Assessment of Integrated Counselling and Testing Centers ( ICTC ) in Chhattisgarh , India

Copyright: © 2017 Kerketta F, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. *Corresponding author: Mr. Fidius Kerketta: State Health Resource Center, State Health Training Centre Building, Kalibadi, Raipur, Chhattisgarh492001; E-mail: fidiusshrc@gmail.com ISSN 2380-5536


Introduction
Ever since the first detection of HIV in 1986 among a female sex worker in Chennai, the disease has penetrated into general population in India.It is no more the disease of only high risk population.Although its greatest spread reported in six high prevalence states namely Andhra Pradesh, Tamil Nadu, Karnataka, Maharashtra, Manipur, Nagaland there is sporadic spread in many other states.
The HIV epidemic in the state of Chhattisgarh, India is concentrated among high risk groups, though, there is an evidence of the infection spreading to the general population.According to the HIV Sentinel Surveillance 2012-13, NACO report, HIV prevalence among ANC clinic attendees in the state is 0.51, prevalence among FSW is 2.73, prevalence among MSM is 14.98, and prevalence among IDUs is 0.42.HIV prevalence among MSM in the state is the highest in the country (India -4.43) and among FSW is the 8th highest in the country (India-2.67).Though the prevalence of the disease is low in Chhattisgarh, as compare to other states in the country, Chhattisgarh State AIDS Control Society (CGSACS) has put all effort to control new infections.Statistically, state has 22165 people living with HIV/ AIDS of these 63% are male.The age range of the disease is between 25-49 years [1,2] (Table 1).

Rationale of the Study
"Chhattisgarh State AIDS Control Society" is a dedicated organization to implement the National AIDS Control programme (NACP) in the state.It has total 129 Integrated Counseling and Testing Centers (ICTC) largely in district hospitals and Community health centers.These centers are supposed to be ideal locations where a person is counselled and tested for HIV, of his/her own free will or as advised by a care provider.These centers are the key entry points to prevent spread of HIV infection, treatment and care of people who are infected with HIV.Th e success of the HIV prevention programme is cantered around the proper functioning of the ICTCs.Therefore the performance of each ICTC plays a vital role in the success of the programme.Hence this study was initiated to assess the performance of the ICTC centre [3].

Objectives of the Study
The objective of the study was to assess the ICTC in terms of physical infrastructure, staffing, services provided, level of utilization, quality of Open Access 2 counseling, knowledge and skill of counsellor so as to improve the ICTC services.The study was not only intended to assess their performance but also to provide information to support health care providers, administrators and policy makers for better service delivery.

Methodology
A Cross sectional facility based structure and process assessment was carried out in the state between June 2015 and August 2015 at ICTCs functioning under NACP III.Sample was selected from five divisions namely Raipur, Durg, Bilaspur, Surguja and Bastar.Random sampling techniques were used for the selection of districts from each division.101 ICTCs were reported to have counsellors posted which were eligible for sample selection.Once a district was randomly sampled convenient CHCs, Civil hospital and PHC were selected.The researchers adopted convenient sampling technique to select ICTCs at district level because this study was not funded.Data was collected from 15 ICTCs located at district hospitals, 10 ICTCs located at CHCs, 2 ICTCs located at medical colleges, 2 ICTCs located at civil hospital and one ICTC located at PHC. Hence there were total 30 reportedly functional ICTCs were selected for the study.
The study tools were developed based on the guidelines of ICTC provided by National AIDS Control Organization and the tools developed by UNAIDS to evaluate ICTC centers in the state.These tools were adapted and modified according to the needs of the service being evaluated for this study and were field tested before finalizing the tools.To assess the knowledge and skill of counselors, semi structured questionnaires were developed.Data analysis made using excel sheet.

Ethical Issues
Approvals from district health authorities and District AIDS control officer were obtained before commencing the study.At each ICTC, additional permission from concerned ICTC managers (medical officers) was also obtained.A written informed consent was also obtained from beneficiaries, counsellors and laboratory technicians at the beginning of the study.

Staffing pattern in ICTC centers
As data provided by Chhattisgarh State AIDS Control Society (CGSACS), there were total 129 ICTC centers existed in t he state.These ICTC centers required a team of skilled persons consisting of the ICTC manager (medical officer), a counsellor and a Lab technician (LT).The study finding suggests that only 73 ICTC centers had both Counsellors and LTs, although there were 101 counsellors and 84 laboratory technicians posted at different ICTC centres.45 ICTC centers had no Laboratory Technician. 10 Lab technicians had no counsellors though there were 18 more counsellors than laboratory technicians.17 ICTC centres had neither Counsellor nor LT.

Physical infrastructure
The counseling room should be an enclosed space, ideally 15' × 15' in area so that one on-one and one-on-group counsellor sessions may be undertaken in an atmosphere of privacy.According to the findings of the study only 57% of the ICTC centers had adequate space for counseling.Many places counsellor space was shared by other services in the facilities which break the privacy and confidentiality of the counsellor.Only 50% of the ICTC visited had adequate waiting area for counsellor and 60% ICTC had chairs between 10-15 for counsellor waiting for counseling.3 ICTCs did not have lockable cabinets for keeping records.Files were kept in the open space [3].

Availability of Communication IEC material
The ICTC must maintain the basic IEC materials which are essential for counselling services.The finding of the study suggests that about 90% to 93% of the ICTC centers had flip charts and leaflets.Condoms and condom demonstration models were available at 83% and written policy on confidentially were available at 63% ICTC centers.Therefore all ICTC centers did not have minimum communication aid at the centers which are essential communication aids for counselling / education at the ICTC centers.

Training of counselor
As per the guideline all ICTC counsellors must have induction training for 12 days before they are posted at designated ICTC centers and they must have refresher training for 5 days yearly.The study findings indicate that about 83% counsellors had induction training and 93% of them had in service training.During the interview the counsellors commented on the quality of the training.Usually trainings are conducted in English and materials provided were in English.According to them the training should have been conducted in Hindi or local language which they were comfortable with rather than in English.Even the training materials provided to them should have been in local language [1,3].

Technical knowledge of counsellors on HIV/AIDS and counselling
According to the finding of the study the counsellors had average technical knowledge on HIV/AIDS and counselling.Only 31% of respondents had correct knowledge on HIV testing and 33% had correct counselling skill.The knowledge on risk assessment and HIV/AIDs ranges between 49% to 65%.The quality of the ICTC services is compromised due to inadequate and lack of proper training.On the other hand there is a lack of conducting written test to test the knowledge of counselors which should have been held periodically.

Performance of counselors
The performance of the counsellors was measured on the number of beneficiaries' counseled and tested by the counsellor in an ICTC per day.About 60% of the counsellors scored excellent grading, 13% of them scored good grading and remaining 17% and 7% of them scored average and poor grading.Hence the performance of about 24% counsellors is below satisfactory.

Quality of counseling
The quality of the counselling was assessed by the drop-out rate of counsellors between testing and post-test counselling.According to the findings of the study about 83% counsellors maintain the quality of counselling and about 17% of the counsellors perform below average in maintaining the quality of counselling.As beneficiaries' counselled and tested were not turning up for post test counselling.No effort was taken by the counsellors to contact these beneficiaries' for post test counselling as none of the counsellors make field visit.

Discussion
HIV/AIDS counselling/education is a confidential dialogue between a beneficiary and a counsellor which aims to bring about behavior change in the beneficiary and to enable the beneficiary to take a decision regarding HIV Testing and to understand the implications of the test results.About 43% ICTC centers in the state fail to provide such facility to counsellors because of lack of privacy.HIV/AIDS is generally associated to the sexual transmitted disease.The beneficiary and the counsellor cannot have a free and healthy dialogue in such situation which is against the spirit of ICTC.The health department must seriously think and either provide adequate counselling space to maintain privacy or improve only those ICTC centre which have adequate space to maintain privacy.
The ICTC must be equipped with a counsellor and a lab technician.The study indicated that some ICTCs had only one of the staff posted.ICTC cannot be functional if it does not have a counsellor and a lab technician.There is no of having an ICTC which is not equipped with adequate human resources.Therefore there is a need to rationalize existing human resources to operationalize key services of ICTC.Lab technicians conducting lab test without counselling undermines the ICTC services in the state.Secondly the department must think on immediate recruitment of staff to replace vacant positions or delisting of ICTC without having adequate HR.Increasing ICTC number without improving ICTC services is equal to not having ICTC services.
All ICTC centers must have compulsorily minimum communication aid like flip chart condom demonstration model, condom, leaflets/ pamphlets and written policy in the counseling room.On the other hand the department must strengthen monitoring and supervision of ICTC centers.Lack of monitoring and supervision and regular feed back to the ICTC staff weakens the functioning of the services of the ICTC centers.

Conclusion
Over all the Integrated Counseling and Testing Centers in the state are performing reasonable well; however there are some key gaps which need to be addressed to improve the functioning of all ICTCs.To address the key gaps following recommendations are suggested: Rationalization of the human resources to operationalize key services of ICTC; Immediate recruitment of staff to replace vacant positions; strengthening monitoring and supervision of ICTC centers and its services.

Limitations of the Study
The primary data collection was made between June 2015 to August 2015.The finding of the study may not reflect the true picture of the ICTC centers if corrective measures were taken to improve the ICTC centers.District Hospital sampling is probably representative, but other institutions were those which were easy to access.
Regularization and improving the quality of training is a must to improve the quality of ICTC services.Counsellors being posted without the induction training are like pushing an individual into water without training.Most of the counsellors employed at the ICTC centres are MSW graduate.They lack counseling skills.Usually counseling is not taught in the college.The department must ensure in availing adequate training to all counsellors to ensure quality ICTC services.