Report: IDENTIFYING THE PROBLEM

Situational Analysis                                       

Since its inception in 2001, the ICTC’s in Mumbai have been consistently delivering quality services across its vast network. People were visiting the centers, getting counseled, tested and referred for further treatment. However, even a decade after its existence, certain problem areas were identified by MDACS.

• Lack of Visual Identification for ICTC: Even within a government hospital, a client could not identify the ICTC. The ICTC had no visual image that the user/non-user could relate to.

• The brand ICTC is almost unknown: An ICTC was an HIV testing center that was a unit of the hospital and that was the end of their (user & non-user) understanding of this service.

• Fear of Testing: There is a fear associated of being stigmatized / discriminated against if one uses the ICTC

Research Strategy

With the identified issues at hand, MDACS planned to develop a comprehensive, evidence based communication strategy to increase awareness about the HIV counseling and testing facilities available in the city; and motivate andmove appropriate population to get counseled and tested in these centers.

As a prerequisite to the strategy development, it was proposed to conduct a  formative study with quantitative and qualitative research methods in order to confirm the above stated premise of the problem areas and also establish baseline indicators on the city residents’ knowledge, attitudes and practices about HIV testing and ICTC.

Research Objectives

• Gauge awareness of, attitude towards and utilization of ICTC and HIV testing
• Understand the motivators and barriers in accessing ICTC services
• Client’s perception about ICTC services
• Gain insights into the media reach and media habits of the target populations so as to ensure maximization of the reach of the resultant communication campaign

Research Questions 

1. Knowledge about HIV testing & ICTC
• Sources of Information for HIV testing & ICTC
• Specific service related knowledge
• Reasons for visiting HIV testing center

2. HIV related knowledge, perceptions and practices
• Self-risk perception of HIV
• Community risk perception of HIV
• Actual HIV testing in last 6 months
• Place of HIV testing
• Reasons for getting tested for HIV
• Intent to get tested for HIV

3. Media Habits of different population groups
• Access to different forms of media
• Exposure to folk media
• Access to advertising media

Sampling – Primary Research

1. Quantitative Survey: A cross sectional study was conducted among 5 target population groups with a total sample size of 450 respondents.

2. Qualitative Research

        a. Rapid Exploration Exercise was conducted among 58 stakeholders to gauge the awareness of, attitude towards and utilization of ICTC and to explore issues in access to these centers.Stakeholders included Users of public health services (Users and Non-Users of ICTC),  Counselors and ICTC administrators from different types of ICTCs, Hospital staff and NGO staff and Potential friends of ICTC (Paanwala, Medical shop owners, Bar owners, Taxi, Rickshaw drivers etc.)
        b. Media habits of different groups of population: Titled ‘A day in the life of’ this research exercise of in-depth interviews was conducted with 15 participants from 5 target groups of population, to understand their media touch points and the type and flow of ICT that reaches them on a typical day.
        c. Structured in-depth interviews was conducted with 3 Communication Professionals from the Advertising Industry with an aim of understanding the most effective media channels to reach different groups of populations in the context of creating universal awareness of ICTC.

Secondary Research

A total of 23 health related communication campaigns were studied out which 14 were national campaigns while the remaining 9 were international.

Findings & implications

One of the key findings that emerged was that although there was a universal awareness of HIV testing; very few had actually heard about ICTC.

HIV testing is a mandatory health routine for pregnant women. Yet it is astounding to see that even though 84% of pregnant women had heard of HIV testing; only a miniscule 7% heard of ICTC, inferring a lack of recognition and identity of this service.

Free HIV testing is one of the key features of the ICTC as it offers a crucial service for all and removes the economical barrier for demand generation.

Universal awareness of free testing was found only among High Risk Group. Two in three respondents from bridge and pregnant population were aware of the free testing element. Only 59% of non-slum based general population feel that HIV testing is voluntary.

Low self-risk perception of HIV was observed across respondents.

Although most respondents feel that they have low/no chance of contracting HIV; nearly 1 in 5 (19%) non-slum based general population reported being at moderate risk of contracting the infection.

When asked if they could go and get tested for HIV in a nearest testing facility majority of respondents across all target groups said that they agreed/strongly agreed with this statement.

Almost half of slum and non-slum based general population felt that they could go to the nearest testing facility and get tested for HIV, highlighting the intent to adopt this behavior.

When respondents were asked they would be able to take the right decisions for future actions if they get tested, most agreed/strongly agreed with this statement implying that people are aware of the benefit of getting tested for HIV.

Respondents were asked about their community’s approval for getting tested for HIV. They were asked to estimate how much percentage of their community would approve of them getting tested.

Although high support for testing was observed from HRG community, 1 in 3 respondents from the remaining groups felt that less than 25% of their community members would approve of them getting tested for HIV. These figures highlight the low extent of social/community acceptance attached to the behavior of testing which further blocks the person from getting tested.

Respondents were asked if they had tested for HIV (ever tested/tested in last 6 months preceding the survey). High testing figures were observed among respondents from High risk group and pregnant women.

The lowest proportion of respondents who had ever been tested for HIV was from bridge and non-slum based general population. Testing behavior needs to be encouraged especially among risk groups.

Majority of respondents from all groups except non-slum based general population got tested in a government facility.

Even though ICTC and government testing facility are the same, respondents were still confused about the co-existence of the two. This is evident in the divided responses between ICTC and government hospital.

Respondents have gone to the government hospital to get tested for HIV but are not aware that this facility is called the ICTC.

Respondents were asked about their intent to get tested for HIV in the next 6 months, on which almost 40% of HRG responded affirmatively.

Low intent to testing was observed among bridge, pregnant and non-slum based general population. However almost 1 in 3 respondents from slum based general population showed intent to get tested for HIV in the next 6 months.

Respondents who showed intent to get tested in the next 6 months were further asked about where they would get their HIV test done. Majority said that they would go to a government facility.

• 79% of HRG will go to ICTC
• 82% of Bridge population will go to Government hospital
• 77% of pregnant women will go to Government hospital
• 55% of Slum based general population will go to Government hospital
• 100% of Non-Slum based general population will go to Private lab

Except for HRG, respondents who want to go to the government facility are not aware that it is called the ICTC.

Top 2 reasons why people from the community might not get tested for HIV

Clearly more than 50% of the low risk groups feel that people from their community may not get tested because of the fear of being stigmatized.

Media Access & Exposure

• Access and exposure to television was high across all groups.
• In the case of newspapers however, low risk groups (pregnant and general population) had higher exposure.
• Majority of slum-based general population (35%) and bridge population (20%) confirmed to have watched ‘Nukad Naatak’ (street plays).

Top forms of advertising media that respondents’ came across while travelling

Proportion of respondents that came across print media on HIV testing

Qualitative Findings Revealed:

NONE OF THE USERS of ICTC except one from the HRG group knew what ICTC was and did not know the testing centre by the name of ICTC. It was known by the OPD no. For instance in one of the Hospital examined it was called ‘OPD no. ‘401’.

Clients would refer to the ICTC in the dispensary, by the name of the dispensary (‘XXX Dawakhaana’)

All USERS knew that HIV testing was free but did not know that they can walk in without doctor’s prescription. Awareness about ‘Voluntary testing’ is essential.

NONE OF THE NON-USERS around ICTC (even those sitting in the same hall or the next OPD very close to ICTC) knew about ICTC or where the HIV test is done.

There were no clear prominent signages highlighting the facility. Long form of ICTC was written in English or Marathi- but this did not make sense to the users& non-users.

OUT OF 14 STAFF of the hospitals (including nurses, attendants, security guards) only 2 had heard the name ICTC. Most did not know the full form.

They all knew about HIV testing and refer to the ICTC by the OPD No.They also guide clients by using the OPD No.

People do not know about the services- though the current ad says how one can get HIV and importance of testing, they don’t say that every BMC hospital next to your house offers free HIV testing - That line is missing from the communication.

Poster and map at the gate (all entrances) is required for easier access and Map with clear indication for direction. Also center/brand name should be in Marathi or Hindi. For referred patients who are illiterate so particular colour for identifying the OPD will help.

Report: INTEGRATED COUNSELLING & TESTING CENTRES – THE SERVICE

Introduction

Globally a total of 2.7 million people acquired HIV infection in 2010, including 390 000 among children less than 15 years. This current prevalence has come down from 3.1 million in 2001, contributing to the total number of 34 million people living with HIV in 2010.

Women constitute half (50%) the adults (15 years and older) living with HIV in 2010, according to UNAIDS estimates. That proportion has shifted very little in the past 15 years. The burden of HIV on women, however, varies considerably by region and is heaviest in sub-Saharan Africa.
Although the rate of HIV prevalence is substantially lower in Asia than in some other regions, the absolute size of the Asian population means it is the second largest grouping of people living with HIV. In South and South-East Asia, the estimated 270 000 new HIV infections in 2010 was 40% less than at the epidemic’s peak in 1996. In India, the country with the largest number of people living with HIV in the region, new HIV infections fell by 56%.

HIV/AIDS – Indian Scenario

• India witnessed the first case of HIV/ AIDS in the year of 1986 in Chennai (Tamil Nadu) among a female commercial sex worker – the core group of transmitters. This was almost a decade after its appearance in the globe.

• As of 2010, India is estimated to have 23.9 lakh people infected with HIV at an estimated adult HIV prevalence of 0.31%. Adult HIV prevalence among men is 0.36%, while among women; it is 0.25%. These figures highlight an alarming rise compared to 2009 estimate of 0.29%.

• HIV infection rates have seen a downfall since 2003, however the recent estimates of 2010 reveal a rise of almost 0.2 % which suggests increasing spread of the infection in low risk populations as well especially among women and youth.

• Nearly 87 percent of HIV infections are still occurring through heterosexual routes of transmission. While parent to child transmission accounts for 5.4 percent of HIV cases detected, injecting drug use (1.6%), Men who have Sex with Men (1.5%) and contaminated blood and blood products account for one percent.

National AIDS Control Organization - A Government of India Initiative 

The 1990s saw the government set up NACO (the National AIDS Control Organization) and subsequently the National AIDS Control Programme (NACP-I) to oversee the formulation of policies, prevention work and control programmes relating to HIV and AIDS.

NACP-I (1992 – 1999)

The objective of NACP-I was to control the spread of HIV infection.

• During this period a major expansion of infrastructure of blood banks was undertaken with the establishment of 685 blood banks and 40 blood component separations.
• Infrastructure for treatment of sexually transmitted diseases in district hospitals and medical colleges was created with the establishment of 504 STD clinics.
• HIV sentinel surveillance system was also initiated.
• NGOs were involved in the prevention interventions with the focus on awareness generation.

The programme led to capacity development at the state level with the creation of State AIDS Cells in the Directorate of Health Services in states and union territories.

NACP-II (1999-2006)

During NACP-II a number of new initiatives were undertaken and the programme expanded in new areas.

• Targeted Interventions were started through NGOs, with a focus on High Risk Groups (HRGs) viz. commercial sex workers (CSWs), men who have sex with men (MSM), injecting drug users (IDUs), and bridge populations (truckers and migrants). The package of services in these interventions includes Behaviour Change Communication, management of STDs and condom promotion.
• The School AIDS Education Programme was conceptualised to build up life skills of adolescents and address issues relating to growing up. All channels of communication were engaged to spread awareness about HIV/AIDS, promote safe behaviours and increase condom usage.
• VCTC‘s (Voluntary Counseling & Testing Centres) and PPTCT‘s (Prevention of Parent to Child Transmission) Programme was introduced to cater to general population and pregnant mothers respectively. Towards the end of NACP II, PPTCT centres were combined with VCTCs to form Integrated Counselling and Testing Centres (ICTCs). Provision of free Anti-Retroviral drugs to people living with AIDS was a crucial step in battling against this epidemic.
• Surveillance was upgraded, with reported AIDS cases being tracked as a source of additional information.

During this second phase of NACP the number of people living with HIV/AIDS went down to half from 5.3 million in 2003 to 2.5 million in 2006 (HSS 2006). By the end of NACP-II, HIV transmission through blood was reduced to less than two per cent (from eight per cent when surveillance first started in the late 1980s).

NACP-III (2008 – 2012)

Currently in its third phase, the overall goals of NACP-III is to halt and reverse the epidemic in India by integrating programmes for prevention, care, support and treatment. This will be achieved through a four-pronged strategy:

• Prevent infections through saturation of coverage of high-risk groups with targeted interventions (TIs) and scaled up interventions in the general population.
• Provide greater care, support and treatment to larger numbers of PLHA (People Living with HIV/AIDS).
• Strengthen the infrastructure, systems and human resources in prevention, care, support and treatment programmes at district, state and national levels.
• Strengthen the nationwide Strategic Information Management System.

The specific objective is to reduce the rate of incidence by 60 percent in the first year of the programme in high prevalence states to obtain the reversal of the epidemic, and by 40 percent in the vulnerable states to stabilize the epidemic.

Mumbai District AIDS Control Society

National AIDS Control Organisation provides leadership to HIV/AIDS Control Programme in India, implementing one National Plan within one monitoring system. State AIDS Prevention and Control Societies (SACS) implement NACO programme at state level.

The Mumbai Districts AIDS Control Society (MDACS) is the Mumbai arm of NACO. Established on 27th July 1998 by the Municipal Corporation of Greater Mumbai (MCGM) for control & prevention of HIV/AIDS in Mumbai, MDACS collaborates with various concerned stakeholders viz. General Health Sector, NGOs, CBOs, people living with HIV/AIDS, Corporate Houses and Media etc.

Detection of the HIV virus - Integrated Counseling and Testing Centers

Integrated HIV counselling and testing is a very important tool both in prevention & control as well as in the early diagnosis of an individual and subsequent care & support. It is a fact that very few people who are living with HIV/AIDS are aware about their HIV status. The only means of knowing one’s HIV status is to undergo a blood test.

The HIV counseling and testing have been implemented by MDACS in Mumbai through the “Integrated counseling and testing centers” (ICTCs) for more than a decade. These ICTCs have been reformed from the earlier Voluntary Counseling and Testing Centers (VCTCs) and facilities providing Prevention of Parent-to-Child Transmission of HIV (PPTCT) services. The ICTCs serve as the entry point for a range of interventions in HIV prevention, care and support.

There has been a continuous scale-up in the establishment of new ICTCs to meet the need of increasing counseling & testing in Mumbai from 21 centers in 2001 to 96 in 2011. The ICTCs have been established in almost all the Govt. and Municipal Health institutions. There are 70 Stand-alone ICTCs and 30 Public-private partnership ICTCs in Mumbai.

As of 2012, there are 100 ICTCs in Mumbai.

MDACS also operates 3 mobile ICTC vans in addition to the 100, that have been providing counseling & testing to hard-to-reach population. These vans are stationed at the Hot-spot areas of the Targeted Intervention projects and the slum areas where the NGOs motivate their clients and bring them to the Mobile Van ICTCs. Counseling and testing is provided to such clients and the clients are provided with the HIV report on the same day along with further necessary referral services.

The ICTC services are also made available for Jail inmates (Arthur Road Jail for male & Byculla Jail for female inmates).

With the scale-up, the number of general clients (excluding pregnant women) tested for HIV at the ICTCs has almost doubled from 99392 in 2005 to 230628 in 2010. HIV positivity among these clients has decreased from 13% in 2005 to 6.75% in 2010.  

ICTC Staff

Each ICTC has a team of skilled persons consisting of the manager (medical officer), counsellor and Lab Technician.