी को आव[यक सुिवधाएं "दान करे गा; और
(ग) ऐसी सूचना उपलHध कराएगा जो िशकायत अिधकारी Dारा िनण/य लेने के िलए अपेित है।
15. के05ीय सरकार के अधीन समुिचत "ािधकारी-
(क) अिधिनयम के उपबंध िजसम+ अिधकार के समाधान से संबिं धत उपबंध भी शािमल हY, के "ित सामा0 य
Uप से आम जनता और िवशेष तौर पर संरित IयिJय , िसिवल "ािधकाAरय और MवाMQय देखभाल क मय
क$ समझ को बढ़ाने के िलए सूचना िशा, संचार और "िशण सामWी को तैयार करे गा और इसका "सार
करे गा;
(ख) ऐसे अिभमुखी और "िशण काय/]म को तैयार करे गा और इनका "सार करे गा िजनका संMथान Dारा
िनयम 9 के उपिनयम 2 के तहत िशकायत अिधकाAरय के "िशण म+ और इस अिधिनयम तथा िनयम 11 के
उपिनयम (1) के खuड (ख) के उपबंध का उलंघन करते पाए गए IयिJय के परामश/ म+ "योग Eकया जा
सकता है;
(ग) उ>च भार वाले िजल म+ संMथान के िलए रा;य सरकार के अधीन ऐसे िजल म+ समुिचत "ािधकारी और
उनके िशकायत अिधकाAरय के सम0वय म+ उaत अिधिनयम और िनयम के E]या0वयन पर "िशण "दान
करे गा और आगे ऐसे "िशण वा षक आधार पर "दान करे गा;
(घ) उ>च भार वाले िजल म+ िसिवल "ािधकाAरय और मा0यता "ात सामािजक MवाMQय क मय (आशा) और
आंगनवाड़ी क मय सिहत MवाMQय देखभाल क मय के िलए रा;य सरकार के अधीन ऐसे िजल म+ उपयुaत
"ािधकारी के सम0वय म+ उaत अिधिनयम और िनयम के E]या0वयन पर "िशण "दान करे गा और आगे ऐसे
"िशण वा षक आधार पर "दान करे गा।
16. इन िनयम म+ अंत व6ट कुछ भी अ0य उपचार के "ित Eकसी IयिJ के अिधकार को "ितिसf, सीिमत या
अ0यथा "ितबंिधत करता हो पर0तु इस अिधिनयम या इस अिधिनयम के उपबंध के उलंघन से िनपटने के
िलए कुछ समय के िलए बनाए गए Eकसी अ0य कानून के तहत उपबंिधत न Eकया गया हो।
299
¹Hkkx IIµ[k.M 3(i)º Hkkjr dk jkti=k % vlk/kj.k 7
2प
िनयम 10 के अधीन िशकायत अिधकारी को िशकायत करने के िलए 2प
1. घटना क$ तारीख ..............................................
2. घटना का Mथान ......................................
3. घटना का िववरण ......................................
4. घटना के िलए उTतरदायी IयिJ या संMथान......................................
िशकायतकता/ के हMतार या अंगूठा िनशान*
नाम: तारीख:
मोबाइल नं. या ईमेल या फैaस या पता :
के वल कायालय योग हेतु :
िशकायत संBया: ................
*जहां िशकायत मौिखक Uप से या टेलीफोन के माjयम से "ात होती है और िशकायत अिधकारी Dारा िलख
ली गई है वहां िशकायत अिधकारी "प पर तारीख सिहत हMतार करे गा।
[फा. सं. नाको (पी ए4ड सी)]
टी-11020/50/1999-
आलोक स7सेना, संयु7त सिचव
300
8 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)]
MINISTRY OF HEALTH AND FAMILY WELFARE
(National AIDS Control Organisation)
NOTIFICATION
New Delhi, the 17th September, 2018
G.S.R. 888I.—In exercise of the powers conferred by section 47 of the Human Immunodeficiency Virus and
Acquired Immune Deficiency Syndrome (Prevention And Control) Act, 2017 (16 of 2017), the Central Government
hereby makes the following rules, namely:—
Chapter – I
Preliminary
1. Short title and commencement.- (1) These rules may be called the Human Immunodeficiency Virus and Acquired
Immune Deficiency Syndrome (Prevention And Control) Rules, 2018.
(2) They shall come into force on the date of their publication in the Official Gazette.
2. Definitions.-
(1) In these rules, unless the context otherwise requires,—
(a) "Act" means the Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome (Prevention
And Control) Act, 2017 (16 of 2017);
(b) "appropriate authority" means;
(i) the National AIDS Control Organisation in case of Central Government; and
(ii) the State AIDS Control Society in case of State Government;
(c) “high burden district” means a district which has-
(i) more than one percent prevalence among antenatal care in Sentinel Surveillance; or
(ii) more than five percent prevalence among high-risk population in Sentinel Surveillance; or
(iii) HIV positivity of more than national average among general clients in Integrated Counselling and Testing
Centre notified by the appropriate authority under the Central Government from time to time;
(2) Words and expressions used herein and not defined in these rules but defined in the Act shall have the meanings
assigned to them in the Act.
Chapter – II
Manner of Notifying HIV and AIDS Policy for Establishments
3. The appropriate authority under the Central Government shall, before notifying a model HIV and AIDS policy for
establishments consult -
(a) all stakeholders including representatives of HIV -positive persons;
(b) HIV -affected persons and protected persons;
(c) healthcare providers;
(d) establishments engaged in providing education, healthcare services, experts and organizations working in the field of
HIV and AIDS, employers, trade unions, and other relevant stakeholders on such policy.
301
¹Hkkx IIµ[k.M 3(i)º Hkkjr dk jkti=k % vlk/kj.k 9
4. The appropriate authority under the Central Government shall notify a model HIV and AIDS policy for
establishments in the Official Gazette.
5. The appropriate authority under the Central Government shall review and update from time to time the model HIV
and AIDS policy for establishments in accordance with rules 3 and 4.
6. (1) The model HIV and AIDS policy applicable to an establishment, engaged in the provision of healthcare services
and every other establishment where there is a significant risk of occupational exposure to HIV shall provide for a
safe working environment and for informed consent for testing, treatment and research in accordance with the
provisions of the Act.
(2) The model HIV and AIDS Policy applicable to an establishment consisting of one hundred or more persons, whether
as an employee or officer or member or director or trustee or manager, as the case may be, shall provide for a grievance
redressal mechanism in accordance with the provisions of the Act and these rules:
Provided that in the case of healthcare establishments, the provisions of this sub-rule shall have the effect as if
for the words “one hundred or more”, the words “twenty or more” had been substituted.
7. (1) The model HIV and AIDS policy as may be applicable and as may be amended and updated from time to time by
the appropriate authority under the Central Government shall be adopted by every establishment upon its notification.
(2) The text of the HIV and AIDS policy shall be communicated to all persons working in the establishment by the
person in charge of or responsible to the establishment.
(3) The person in charge or responsible for the establishment shall prominently post the text of the HIV and AIDS policy
as a notice in English and in the language understood by majority of persons working in or accessing such establishment
on special boards to be maintained for such purpose, at or near the entrance through which the majority of the persons
working in or accessing the services of the establishment enter such establishment.
(4) The establishment shall conduct annual training sessions for persons working in such establishment in understanding
and implementing the HIV and AIDS policy.
8. (1) The notice referred to in sub- rule (3) of rule 7 shall state the manner in which copies of the HIV and AIDS policy
shall be obtained and persons working in or accessing the services of the establishment shall be entitled to a copy of such
policy free of charge.
(2) The copies of the HIV and AIDS policy of establishments shall be made available in the public domain by those to
whom the policy has been made available including on their website if any and in case of hard copies for a nominal price.
(3) The appropriate authority of every State shall make available the copy of HIV and AIDS policy to heads of all
educational establishments who shall further provide a copy of the policy to the learners and their parents or guardians
free of charge immediately upon admission of the learner to the establishment.
Chapter – III
Grievance Redressal Mechanism for Establishments
9. (1) Every establishment having one hundred or more persons, whether as an employee or officer or member or director
or trustee or manager, as the case may be, shall within one hundred and eighty days of the commencement of the Act,
designate such person of senior rank, as it deems fit, as the Complaints Officer who shall dispose of complaints of
violations of the provisions of the Act in the establishment, in accordance with these rules:
Provided that every branch of an establishment having one hundred or more persons, whether as an employee or
officer or member or director or trustee or manager, as the case may be, shall within one hundred and eighty days of the
commencement of the Act, designate such person of senior rank, as it deems fit, as an additional Complaints Officer for
such branch who shall dispose of complaints of violations of the provisions of the Act in the establishment, in accordance
with these rules:
302
10 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)]
Provided further that in the case of healthcare establishments, the provisions of this rule shall have the effect as
if for the words “one hundred or more”, the words “twenty or more” had been substituted.
(2) The establishment shall within thirty days of appointment, provide training to the Complaints Officer on the
provisions of the Act including information on prevention, care, support and treatment related to HIV, human sexuality,
sexual orientation and gender identity, drug use, sex work, people vulnerable to HIV, stigma and discrimination,
principles of the greater involvement of people living with HIV, strategies of risk reduction, etc. During the training
assistance of experts including protected persons and persons vulnerable to HIV may be provided to the Complaints
Officer.
10. (1) Any person may make a complaint to the Complaints Officer, within three months from the date that the person
making the complaint became aware of the alleged violation of the Act in the establishment:
Provided that the Complaints Officer may, for reasons to be recorded in writing, extend the time limit to make
the complaint by a further period of three months, if he is satisfied that circumstances prevented the complainant from
making the complaint within the stipulated period.
(2) Every complaint shall be made to the Complaints Officer in writing in the Form set annexed to these rules:
Provided that where a complaint cannot be made in writing the Complaints Officer shall render all reasonable
assistance to the complainant to reduce the complaint in writing.
(3) The Complaints Officer may receive complaint made in person, or by post or telephonically or in electronic form:
Provided that the establishment shall within a period of thirty days of appointing the Complaints Officer,
establish a method for receipt of complaints in electronic form either through dedicated website, webpage or by
providing an official email address for the submission of complaints to the Complaints Officer.
(4) The Complaints Officer shall, on receipt of a complaint, provide an acknowledgment to the complainant and record
the Complaint in a register to be kept solely for that purpose.
(5) The time of the complaint and the action taken on the complaint shall be entered in a register.
(6) Every complaint shall be numbered sequentially in the register.
(7) The Complaints Officer shall act in an objective and independent manner while deciding complaints made under the
Act.
(8) The Complaints Officer shall decide a complaint promptly and in any case within seven working days:
Provided that in case of emergency or in the case of healthcare establishment where the complaint relates to
discrimination in the provision of, or access to health care services or provision of universal precautions, the Complaints
Officer shall decide the complaint on the same day on which he receives the complaint.
11. (1) The Complaints Officer, if satisfied that a violation of the Act has taken place as alleged in the complaint, shall-
(a) firstly, direct the establishment to take measures to rectify the violation;
(b) secondly, counsel the person who has committed the violation and require such person to undergo training in
relation to HIV and AIDS, provisions of the Act, rules and guidelines, particularly in relation stigma and
discrimination, for a period amounting to one week, and a fixed period of social service, which shall include
working with a non-governmental organisation working on HIV and Acquired Immunodeficiency Virus, a
protected person’s network, or the appropriate authority under the State Government that shall be monitored,
and may also require that the person supervising the violator undergo such training.
(2) Upon subsequent violation of the Act by the same person, the Complaints Officer may recommend the establishment
to take disciplinary action in accordance with the law.
(3) The Complaints Officer shall inform the complainant of the action taken in relation to the complaint and of the
complainant's right to approach the Ombudsman or to any other appropriate legal recourse in case the complainant is
dissatisfied with the action taken.
(4) The Complaints Officer shall, on deciding a complaint, provide brief reasons in writing for the decision to the
establishment and the concerned parties to the complaint within a period of ten days from the date of decision.
303
¹Hkkx IIµ[k.M 3(i)º Hkkjr dk jkti=k % vlk/kj.k 11
12. (1) The Complaints Officer shall ensure that the complaint, its nature and number and the action taken are reported to
the appropriate authority under the Central Government every six months subject to the provisions of section 11 of the
Act and rule 13 of these rules.
(2) The Complaints Officer shall ensure that the complaint, the nature of the complaint, the number of the complaint and
the action taken are published on an annual basis or the establishment publishes annual report or on the website of the
establishment or in such annual report , subject to the provisions of rule 13 and section 11 of the Act.
13. (1) The Complaints Officer shall, if requested by a protected person who is part of any complaint, ensure the
protection of the identity of the protected person in the following manner, namely:-
(a) the Complaints Officer shall file one copy of the document bearing the full name, identity and identifying
details of such protected person which shall be kept in a sealed cover and in safe custody with the Complaints
Officer;
(b) the Complaints Officer shall provide pseudonyms to protected person involved in complaints before him;
(c) the identity of protected person involved in complaints before the Complaints Officer and their identifying
details shall be displayed in pseudonym in all documentation and records generated by the Complaints Officer and
the establishment in relation to the complaints including in the register of complaints under sub-rule (4) of rule 10;
(d) the identity and identifying details of the protected person involved in a complaint before the Complaints
Officer shall not be revealed by any person or their representatives including assistants and staff.
(2) No person shall print or publish any matter in relation to a complaint before a Complaint Officer unless the identity of
the protected persons in the complaint is protected.
(3) The Complaints Officer shall comply with the data protection measures in accordance with the provisions of section
11 of the Act.
14. Every establishment which requires to appoint a Complaints Officer shall-
(a) on an annual basis, organise workshops and awareness programmes for sensitising its employees with the provisions
of the Act and orientation programmes for the Complaints Officer;
(b) provide necessary facilities for the Complaints Officer for deciding the complaint; and
(c) make available such information as the Complaints Officer may require in deciding the complaint.
15. The appropriate authority under the Central Government shall-
(a) develop and disseminate information, education, communication and training materials to advance the understanding
of the public generally and in particular of protected persons, civil authorities and healthcare workers of the provisions of
the Act including relating to redressal of rights;
(b) formulate and disseminate orientation and training programmes that may be used by establishments in the training of
Complaints Officers under sub-rule (2) of rule 9 and in the counselling of persons found to have violated the provisions
of the Act and clause (b) of sub-rule (1) of rule 11;
(c) provide training for the establishments in high burden districts, in coordination with the appropriate authority under
the State Government and their Complaints officers in such districts on the implementation of the Act and the rules and
shall further provide such trainings on an annual basis;
(d) provide training for civil authorities, and healthcare workers including Accredited Social Health Activists and
Anganwadi Workers in high burden districts, in coordination with the appropriate authority under the State Government
in such districts on the implementation of the Act and the rules and shall further provide such trainings on an annual
basis.
16. Nothing contained in these rules prohibits, limits or otherwise restricts the right of a person to other remedies
provided under the Act or any other law for the time being in force to address violations of the provisions of the Act.
304
12 THE GAZETTE OF INDIA : EXTRAORDINARY [PART II—SEC. 3(i)]
FORM
Form for making Complaint to Complaints Officer under rule 10
1. Date of Incident ____
2. Place of Incident ____
3. Description of incident _______
4. Person or institution responsible for the incident _____
Signature or Thumb Impression of Complainant*
Name: Date:
Mobile No. or email or Fax or Address:
For Official Use only:
Complaint Number: ____
*Where the complaint is received orally or telephonically and reduced to writing by the Complaints Officer, the
Complaints Officer shall sign and date the Form.
[F. No. T-11020/50/1999-NACO (P&C)]
ALOK SAXENA, Jt. Secy.
Uploaded by Dte. of Printing at Government of India Press, Ring Road, Mayapuri, New Delhi-110064
and Published by the Controller of Publications, Delhi-110054.
305
306
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