2

National AIDS Control Programme III

Revised Scheme for Link ART Centres

1. Background

The observations and results from a NACO study on “ Factors affecting Enrolment of PLHIV in ART

Centres” have revealed that distance from residence to ART Centres and geographical barriers and

economic consequences thereof, are the main constraints in accessing ART services and may affect

adherence to treatment. The ART services are presently being rolled out through ART centers which

are located mainly in Medical Colleges, Tertiary Hospitals and District Hospitals. As the treatment is

lifelong and drugs are provided once a month, the frequent visits lead to inconvenience, long travel

distance and cost to the patients and may lead to sub-optimal drug adherence and irregular treatment

leading to risk of early drug adherence. To make the treatment services more accessible to PLHIV, it

was decided to set up Link ART Centers located mainly at ICTC in the district /sub- district level

hospitals/CHCs nearer to the patient‟s residence and linked to a Nodal ART center within accessible

distance.

2. Rationale for Revision of Scope:

Initially, the main functions of LAC were monitoring of patients on ART, drug distribution to patients

on ART, treatment of minor OIs, identification and management of side-effects and reinforce

adherence on every visit. At present there are more than 500 functional LAC. It is proposed to

gradually scale up LAC to 1200 by 2015-16 (RCC Round 4 target) by 2015-16. As part of mid-term

review, an assessment of the LACs scheme was undertaken which revealed that after the roll out of

LAC, patient satisfaction has increased significantly and cost as well as time on travel to access ART

has decreased.

It has been observed that nearly 40% of persons detected HIV positives at ICTC are do not get linked

to Care , Support & Treatment Services. The reason for this could be that many persons are

asymptomatic at the time of detection and long distances to reach the ART centre even for registration

and basic investigations may compel them to postpone the visit to ART Centres. It has been observed

from on ART data that nearly 20% patients reach the ART Centres at a very late stage (CD4 count

<50) when the risk of mortality is nearly 3 times higher.

In view of the above facts, the scope and functions of Link ART Centre are being revised as per

details given hereunder.

3. Revised Objectives of Link ART Centres:

1. To integrate HIV Care Support & treatment services with the Primary / Secondary Health

Care system.

2. To build the capacity of the health care providers at the Primary Health Care Level for Care ,

Support and treatment services.

3. To increase the access of ART services to the PLHA.

4. To bridge the gap between ICTC ( Counseling & Testing services) and CST ( Care Support

& Treatment) services

5. To improve the ARV drug adherence of patients onART.

6. To reduce the travel cost and travel time of PLHA in accessing ART services.

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4. Revised Functons of LAC: The functions of LAC are being revised as indicated below:

4.1 Pre – ART management (The LAC which will perform Pre-ART management will be

designated as “LAC Plus”:

The patient detected HIV positive in the catchment area of the LAC would be referred by ICTCs to

nearest LAC/ ART Centres. Patient shall be enrolled at ART Centre but also have a choice to get

registered at the selected LAC for pre-ART care and baseline investigations. Sample for CD4 count

shall be collected at LAC itself and sent to nodal ART centre. Pre-ART follow up shall be done at

LAC & once the PLHIV becomes eligible for ART, he/she would be referred to nodal ART Centre.

4.2 Monitoring of PLHIV on ART :

LACs shall monitor the patients on ART in terms of OIs, Side Effects of drugs, Drug Adherence.

Referral to the ART center shall be required in case of major OI, serious side effect of drugs,

pregnancy etc. LAC shall also be responsible for patient follow up to maintain optimum drug

adherence, prevent and trace MIS and & LFU cases of both pre-ART & ART categories.

4.3 OI Treatment & prophylaxis :

LACs shall also identify & treat minor OIs. Depending upon facilities, the hospital may have

provision will be made for inpatient care for OIs.

4.4 HIV TB co infection :

All PLHIV will be screened for TB and all patients with symptoms of TB should be referred to the

nearest RNTCP unit for diagnosis and treatment of TB and to nodal ART centre for initiation of ART.

LAC will do line listing of HIV-TB co infected cases. Intensified case finding for TB should be

undertaken by LAC as per guidelines

4.5 Psycho-social Functions:

LAC staff shall provide psychological support, counseling on adherence, nutritional & positive

prevention to PLHIV accessing the Link ART center.

4.6 Tracing LFU & MIS ( Pre-ART & on ART):

Daily Due list of PLHIV on ART patients and CD4 due list for pre-ART PLHIV shall be maintained

by LAC. The Missed/ LFU cases will be traced by Staff Nurse & Counsellor through phone and

outreach. Referring ICTC and DLN will also be involved in tracing of Missed & LFU

Existing Functions Revised Functions

1. ARV Drug distribution

2. Monitoring of PLHIV on

ART

3. counseling on adherence,

nutritional & positive

prevention

4. Identification of side –

effects

5. Treatment of Minor OIs

1. Enrolment of PLHIV into HIV care and treatment (Pre-

ART Care)

2. Pre-ART management inc. basic investigations and sample

collection for CD4 count.

3. Follow up of pre-ART patients not eligible for ART.

4. Referral of eligible patients to Nodal ART Centre for ART

initiation.

5. Screening of HIV-TB co infection

6. Monitoring of PLHIV on ART

7. ARV Drug distribution

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8. Treatment of Minor OIs

9. Identification of side –effects

10. Counseling on adherence, nutritional & positive prevention

11. Tracing of LFU and MIS

LAC will not initiate ART in any patient

Functions of LAC

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Monitoring of

PLHA on ART

Screening of

HIV -TB

Coinfection

Enrollment of

PLHA in HIV

Care and basic

investigations

Pre-ART

Management (

only at LAC plus)

Treatment of OIs

Psycho–social

Support to PLHA

LAC

Number of days / week: The patients at LAC will be examined in the General OPD on all the

working days within the OPD timings.. Pre-ART registrations will be done on all days. The LAC will

follow the holidays same as their Hospital OPD.

5. Eligibility Criteria for Link ART Centre:

Link ART centers shall be established at district level in low prevalence districts and sub-

district/block level in moderate/ high prevalence districts, on the basis of one or more of the following

criteria:

- High sero-prevalence.

- Large no. of positive cases detected in ICTC ( > than 100 PLHA over last five years in the

catchment area )

- ART centers where patient load is high (>1500 PLHA on ART).

- long distance from patients residence to reach ART Centre ( >50 Km) and longer time taken

from public transport (>1 hour)

- The above criteria may be relaxed in hilly terrains, desert areas, tribal regions and other areas

with difficult accessibility

Sites for LAC for roll out of revised Scheme: The roll out of the revised scheme shall be initiated

at existing Link ART Centres with a patient load of more than 100 PLHIV on ART and will be

expanded in a phased manner after getting prior approval from NACO. The centres with more than

100 PLHIV will be provided additional staff (Nurse) and do pre-ART maangement also. These sites

will be designated as “LAC Plus”

6. Staff at the LAC:

The LAC will utilize the existing human resources of the original facility (ICTC.).

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Doctor - The institute (ICTC in hospital setting) should identify 2-3 Doctors (at least 2) in such a

way that the patients can be attended and examined on all working days. If this is not feasible ( eg

due to shortage of doctors etc) LAC should be functional at least on three days a week, but even if

patient comes on days other than the scheduled days, care should not be denied. The senior most

doctor amongst them (preferably a specialist physician) shall be the LAC In- charge and responsible

for day to day activities and reporting to the Nodal ART centre.

The Doctor identified should be preferably MD Medicine / Pediatrics / of any other specialty / MBBS

(in the order of preference) and should preferably be computer literate with working knowledge of

computer applications and usage of Internet and electronic mail (e-mail)

6.1 Responsilities of Link ART Centre In charge :

Overall responsibility of the functioning of the Link ART centre.

All administrative matters relating to the centre as per guidelines.

Ensure Pre-ART management and CD 4 testing of PLHA enrolled at LAC

Ensure adherence to the highest standards of quality.

Ensure that PLHAs are not discriminated in the hospital.

Review and monitor the functioning of the Link ART centre every week and ensure

submission of reports as required.

Ensure timely receipt of drugs from the Nodal ART centre by coordinating with NO/SMO of

the Nodal ART centre.

Coordinate and develop referral system and linkages with Nodal ART centre, NGOs, and

Positive Network Groups etc.

Supervise the administrative and medical functions of the Link ART center on a day to- day

basis and provide leadership to the staff to work as a cohesive team and deliver the services

effectively.

Complete and/or supervise the recording of information in the various recording and reporting

tools used by the Link ART center, including software for data recording, if and when

installed. Ensure that the records are updated on a daily basis and reports are sent to the Nodal

ART centre by the last day of every month.

Attend meetings at Nodal ART Centre/SACS as required from time to time. Coordinate with

DAPCU officers.

6.2 Doctor at LAC ( including LAC I/C) :

Monitor the patients enrolled at LAC for Pre-ART care.

Get the basic investigations & CD4 testing done, refer eligible PLHA for initiation of ART to

Nodal ART Centre, treat minor OIs.

For pre-ART patients, inform the SMO of the Nodal ART centre by e mail and telephone /

post whenever the patient is referred to the Nodal ART centre.

Monitor the patients on ART & identify the symptoms suggestive of OI, Side effect of ART /

OI medication, Pregnancy and ANC care, etc.

Inform the SMO of the Nodal ART centre whenever the patient is referred to the Nodal ART

centre by e mail and telephone / post and also if the patient does not return on the due date

after being referred to Nodal ART centre for six monthly investigations / for management of

OIs and Side effect of drugs.

Supervise the staff at the center, ensure that record keeping and reporting are carried out

properly and on time and see that all the guidelines for running and maintaining the Link

ART center are abided by.

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To facilitate linkages between other service providers.

Refer the cases to the Nodal ART center for further expert opinion/ intervention including

admission and inpatient care, if required

Ensure drug adherence and counsel the patient towards safe sex, condom usage, proper

nutrition and positive living.

Monitor the consumption and availability of ARVs, other medicines and to alert the Nodal

ART centre in case of impending shortage well in advance so as to enable adequate

replenishment without disruption of ART care and support to PLHA.

6.3. Nurse: the institute/ care centre should depute a nurse to assist the Doctor and the Counselor.

Computer literate nurses should be given preference for deputation in the LAC.

Assist LAC Incharge in administrative and clinical work.

Registration of PLHA in HIV Care and ensure their basic investigation.

Referral of all eligible PLHA to Nodal ART Centre for initiation of ART under

supervision of LAC incharge

Maintain all M& tools as per guidelines

Preparation of Monthly report under supervision of Medical officer

Communication with Nodal ART Centre on Link in & Link out patients.

Patient counseling on treatment, adherence, positive prevention and nutrition.

Drug dispensing in absence of pharmacist

Blood collection in absence of Lab Technician.

In view of the additional functions, it is proposed to provide staff to appoint Nurse at the sites with

more than 100 PLHA on ART. The staff Nurse should be B.Sc. Nursing preferably with knowledge of

computers. If not available, GNM may be appointed. The Remuneration shall be Rs 8000-12000/ per

month. The recruitment of the N

6.4 Counselor: The ICTC counselor shall bear the responsibility of ART counseling of PLHAs on

ART. S/he also should be computer literate with working knowledge of MS Word, MS Excel and

usage of Internet and electronic mail (e-mail)

The counselor plays a very important role as a member of the team and his/her responsibilities are

crucial for the success of the programme and improved outcomes of the patients. The counselor deals

with the following:

Pre- ART Counselling

Address issues related to ARV treatment i.e.adherence and side effects.

Explain the details of treatment and its importance, side effects of the ARV drugs

Adherence counseling and monitoring, identification of barriers to adherence and

suggestions (remedies) to remove these barriers.

Provide emotional, social, and psychological support to patients and/or direct the patient

to the concerned person or organization that can do so.

Repeatedly stress on positive living, prevention

Address issues of stigma and discrimination and rights of IV

6.5 . Pharmacist : The existing pharmacist or shall be the in charge of drug storage, dispensing and

drug record keeping. Computer literate staffs should be preferred.

The pharmacist / nurse (as per the availability) should perform the following tasks:

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Dispense the ARV drugs.

Maintain the drug stock register and drug dispensing register.

Ensure that the center has stock of ARV drugs for each patient which will last till the time of

next visit of the patients to Nodal ART centre.

Inform the LAC Incharge if there is a problem with the drug stock (e.g. Expiry, delay in

release of drugs from Nodal ART center, improper package / damage) of the patients.

Advise the patients and family about importance of adherence during each visit.

Advise the patients on possible drug toxicities and reporting of the same.

It will be preferred that pharmacist carries out these activities. In case the pharmacist is not

available, the institute should depute a nurse to carry out these duties.

6.6 Lab Technician: The existing Lab Technicain in the ICTC/institution shall be involved.

Sample collection for baseline investigations and CD4 testing.

Sample transport to CD4 lab facility in the ART centre will be the responsibility of ICTC

lab technician

7. Standard Operating Procedure at Link ART Centre for on ART Patients:

7.1 Referral of Patient from Nodal ART Centre to Link ART Centre

7.1.1 Eligibility Criteria for “link out” of patients from Nodal ART centre to LAC:

Patients satisfying all of the following conditions will be shifted to Link ART centers:

1. Patients stabilized on ART for minimum 6 months at the Nodal ART centre.

2. Those who have exhibited weight gain and increase in CD4 count after 6 months of initiating

ART.

3. Do not have any active OI.

4. The patient is a resident of an area closer to the LAC than to the Nodal ART centre

5. Those who are willing to be shifted and collect their ARV from the LAC, once the above

conditions are fulfilled.

Link ART center shall not initiate ART in any patient .

Only the patients from the designated Nodal ART centers will be dispensed ART at the attached

LAC. For eg. If Ambala LAC is a Link Centre for Chandigarh Nodal ART centre, it will cater care to

PLHAs originally registered with Chandigarh ART Centre who are staying in and around Ambala

district only and not to patients registered with ARTC (NAC) Jalandhar or Amritsar . In case a new

ART Centre and LAC are opened near the patients residence, patient will have to be first transferred

to the new Nodal ART Centre and then linked out as linkage plan

The patients at Link ART Centre will remain the patients of Nodal ART centre and will not been

shown as transferred out from the Nodal ART Centre. Instead the terms “shifted out “or “linked out”

should be used. The nodal centre will inform NACO about the total patients sent to Link ART Centers

in the new monthly ART reporting format and CST minthly report

7.1.2 Once it has been decided that the patient is fit to be shifted to a Link ART Centre as per 7.1.1

(preferably the patient should have had a CD4 count done within last one month) patient should be

given the following documents:

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Photo-copy of the Patient‟s Treatment (white) card,

Original green Patient booklet,

Nodal ART Centre →LAC referral/Link out form ( Annexure „2‟),

One month‟s drugs.

7.2 Transfer of Drugs:

7.2.1 Drugs for 3 months ( at a time) more will be sent by the Nodal ART Centre through the

Community Care Coordinator or some other designated authorized NAC /LAC staff or through

courier/ speed post/ Postal department to the LAC.

7.2.2 The authorized staff at Nodal ART Centre will transfer the drugs for the shifted patients for 3

months to the each LAC every 15 days for all the patients transferred in last 14 days (e.g.15th and 30

th

of every month) along with a copy of the NAC to LAC referral form for patients transferred during

that period.

7.2.3 TA / DA for staff involved in drug shifting will be as per government guidelines and shall be

borne under operational cost head of the funds provided to the Nodal ART Centre. The contingency

cost of Rs. 20,000/ given to lAC may also be utilized for this porpuse by LAC as well as NAC as

TA/Da reimbursement or courier charges reimbursement by LAC to NAC.

7.2.3 Drug stock reporting by Nodal ART Centre: The Nodal ART Centre shall not deduct the

drugs for 3 months transferred to Link ART Centre in the monthly report. It should only

deduct the drugs dispensed by the LAC during the month as reported in monthly reporting

format by LAC.

7.3 Services at Link ART Centers:

7.3.1 Once the patient reaches LAC, he/she is enrolled in ART Enrolment register of LAC

(Annexure „3‟). This data should be computerized at the Link ART centre by the Staff Nurse

7.3.2 On monthly visits to the LAC, following patient parameters (WAAO) are recorded in the LAC

register sheet and Patient‟s Green Book:

Weight of the patient.

Adherence.

Adverse Effects of ARV drugs, if any

OI, if any.

7.3.3 Flow of patient at Link ART Centre

Registration at the OPD counter.

LAC ( ICTC)Counselor

General OPD (to the trained Doctor)

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Pharmacy: Drug dispensing (by pharmacist / nurse) and white card collection

PATIENT GOES HOME

7.4 Referral of Patient from Link ART Centre to Nodal ART Centre

7.4.1 Patients shall be referred back to Nodal ART Centre in following conditions

[Only after filling the LAC to NAC referral back form (Annexure „2‟)]:

7.4.1.1 Once every Six Months – for repeat CD4 Count and comprehensive clinical review.

For 6 monthly referral patient should be sent at least 1-2 week before due ARV refill date so that there

is enough time for CD4 count and other necessary investigations and the patient does not fall short of

his medicine.

7.4.1.2 Before Six months

a) If any major OI is diagnosed.

b) If there are any major side effects of ARV Drugs.

7.4.2 When the patient is referred to Nodal ART Center he/ she should be given / have following

documents for follow up at Nodal ART Centre:

1. Photocopy of White card.

2. Green book of the patient.

3. LAC to NAC referral back form.

7.4.3 Following activities will be done at Nodal ART Centre on a routine 6 monthly basis:

CD4 Count and other investigations which will be communicated to the LAC first by e-mail

which will be followed by hard copies of the reports.

Clinical review of the patient.

Review / Modification of the drug regimen (only prescription and no dispensing. After first

time of link out, drugs will be given from LAC only.). In case regimen is changed, one month

drug will be given by NAC.

Filling up of the patient‟s original white card from the photocopy of the Individual page of

the patient from the LAC register and green book.

Refer back to LAC with next 3 months drugs to be transferred through Community Care coordinator

or authorized NAC staff/Courier//speed post In case the regimen is changed, drugs of old regimen of

this patient should be returned from LAC to the NAC, and drugs of new regimen should be sent from

the NAC to the LAC after giving the first refill of the new regimen at the NAC.

Drug stock reporting by Nodal ART Centre: The Nodal ART Centre shall not deduct the drugs for

3 months transferred to Link ART Centre in the monthly report sent to NACO. It should only deduct

the drugs used (consumed by patients) at the LAC during the month as reported in monthly reporting

format by LAC.

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8. Standard Operating Procedure at Link ART Centre for Pre -ART Patients:

8.1 Enrollment at Link ART ART Centre:

Any patient getting detected positive in the ICTC ( within the institutional/ ICTC in

periphery) shall be registered at the Link ART Centre in the Pre-ART register ( HIV

Care) by giving a LAC serial Number .

White card of the patient will be maintained by LAC . Pre –ART number will be

issued only by Nodal ARTC after receiving sample for CD4 testing and enrolling the

patient in their register. The photocopy of White card issued at LAC will be retained

by the NAC after issuing pre-ART registration number for that patient .

Pre-ART Counselling to be done by Counsellor/ Staff Nurse

Essential investigations to be done :Haemoglobin ( at LAC) & CD4 count ( sample to

be transported from LAC)

Screening for TB symptoms ( X Ray chest/ USG if required) and other OI screening.

8.2 CD4 testing :

Blood sample will be collected at LAC once a week preferably in morning hours and sample

transport to be done to Nodal ART Centre for CD4 testing by Lab Technician.. The CD4

reporting by Nodal Centre shall be done on same day. Vacuutainers to be provided by Nodal

ARTC to their LACs

Options for sample transport by Courier and linking with other logistic agencies may be

worked out after taking necessary permission from NACO.

8.3 Referral of Eligible patients for ART:

All patients eligible for ART as per CD4/Clinical stage criteria will be referred to ART Centre for

initiation of ART with a referral form ( “Link in Form”). The same shall be intimated to Nodal Centre

through e-mail communication also.

When the patient is referred to Nodal ART Center for ART initiation he/ she should be given / have

following documents for follow up at Nodal ART Centre:

- Referral Form/ “Link in” ( LAC-NAC) (Annexure 2 b)

- Photocopy of white card. Original White card to be sent to NAC through LAC staff & to

be retained by NAC

The patients registered at LAC and then sent to Nodal Centre for ART initiation can be linked back to

LAC after stabilization on treatment for 6 months

8.4 Basic Workup of patient to initiate ART: Basic work up of the eligible PLHA for ART Shall

be done at LAC Plus as per Technical guidelines. If the facilities are not available at LAC, the

investigations may be done at NAC.

Flow of patients in Pre-ART care at LAC

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Pre-ART patients already registered at NAC may also be “linked out” to LAC for Pre-ART HIV care .

The sample collection for 6 monthly CD4 testing will be done at LAC in such cases. When the patient

is referred to Link ART Center for Pre-ART care he/ she should be given / have following

documents for follow up at Nodal ART Centre:

- Referral Form ( NAC-LAC)/Link out (Annexure 2a )

- Photocopy of white card. Original White card to be sent to LAC through LAC/NAC staff

& to be retained by LAC until patient becomes eligible for ART

The Nodal ART Centre should include LAC patients as Nodal Centre patients.

9. Linkages and Referrals:

In view of the functions to be performed by Link ART centre it needs to have well developed linkages

with:

9.1 Nodal ART Center: The Nodal officer / SMO of Nodal ART centre and Link ART Centre In

charge should exchange Mobile numbers of each other as well as e mails of both the centers.

The link ART centre shall have communication with the Nodal ART Centers through telephone &

email with regards to:

Number of patients shifted to Link ART center in that week.

Number of patients referred to Nodal ART center each week, reasons of referral and

their subsequent management at the Nodal ART centre.

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Formats to be used are at Annexure „1‟

The counterpart staff at Nodal ART Centre and LAC (i.e. Doctors, Counselors, Nurse and Pharmacist)

should communicate regularly (weekly) by phone and email for smooth functioning of the linkage.

9.2 Regional PLHA Networks: In order to ensure ART drug adherence among the PLHAs and

follow up of PLHAs not attending Link ART centre regularly.

9.3 Non – Governmental Organizations and Community based Organizations: The Link ART

centre shall involve the organizations (esp. those working with ART programme ) and also

those already working with ICTC and also may envisage new partnerships with other organizations to

carry out home visits for the patients who are irregular on the treatment.

10. M & E tools:

10.1 M & E tools to be maintained at Link ART Centre for Pre-ART Monitoring

9.1.1 LAC Pre-ART Register ( HIV Care): to be filled by Staff Nurse

9.1.2 Patient White card

Nurse : Section 1-5, 9-12, 13 ( pt 1-5)

Counsellor : Section 13 ( pt 11,16,17)

LAC Doctor : section 7, 13 ( pt 6-10, 12, 13,14,15)

Nodal centre : section 6, 8

9.2.3 Green Book : to be filled by Staff Nurse & Doctor

9.2.4 CD4 Lab sample transport register: ICTC Lab Tech

10.2 M & E tools to be maintained at Link ART Centre for on-ART Monitoring

9.2.1 LAC ART Enrollment Register : Columns 1 to 8 to be filled by the Staff Nurse

Columns 9 to 19 are to be filled by the doctor. The

nurse may update the columns 9 to 12 under supervision of the treating physician.

The overall responsibility of the register is with the staff Nurse

9.2.2 LAC Drug Stock Register. To be filled by Pharmacist / Nurse.

9.2.3 LAC Drug Dispensing Register. To be filled by Pharmacist / Nurse

10.3 Formats for Linkages and referral

11.3.1 Link in Format : To be filled by LAC whenever patient is sent from LAC to NAC &

given to patient (Annex 2b)

11.3.2 Link out Format : To be filled by NAC whenever patient is sent from NAC to LAC &

given to patient (Annex 2a)

11.3.3 Weekly Communication Format ( LAC to NAC) for Pre-ART & on ART patients

(Annex 1b)

11.3.4 Weekly Communication Format ( NAC to LAC) for Pre-ART & on ART patients

(Annex 1a)

10.4 LAC Monthly Report format. To be filled by MO.

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Each LAC will create its own E mail id such as [email protected] (lac followed by a dot

followed by name of the town) and will report to the Nodal ART centre in the Monthly Reporting

Format (Annexure „6‟) by 25th of every month by email followed by a hard copy. The reporting

cycle for LAC is 26th of previous month to 25

th of the current month.

NO LINK ART CENTRE REPORT WILL BE SENT TO NACO unless specifically asked for.

11 Financial guidelines :

11.1 Financial Assistance:

The funds provided to the LAC are as below :

a) One time grant for furnishing of centre = Rs. 15,000/-

b) Cost of training of staff – (to be borne from GIA to SACS for training)

c) Recurring grant :

1. Internet connection @ Rs. 650/- p.m. x 12 = Rs. 7,800/- p.a.

2. Cost of stationery, records and contingency (including phone) = Rs. 10,000/- p.a.

3. Cost of travel and drug transfer = Rs. 20,000/- p.a.

4. Remuneration of Nurse@ Rs. 8000-12,000/month (For LAC plus only) =Rs. 96,000/- p.a.

Total Recurring Grant:

Link ART centre: = Rs. 37,800/p.a.

LAC Plus : = Rs. 1,33,800/p.a

The Link ART centre will utilize the computers facility already available with the site (ICTC).

The LAC shall get a broad band internet and phone connection from the funds provided as per

the LAC approved financial support.

11.2 Bank account for LAC:

A separate bank account shall be opened by LAC for maintenance of fund.

The two signatories of the account will be the Medical superintendent of the hospital and LAC In

charge.

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ANNEXURE 1a

Formats to be used for weekly communication between Nodal ART centre and LAC by email.

Form – LAC 1

Nodal ART Centre to LAC for Pre-ART Patients

Name of the Nodal ART Centre

Name of the LAC

Sr.no.

Pre-ART

No.

Name

of the

Patient

Age Sex DATE OF

Link out

Next Visit

date to

LAC

Next CD4

date

Nodal ART Centre to LAC for on ART Patients

Form – LAC 2

Name of the Nodal ART Centre

Name of the LAC

Sr.no.

ART

No.

Name of

the

Patient

Sex Age DATE

OF

TRAN

SFER

Current

regime

n

Qty

(Pills)

Next

date of

dispensi

ng ART

Next CD4

date to

Nodal

ARTC

Other Details :

Regimen No of Tablets Expiry Date

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ANNEXURE 1b

LAC to Nodal ART Centre for Pre-ART patients

Sr.

no.

Pre-

ART

no.

LAC

no.

Name of

the Patient Address

Reasons for

referral

Clinical

stage CD 4 count

Remarks

LAC to Nodal ART Centre for on ART patients

S.No.

ART no.

LAC no.

Date of Visit

Date of Next Visit

Clinical Stage

OI Code

CTX or other prophylaxis

Regimen

Adherence to ART (No. of doses Missed

Any other Medicine

Pregnancy

(Y/N)

OR

Condoms given (Y/N)

Reason for refrral

Remarks

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Annexure 2 a

Referral form (Form for shifting from Nodal ART Centre to Link ART Centre) Link out form

Date of link Out:

Name & address of NODAL ART CENTRE _________________________________.

Name & address of LINKED ART CENTRE, _____________________________

Name of Patient: Pre-ART No

ART No. of the patient :______________________

Address

Date of starting ART : (Date/Month/Year);

Initial Clinical Stage –___ & WHO Stage - ______, on date_______CD4 count ________ on

date___________

Current Clinical Stage –_____ & WHO Stage - ______, on date__________ CD4 count ________

on date_______

Last date of dispensing ARV___________________________

Next date of dispensing drug _______________ & Expected pill balance on that date:_________

Current Regime - _______________________,

Reason for shift : Pre-ART Care/ ART monitoring & refill

Remarks

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________

Date/month for CD4 count, when the patient is to be shifted back to Nodal ART center-

Please find the following documents handed to the patient:

Patient Treatment Card (White Card) ( photocopy) □

Patient ID card (Green card) □

Patient‟s green booklet □

Others, if any

(mention)________________________________________________________________________

Name and Signature of

SMO/MO________________________________________________________________

Phone no. _________________________and E mail______________________________________

of SMO/MO:

To be filled by the receiving of Linked ART centre and sent back to the Nodal ART centre by post /

email

…………………………………………………… (Name of Patient) with ART No.___________,

transferred by you on

date …….. / ……. / ……. has reported and been registered with us on ………. / ………. / ………..

The documents

sent by you have been received.

Name and Signature of MO Phone no. with E mail of MO

Refer form (Form for referral from LAC to Nodal ART Centre) Link in form

17

Date of Referral Back

Name LINK ART CENTRE, address _____________________________of ART centre where

patient is transferred.

Name NODAL ART CENTRE, address ____________________________of the Transferring ART

Centre.

Name of Patient: Link ART Id.No.________________

Nodal Pre- ART ID NO. ( for Pre-ART )_________ Nodal ART ID NO. ( for on ART)._________

Address

Current Clinical Stage – WHO Stage - ______, CD4 - ____________

Last date of ARV refill:

Next date of dispensing drug:

Current Regime –

Reason for referring : ART eligibility/ Routine 6 monthly Follow up / major OI / major SE /

Others (Please Specify)

Remarks:

Please find the following documents handed to the patient:

Photocopy of the Patients Page from LAC Register.

Patient ID card (Green Card)

Patients Green booklet

Others, if any (mention)

Name and Signature of M.O of Link ART Centre Phone no. and E mail of

M.O of Link ART Centre

To be filled by the receiving of Nodal ART centre and sent to the referring Linked ART centre by

post / email

…………………………………………………… (Name of Patient), with Link ART Id No.

_____________ referred by you on date …….. / ……. / …….

has reported to us on ………. / ………. / ……….. The documents sent by you have been received.

Name and Signature of SMO/MO Phone no. with E mail of SMO/MO

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ANNEXURE 3

LAC ART Enrolment register Register

Annexure 4

LAC Pre-ART enrolment register

Annexure 5

White Card

Annexure 6

Monthly Reporting Format

19

Annex 7 : Checklist before Setting up A Link ART Center

Check List for setting Link ART Centre ( In ICTC setting)

1 Name of the town:

2 Type of Hospital:

3 Name of the Medical Superintendent

4 Names of the LAC in charge Physician

a

b

c

5 Are the hospital staff sensitized about LAC (Y/N)

( At least 30 min interaction with the hospital staff (MS, LAC in charge, Nurse, Pharmacist, Counselor) about the concept of LAC )

6 Hospital Phone Number with code

7 Complete postal address with pin code:

9 Name of the Nodal ART Centre

8 No. of HIV positives detected in the ICTC in last 5 years

9 Mention the catchment area of the ICTC

10 No. of HIV positives detected in the cactchment area ICTC in last 5 years.

11 No of PLHA registered at ART Centre form the catchment area

12 No of PLHA registered on ART Centre form the catchment area

10 Commitment

a Is the DCHS committed towards the National ART Program

b Is the hospital administration Committed

c Are the identified LAC in charge doctors committed

d LAC Staff nurse identified

e LAC Pharmacist identified

11 Space and Infrastructure

20

a Is there an ICTC functioning in the hospital.

If yes then

b How many rooms does the ICTC have

c Counselor in place

d Name of the counselor and contact number

e Counselor trained

f No of HIV testing in the last year

g No of Positives

h Computer Available (Y/N)

i Telephone Available (Y/N)

j Internet Available (Y/N)

k Space available for Counseling (Y/N)

l Space available for drug storage (Y/N)

m DOTS available

12 Human Resources ( In Hospital or linkages)

a Specialists available

b Physician

c Pediatrician

d Obstetrician

e Chest Physician

f Dermato-venreologist

g Others (Mention)

13 Lab investigations

a Hemogram

b RFT

c LFT

d CXR

e Sputum for AFB

f Others ( Mention )

21

14 General Information regarding the Hospital

a No of Doctors available

b No of Beds available

c No of Positive deliveries conducted in the last year

c Drugs available at the hospital pharmacy

1 Assessment done by:

2 Date of assessment:

3 Recommended for LAC (Y/N)

If not mention reasons:

Signature

22

Annex 8 : Checklist for Supervisory Visit Format of Link ART Centre

(This checklist is to be used by the designated supervisory team in conjunction with the ARV treatment unit staff during their visit to an ART center. The aim is to see the quality of services offered their conformity to national guidelines, to identify problems and take corrective actions.) Name of LAC: ______________________

Name of Nodal ART Centre

Date of visit______________________________

Name of Supervisor:____________________________________________________

Name of LAC In charge: _________________________________________________

No of Patients in registered in Pre-ART care* _____________________

No of patients on ART _________________

I Institutional commitment & functioning of ART Centre Remarks

1. Is there high commitment to the national ART programme:

(this will be indicated by involvement of the institution in the

ART services)

� Yes � No

2. Is proper space and infrastructure available at LAC � Yes � No

3. Are there proper signages for the LAC � Yes � No

4. Is internet, computer with printer, available at LAC? � Yes � No

5. Is the LAC staff identified as per NACO guidelines?

6. (LAC incahrge, LAC Medical Officers, Lab Technician,

Counselor, Pharmacist, Nurse).

� Yes � No

7. Has the LAC medical officer undergone NACO training? � Yes � No

8. Has orienatation/ hands on training of LAC staff been

carried out as per NACO guidelines ?

� Yes � No

9. Does LAC function every day? � Yes � No

10. Is the IEC material displayed in Link ART Centre � Yes � No

11. Are the LAC services well organized: will be indicated by the

channel of movement of the patient to access services as

required (clinical, lab, drugs, counseling).

� Yes � No

12. Is the SOP for the functioning of the LAC is being followed

as per operational guidelines?(specifies roles and

responsibilities, patient flow, etc)

� Yes � No

13. Is there adequate co-ordination of the LAC with other

departments of the institution?

� Yes � No

14. Are the indoor admissions done for OI treatment ( if

required)

� Yes � No

II Recording & Reporting

15. Are the NACO specified patient and programme monitoring

records being maintained

� Yes � No

i. Pre ART register * � Yes � No

ii. ART Enrollment register � Yes � No

iii. Drug Stock register � Yes � No

iv. Drug Dispensing register � Yes � No

v. Patient Treatment record ( white card for Pre-ART & on

ART patient)

� Yes � No

vi. Green Book ( for Pre-ART & on ART � Yes � No

16. Is confidentiality of records maintained? � Yes � No

23

17. Are the records properly stored? � Yes � No

18. Are the patient treatment records up to date? � Yes � No

19. Are periodic communications sent to Nodal ART Centre � Yes � No

20. Is the LAC monthly report sent to Nodal centre at the end of

each month?

� Yes � No

Pre-ART services ( for LAC plus only)

21. Is the blood collection for CD4 done regularly been done

every 6 months for all registered patients

� Yes � No

22. CD4 testing is done every 6 months for all registered patients � Yes � No

23. Is Pre-ART CD4 due list being maintained and followed � Yes � No

24. Is there a mechanism in place to track back patients with

borderline CD4 results

� Yes � No

25. Are all patients eligible for ART referred to Nodal ART centre � Yes � No

26. Are all PLHA screened for TB symptoms � Yes � No

ART services

27. Are the national guidelines for ART being followed? � Yes � No

28. Is adherence issue being given due importance (adherence

counseling, pill count)?

� Yes � No

29. Is the daily due list of patients maintained and followed up? � Yes � No

30. Are the patient referred back to Nodal ART centre at 6 months

for routine monitoring & CD4 testing

� Yes � No

31. Are the patients screened for side-effects or OIS and referred

to Nodal ART centre

� Yes � No

III Drug stocks

32. Is the drug stock register and dispensing register ( adult,

paediatric & OI) up to date?

� Yes � No

33. Are there adequate drugs for the next 3 months (stock

position)?

� Yes � No

34. Are the drugs stored as per the specifications? � Yes � No

35. Is the “First Expiry First Out” principle followed? � Yes � No

36. Does the regimen wise consumption of drugs matches with

the no of patients on ART?

� Yes � No

IV Laboratory Services Availability

i. HIV testing � Yes � No

ii. Sample collect for Enumeration of CD4 cells � Yes � No

i. CBC and other routines biochemistry investigations � Yes � No

ii. LFT � Yes � No

iii. Blood sugar � Yes � No

iv. Lipid profile � Yes � No

v. S. Creatinine � Yes � No

vi. CXR � Yes � No

vii. Sputum for AFB � Yes � No

37. Are baseline tests being done for all the patients? *( For LAC

plus only)

� Yes � No

38. Any of the above testing is charged � Yes � No

V Referral & Linkages

39. Are there referrals from the ICTC to the LAC? (Write the

number in last 3 month). Compare with total positives

detected at ICTC in same period.

� Yes � No

40. HIV / TB linkages is maintained? )( check linelist register � Yes � No

24

& monthly report)

41. Is there effective communication between LAC & Nodal

ART centre

� Yes � No

42. Is a proper MIS/ LFU tracking mechanism in place � Yes � No

43. Does the ART Centre has any mentoring of LACs � Yes � No

Other Information

44. Are the PEP drugs available in casualty , ICU & labour

room?

� Yes � No

45. Are the Universal Work precautions followed? � Yes � No

46. Measures for airborne infection control is in place? � Yes � No

*Applicable for LAC Plus

OtherComments________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

25

Annex 8

Steps in setting up Link ART Centre

Activities Responsibilities

Letter from NACO for administrative Approval NACO

Meeting between SACS, Civil surgeon of Hospitals, and RC to identify and sensitize the key staff at hospital.

Concerned SACS, In-charge of district / Taluka hospitals, Medical Officer and RC

Hands on training of Medical Officer ( LAC Incharge) for 4 days at training institute

NACO, Regional coordinator, Concerned SACS

2 days orientation of whole LAC team ( MO, Counsellor, staff nurse, pharmacist) at nodal ART Centre

Concerned SACS, Regional coordinator , Nodal centre In charge, LAC incharge

Cards records and registers at the center, SOP Concerned SACS

Operationalisation of Link ART centers Regional Coordinator, Nodal centre Incharge, LAC incharge

Steps in upgrdation of Link ART Centre into LAC plus

Activities Responsibilities Identification of LAC with more than 70 PLHIV on ART

SACS

Appointment of Staff nurse SACS /DAPCU/Institution

Training of Staff Nurse & Lab Technician NACO/SACS/Regional Coordinator

Orientation of whole LAC team ( MO, Counsellor, staff nurse, pharmacist) at nodal ART Centre

Concerned SACS, Regional coordinator , Nodal centre In charge, LAC incharge

M & E tools (Cards records and registers at the center, SOP)

SACS

Operationalsation of LAC Plus Regional Coordinator, Nodal centre Incharge, LAC incharge

operational guidelines for link art centres october 2010

Documents