CD4 is the test done routinely on patients to assess the progress of the disease and response to treatment. It is one of the factors to decide whether patient is adherent, requires a change of regime or has some underlying undiagnosed or untreated condition. In Bowring hospital, the CD4 testing starts at around 10.30 am and is expected to go on till 1 pm. However there are many instances of irregular CD4 testing. Since Bowring is a Centre of Excellence, many patients come from other districts. If they reach after 1 pm they are asked to come back again. Given the fact that travel allowance by Karnataka State AIDS Control Society (KSAPS) has been stopped several months ago and several patients are either daily wage labourers or unable to work because of their HIV status, it is important that patients are adequately counselled and informed one month early about the need to do CD4 count. When questioned, the ready answer by counsellors is that patients have been informed and don’t care to come before 1 pm. However all the patients who have been sent back without medicines have stated that they had not been informed in advance during their last visit the previous month.
Patient A came to the ART centre on 20/11/2015 at 11 am but when his card was finally issued and when he met the counsellor, it was 2.30 pm. The counsellor told the patient that he was due for CD4 that month and would therefore not be issued tablets. Patient was sent away to come back the next day before 1 pm for CD4 and only then given the ART tablets. When enquired, the patient said that he had not been told the previous month (October) that he should come before 1 pm for his CD4. Owing to this the patient missed one day of TB and ART medicines.
Patient B had his last CD4 done on 24/12/2014. When the patient came on 20/11/15, he was told at 11 am that CD4 is not being done as ‘time is up’ and that the patient should come back the next day.
On the same day, patient C was sent back from CD4 lab at 11 am saying the machine was spoilt. Patient was sent back again by the MO and then the CD4 was done the second time. This was the day of the planned strike by the KSAPS employees for a pay hike. Although they were issued a strict warning that work should not suffer, the CD4 collection was stopped at 10.30 am. When this issue was raised to the nodal officer, his response was that on government and general holidays, the lab technicians can stop collecting CD4 samples at 10.30 am as he felt that there was no need to collect samples till 1 pm and keep them in the fridge for processing the next day as per protocol.
Patient D said that she was sent to do to CD4 in October. During her visit on 20/11/2015, she was shouted at by four counsellors and told that her CD4 was not done and that she would not be issued tablets. Patient was asked to come back on 21sth November 2015 again for CD4 after which only she would be issued tablets for the month.
After 1 pm, the laboratory staff are found in the Centre of Excellence either surfing the internet or chit-chatting loudly and being disruptive.
The male lab technician has made inappropriate comments about a patient E from Nigeria saying “You take my phone number and call me from Nigeria. You can be my girlfriend from Nigeria”. When the community representative of the Karnataka Positive People’s Network took offence to the behaviour of the male lab technician following complaints that he was refusing to do CD4, his response was ‘Who is that woman? Why should I bother about her? I don’t care about her complaints.” Although an enquiry committee was set up and several complaints were made to the Senior Medical Officer, Dr. Nirmala, the nodal officer, Dr. Ravi, the regional co-ordinator, Dr. Sunil and the project director of KSAPS, about the abusive and offensive behaviour of the lab technician, he continues with impunity secure in his ability to bypass any regulatory mechanism owing to support from the lab technicians association – an association that, similar to most other employee associations in the country, focus more on increasing salaries and ensuring permanent positions for their staff, rather than regulating and monitoring performance to benefit patients.
Bowring hospital is a tertiary centre and is expected to have basic blood facilities. However there are many issues with the laboratory support.
Patients who come by eight in the morning wait till 2 or 3 pm only to be told that their reports will only be available the next day. Patients have been asked to do basic tests for malaria, HBSAg, VDRL and typhoid at outside labs often at huge costs since the last two months. Urine tests are not being done as there are no containers to collect urine. People who have some influence are told to bring urine in tea cups and that they will be tested. The reason given by the lab is that reagents and urine testing kits are not being supplied in spite of indents being sent.
There are instance of patients being charged extra and not issued a bill. The reason being given is that the samples have to be tested ‘outside’. This makes the reliability of the test doubtful and leads to lack of accountability by the laboratory.
Almost 70% of the patients registered at the Bowring ART centre have not had laboratory investigations for more than a year and a half, sometimes for as long as two or three years.
The excuse that is being used by the medical officers is that the patients are too poor to pay, however this is blatantly untrue and is an attempt to blame the patient for a lapse on the part of the ART centre. All patients issued requisition forms by me in the last two months at the rate of 15 to 20 every day for the basic blood investigations of CBC, ESR, RBS, LFT, Lipids, S. Creatinine and B. Urea, have all done the investigations. About 5% of the patients have done the tests after two months. 1% of the patients are destitute and state their complete inability to pay the Rs. 350/- for the blood tests, in which case they are just monitored clinically or a letter written to the RMO to waive of charges completely which he has obliged in all instances.
There are several adverse drug reactions that have been emerging primarily hyperlipidemia, hyperbilirubinemia, hyperglycemia and anemia. While these could or could not be due to the drugs per se and could be due to OIs or the underlying disease itself, this would have to be analysed and interpreted separately.
The lack of laboratory monitoring of patients has led to an undue and unacceptable degree of preventable complications in patients.
This is further aggravated by the SMO instructing counsellors to write the regimen and they are not seen at all by a doctor. The medical officer does not touch the patient to look for any form of ADR.
TB and HIV co-infection is a huge crisis in the country. However in Bowring hospital, HIV positive patients who are referred for TB testing are not given reports and instead asked to come back the next day or after a weekend. The reason given is that one or the other staff is on leave. This leads to some patients having to spend out of pocket to come back sometimes from long distances, and other patients to wait for a month (for when they come back for the next month’s supply of ART medications) before collecting the reports. In the instance that they are positive for TB, it means that the disease has been left untreated for a month, been infectious to other contacts of the patient or progressed further. It means the burden of TB in the country is growing. The TB centre has also arbitrarily decided that they will not test for sputum on government holidays and will only do documentation. This requires patient to come back again the next day to give the sample and again on the third day for the report.
Referral rate for TB from the ART centre is poor. Often lymph nodes are missed as the medical officer does not physically examine any of the patients.
There is no Dermatology OPD in the afternoons at Bowring hospital, so there is difficulty referring patients who come in the afternoon for STD treatment and drug reactions. Patients have to be asked to come again the next day.
Initially, it would take anywhere between two to three days for a patient to be issued an X-ray by the Department of Radiology, Bowring hospital. This means patients could not be issued appropriate treatment for this period of time. The issue was raised with the Head of Department, Radio-diagnosis and has currently been resolved satisfactorily.
Patients have complained about discrimination in the OPD and hesitate to take their green ART book to the OPD even if referral letters are written in them. They say that when the OPD staff see the green book, their attitude changes instantly. One patient says “When they saw the green book, they shouted at the PG – this one has the kayile (disease) See him quickly and send him out”. Another patient was asked “Where did you go and get this disease?”
There is discrimination of some patients at the Gynaecology ward. The department has three units. Patients of one unit are not seen by doctors of another unit and they are not even informed about the right day to come back. This leads to undue stress for the patient and multiple visits with great financial and psychological (and physical) implications . One patient Fwho is registered at the Victoria ART centre had continuous bleeding and went to Vani Vilas where she was made to run around for a week. Since she had continuous bleeding she came to Bowring where she had to spend another two weeks without her condition being adequately treated. Finally she was asked to go back to Vani Vilas as she was initially registered there. This patient’s number is also available. There is no clear and efficient system of referral or cross referral between tertiary hospitals in Bangalore. Onepatient H who was positive and went into labour was made to lie on the floor and denied even basic care until the intervention of the PA to the medical superintendent when approached by the patient’s family.
Patients who are HIV positive are being segregated in separate wards – 6thfloor for women and 7th floor for men. They often receive poor treatment. Onepatient G with cerebral infection was not given lifesaving treatment as his case file was ‘missing’ for five days.
Travel allowance is not being issued to patients since August 2015. Even prior to closing the travel allowance, the TA was not being issued in the afternoon. This decision was made arbitrarily by the data entry operators and overlooked by both the senior medical officer and nodal officer despite complaints by patients.
Doctors and staff who support patient rights are being harassed and threatened. Rules have been laid down by the nodal officer and Senior Medical officer that complaints should go only to them and not outside the ART centre. The outsiders include NACO, KSAPS and Karnataka Positive People’s Network (KNP+) Doctors duties are first to the patient and then to the system, but in Bowring the doctors who support patient rights are penalised and threatened. Patients who lodge any kind of complaint are penalised by the doctors, counsellors and lab technicians and ranging from denial of service, verbal abuse and threats of transfer against patient wishes.
NGOs are being kept out as they are perceived to be ‘instigating ‘ patients. This is inspite of NGOs having permission to accompany sick patients to the hospital.
The nodal officer, Dr. Ravi has repeatedly warned doctors and other staff that I should not ‘entertain’ patient complaints. In the atmosphere of Bowring ART centre, thinking or working towards patient’s rights is seen as a violation and staff are expected to only protect themselves and each other, and particularly their ‘higher authorities’ even if the consequence is unduly and unacceptably borne by the patient. This attitude of the nodal officer has a trickle-down effect and adversely affects the attitudes of all the other staff towards patient care. All options for patients to raise their concerns has been completely shut down in the existing system. NGOs working with people living with HIV have also been refused entry by the Bowring ART centre and this is with the knowledge of the nodal officer.
Even a complaint box is not available.
Many first line patients are being retained by the Bowring ART centre inspite of requests for transfer. Patients on second line are expected to be transferred after six months if CD4 and viral load have been done, however many patients have not been transferred inspite of repeated requests saying ‘drugs have not come’. When a patient enquired with the MO about transfer, the doctor said “I am not an astrologer to predict when the tablets will come. You think I am interested in seeing more patients? Whenever the government gives the tabs you will get them. Now don’t eat my head.”
Patient I is from Davangere and initiated on second line at Bowring on 7/2/15. Since then she has been repeatedly asking for transfer but being denied as there are ‘no medicines’. She spends Rs. 300 for each visit and TA is also not being given.
Patient J is coming from Shimoga since 12/01/15 and is on second line. The cost for the patient works to around Rs. 1000/- for each visit for patient and attender. Patient is repeatedly requesting for transfer but he is not being given transfer as there is ‘no drug supply”
Patient K was transferred to KIMs where she received second line drugs for five months. Last month she was told that her drugs had not been sent by Bowring so she had to come here and collect the meds. This month she was told the same thing. Patient has to make two trips – once to KIMs and once to Bowring.
The role of the COE is in-depth analysis of data of various services including ART centres linked to them, conduct operational research for NACP and serve as a repository of information related to HIV/AIDs. It is expected to build partnerships with organisations like CDC, NIH for multi-site, multi country partnerships.
However, the CoE at Bowring hospital has absolutely no capacity for conducting research of this nature. For the amount of funds invested in the infrastructure and other facilities for the ART centre, the output is woefully inadequate. The COE is a stand-alone entity that does not seem to be accountable. There is no co-ordination between the ART centre and COE and the ART staff are blocked from accessing COE emails. COE does not share any information with the ART centre regarding planned or other studies.
There is no linkage with other departments. There are no infection control practices except for the CoE staff to take the supply of sanitiser meant for use by the doctors and use it to clean their laptops and desks!!
The CoE multi-disciplinary team has never met in the five months that I was there. The nodal officer was of the opinion that senior doctors wouldn’t have time to attend these meetings and that the SMO should just write some minutes and include all their names and forward to NACO!!
The departments of Ophthalmology, Radiology and Dermatology of Bowring hospital are keen to conduct studies in collaboration with the CoE but there has been no response from the CoE to initiate these studies or support ongoing studies in these departments
Although large sums of money have been invested in this facility, there is no measurable output.
The non-medical researcher (NMR) claims to be unable to function without a clinician constantly supporting her. Since the post of clinical research co-ordinator has been vacant for well over two years, this means that, with a salary of Rs. 25,000/- per month, the non-medical researcher has absolutely no work throughout the day. This explains why she spends the entire day surfing the net, playing music, laughing, chatting and disrupting the functioning of the other staff. The non- medical researchers post is redundant. An independent evaluation of the output by the NMR in the absence of a clinical officer shows that the salary for this post is a wasteful expenditure and should have been the first to have been slashed in a budget crunch. The salary of the NMR amounts to Rs. 3,00,000/- per year and could have been more usefully spent to address the drug crisis or the lack of funds for patient travel allowance.
This is the same situation with the training co-ordinator who receives a salary of Rs. 18,000/- a month amounting to Rs. 1,80,000/- annually. Training co-ordinator does not have responsibilities during most of the year. The post can be converted to training and administrative officer so that the SMO is freed of some administrative responsibilities.
The non-medical researcher is expected to enter the adverse drug reactions into a database. Although 58 cases of ADR have been recorded manually over the last five months into the ADR register, these have not been entered by the non-medical researcher into the database. This means that these 58 ADR have not been included in any official statistic since the last five months. When questioned, the non-medical researcher claims that she is accountable only to the nodal officer. The nodal officer is also quite comfortable with her staking privileged claims on him.
According to the CoE guidelines, the staff should be sensitive to the needs of patients and avoid discrimination. However CoE staff have more impunity than other ART staff and feel that they have the overt and covert support of the nodal officer and regional co-ordinator. Inspite of repeated requests, the ‘research room’ has become the den for some staff to collect and chit chat and surf the net. In the back drop of sick patients accessing the ART centre and those who have been bereaved or requiring sensitive counselling support, one hears the constant laughing and chit chatting by these staff. When requested to tone down the laughter, it escalates. This issue has been brought to the notice of the regional co-ordinator, the KNP plus representative, the APD and the DAPCU to no avail.
In both the permanent facility that is currently under renovation and the existing temporary facility in the CoE premises, there are no seating facilities for the patients when waiting to see the counsellors and doctors. Patients wait anywhere between 2 – 3 hours standing in line to see doctors.
There is no drinking water facility for the patients at the ART centre.
The overall attitude of staff of CoE to patients is disrespectful and derogatory. The SMO made a statement ‘These patients have got this disease due to their own arrogance. Why should so much tax payers money be wasted on them and why should we work so hard for them’”
When a sex worker (Patient L) was brought to the ART centre, the counsellors and Medical officer refused to register her saying “These people never come to the OPD properly and they keep traveling to different places. We should never register them as they make our statistics look bad. The patient was repeatedly asked to go to some other centre and not to ‘eat our head.” The lady was publicly humiliated and insulted as being irresponsible and not deserving of enrolment in the ART centre.
One medical officer asks the patient “Do you have the disease or do I?” The patient is forced to then say “Madam I am the one with the disease not you” The same doctor has not prescribed lab tests for patients for more than two years. When this was brought to the nodal officer, his response was silence. The doctor is vegetarian and promotes vegetarianism to patients. Patients are asked to stop eating ‘mutton/chicken’ Patients ask “Madam should I never eat meat again?” and are told “Why do you want to eat all that? Just eat vegetables.” There is no instruction in any medical text book or NACO guideline that patients living with HIV should turn vegetarian. This is entirely a prejudice on the part of the doctor which is being indiscriminately forced on a patient who is placed in a position of vulnerability and having to accept the ‘doctor’s advice.’ Patients have had to give up their regular eating practices along with their other family members.
When a patient expressed that he was not able to sleep, the doctor responded saying “Now that you know you have the disease, how will you be able to sleep henceforth?”
Patient came on 20/11/15 for ART initiation but was asked by SMO to come back the next day as she was “busy”. The SMO has very good clinical skills that are very beneficial to patients, however is does not have the time or the skills to manage administrative responsibilities. Some of the administrative responsibilities could be handed over to the training co-ordinator as he has a lot of time available on his hands.
Till one month ago, there was no female counsellor at the ART centre. The average time spent by a counsellor with a patient was 1 – 2 minutes. The counsellor is referred to by both staff and patients as the person who does the ‘pill count’. Beyond entering the pill count, the counsellors do not focus on key issues related to sexual behaviour, nutrition, use of condoms, partner counselling, child counselling.
Child counselling is completely absent and many of the PLHIV especially single mothers have expressed extreme difficulty in handling children especially following disclosure about their own (mother’s) illness. This leads to truancy, children running away from home and substance abuse. There is absolutely no counselling facilities available for infected or affected children
Patients are consistently not being informed about condom use.
There is no fast tracking of pregnant women, children or persons with TB.
Patient not being informed about PPTCT protocols – A lady, Patient M at 7 months antenatal was not aware of what measures she should be taking to prevent transmission to the baby, breastfeeding options, when the baby should be tested and how baby should be protected. When questioned, the counsellor said ‘We don’t want to overload patients with too much information. We will go to the labour ward and inform them. They anyway do not have the capacity to understand,’
Patients are not given any kind of psychological, social or emotional support. Any gap in care is immediately attributed to patient’s ‘ignorance’, ‘bad attitude’ or ‘carelessness’. The entire responsibility and burden of any negative outcome is placed on the patient by doctors, counsellors and lab technicians. Patients are consistently being projected as burdensome individuals, who do not care about their own or their family’s health and that any lapse on their part is wilful and deliberate. Patients are not seen as individuals struggling against oppressive structures, with ongoing financial, social and psychological stressors owing to and aggravated by their disease status.
A patient N who had an MTP on October and planning a tubectomy in December didn’t know about condoms to protect herself from unwanted pregnancy in the interim period. The reason given by the counsellor was that there was no privacy to discuss these things.
Patient O who had a 6 month old baby was being pressurised by the family to conceive a second baby in the hope of a male baby. When the couple was sent to the counsellor and asked later what was told, the husband said ‘I have no idea. He was speaking in Kannada and I understand only Hindi”
Although it is stated that there should be no stigma or discrimination in the institution where the CoE is located, in practice this is not followed at all and in fact the ART centre at Bowring practices extreme degree of discrimination. When patients complain about any form of violation, they are immediately transferred even against their wish. Staff who complain about violation of patient rights are again penalised and harassed.
As the Community Care Co-ordinator is one of the few persons from the community of positive people at the CoE, one would expect a sensitive attitude by the staff of the ART centre. The CoE staff have harassed her in several ways.
- In other centres, People living with HIV are available as first point of contact for patients and are more likely to be understanding and empathetic. The CCC is expected, as part of her job description to be the first point of contact, however the CCC at Bowring has been denied the CCC this role and she is instead penalised for any kind of interaction with patients, KNP+ or NGOs and other organisations working with PLHIV. The male and female social workers sit at the front desk with approval by the SMO and nodal officer ignoring their own responsibilities. This leads to poor LFU care. Although the CCC is not being allowed to do her job responsibilities, she is threatened with dismissal by higher authorities if these responsibilities are not fulfilled.
- When the CCC is supportive of other PLHIV like visiting them in the ward, she is told not to get involved.
- CoE staff abuse her in the singular.
- She is ordered to bring tea and coffee during meetings and serve everyone
- She is expected to be the first to come in the morning to open the ART centre and the last to leave and lock up.
- The ART white cards are handled by multiple staff at the centre. Cards are being held by the medical officers, counsellors, data entry operators, non-medical research co-ordinator. The CCC is then expected to find all cards as and when patients come. Patients are instigated by the counsellors and social workers to shout and abuse and complain about the CCC. This issue has been discussed in detail at a meeting with the regional co-ordinator where it was clarified that the entire team at the ART centre were responsible for ensuring that cards that were taken out of the rack were replaced promptly and in the proper rack. However, many of the staff have deliberately and wilfully placed the cards in their drawers, bags, tables and shout at the CCC as though she is responsible for missing cards. All staff have access to the white patient cards, but in the event of it being misplaced, often deliberately, the entire onus is placed on the CCC and she has no recourse to any form of support mechanism. She is repeatedly asked by the medical officer, nodal officer, regional co-ordinator, counsellor and data persons to leave the job if she cannot ‘manage’.
- This harassment started when she raised issues with KNP+ of counsellors collecting bribes from patients to ensure fast-tracking and following a complaint of harassment made by the CCC to the Medical Superintendent of Bowring` hospital against the previous training co-ordinator.
- Many of the staff also use her for their personal work – collecting laboratory supplies, indents, linen, drugs etc. She is also sent to DAPCU office by the data entry operators to submit attendance list for every month. She is made to attend TB co-ordination meetings, collect drugs from other centre and visit KSAPS office if required. She is treated like an office assistant and has absolutely no interaction with patients.
- I have heard two counsellors telling male patients to shout at her for not issuing cards on time. These male patients start yelling and shouting at her in a very offensive way leaving her in tears. This amounts to outright harassment of a positive person working in the CoE and goes against the principles of why the CoE was set up in the first place.
- She is not given the patient due list and has to repeatedly request the pharmacist and data entry operators for this. This makes it difficult for her to prepare for the day’s scheduled patients.
- The CCC is one of the few staff of the ART centre who is HIV positive. She is the first to come and the last to leave and is expected to work on all days and not take any leaves. When she applied for a week of sick leave inspite of working almost every working day in the last year without leave, she was questioned by the nodal officer who said “I myself don’t take leave. Why should you?” She was then forced to say that she was from the community of positive people and therefore likely to fall ill more often.
- When the issue of harassment of CCC was brought to the notice of the nodal officer, his response was ‘You should be careful about the people from the community. They only have criticisms to make.”
Lost to follow up
Patients who have been lost to follow up are punished in several ways. They are abused by the counsellor and doctors and told that they are irresponsible and ignorant. The medical officer tells the patient ‘If it is a child, we can slap them and tell them what is wrong and right. What can we do with people like you?”
LFU patients are made to wait for long hours to ‘teach them a lesson’.
One young patient P who had missed tablets for a month said that she had missed tablets for two days and had been verbally abused so badly by the counsellor that she went home and cried for a day and decided never to come back again to the ART centre.
The LFU monitoring staff of Bowring ART centre and CoE never visit the field. The LFU calls are made in a callous and casual manner. The LFU monitoring staff lack skills of communication and spend most of their time chit chatting or sleeping. The process of tracking LFU patients is not monitored. The calls are made from the research room where other CoE staff can be heard laughing and joking in the background.
There is a lack of co-ordination between the regional co-ordinator and nodal officer. Contradictory and conflicting messages were being sent to the staff and this was misused by the staff to get away with poor behaviour and performance. For e.g., the lab technicians have been asked by the regional co-ordinator to collect CD4 samples till 1 pm. On the days of government holidays, they have to leave the samples in the fridge and process them the next day. The nodal officer, on the other hand stated that there was no need to leave samples in the fridge and that collection of CD4 could be stopped at 10.30. The fallout of this is that patients are therefore made to come again the next day, and the laboratory staff can refuse to draw blood from 10.30 am with impunity. Considering that they start collecting samples anyway at 10.30, this means that they have absolutely no work to do on that day.
Nodal officer responds subjectively to the leave and absence of staff. The nodal officer has been partial and showing favouritism which leads to some staff taking undue advantage with regard to leave and being pardoned in spite of repeated complaints against them. While some staff get questioned others are left scot free. When the CCC took a week of sick leave she was humiliated by the nodal officer. However, the non-medical research officer had been late 20 days in a month but when the PA to the medical superintendent was to take action, he was told by the nodal officer ‘Yake sumne thale kedskothira?” (Why do you unnecessarily stress yourself over this issue?).
Patient Q was started on Stavudine and Lamivudine combination. In October, he was told that supply was only for five days so he had to go to Davangere and then his brother came after five days to collect the drugs and had to send it by courier to the patient. Patient has been coming since the last six months. In November, the patient was asked to buy the drug from an outside pharmacy as it was not available in Bowring. The drug costs Rs. 600/- at a pharmacy in Bangalore but patient had not brought the money.
Sometimes drugs have to be brought from the store room to the ART centre. Even in such instances, patients are told to come back the next day as none of the staff are ready to collect the drugs from the store room within the hospital premise and bring them to the pharmacy.
Cotrimoxazole tablets were not available for three months and have become available since the last two months.
The staff nurse who was running the pharmacy in the absence of a pharmacist initially used to shut the pharmacy promptly at 4 pm and leave even if patients were waiting for medicines. However, with a warning she is now available everyday till the last patient receives medicines. This is to be appreciated. It is a good example of how when given feedback about negative attitude and behaviour, some staff are willing to change and work towards better patient care.
The public health system is under threat with the expanding market and large scale privatisation processes. In this backdrop, it is important that public health services are sensitive to patient’s needs and responsive. With the increasing budget crunch, it is further important that limited resources are used in an efficient manner.
People living with HIV are already facing a great deal of discrimination in the larger society. The CoE is intended as a facility that will be a role model on inclusive and comprehensive patient care. There is therefore a need for checks and balances for all actions that affect the patients emotionally, socially, psychologically and in terms of their health.
The ART centre and CoE of Bowring and Lady Curzon hospital has to be a role model for all the other ART centres in the state and possibly outside the state. This report is being submitted to help facilitate that process.
(After receipt of this report and independent complaints by the Bangalore HIV/AIDs Action Forum (BHAF), a meeting(meeting minutes attached) was conducted by the Project Director, Mr. S G Raveendra KSAPS where he took serious cognisance of the complaints and directed specific actions. However, the Project Director was transferred immediately (it is unsure if this is just pure co-incidence) and none of the actions were implemented. The CCC who faced harassment at Bowring ART centre was transferred immediately to KC General inspite of her repeated requests not to. She was penalised while the people against whom complaints were raised continue the same behaviour and attitude.)
- Laboratory technicians to be in the lab at 9 am upto 1 pm whether patients are there or not. After 2 pm, atleast one lab technician should be available in the laboratory.
- Peer counsellor to be placed at all ART centres, LAC and LAC + centre as first point of contact.
- Counselors to give the CD4 forms one month prior to the due date and advice patients to come before one pm the next month. Patients should not be penalised or punished by refusing to give them medicines. Counselors should document when they have advised CD4 testing. In some centres (KC general/Victoria) only 30 CD4 are done per day.
- Patients who are due for CD4 should be fast-tracked and sent to the Lab. They should not be made to wait till after 1 pm.
- Due list to be issued to the CCC in advance.
- Except CCC, the white cards should not be handled by any other staff for removing or placing in the racks otherwise cards are getting lost. The CCC should be the point of contact for issuing and returning white cards.
- Staff should be strictly warned about discriminatory behaviour towards positive patients. Any complaints of harassment or discrimination should be referred to the grievance redressal forum and strict action to be taken.
- Absence, late coming and any written complaints against any of the staff should be strictly addressed and a memo issued. In the event of three memos being issued, the concerned staff should be suspended with loss of pay for a period of a month as warning to the other staff
- New staff to be given training at the earliest and not later than two months.
- Patients who are on LFU should be counselled and supported to re-enter the system rather than being punished.
- Child friendly counsellors who have been trained and monitored regularly.
- NGOs accompanying patients should be allowed to enter the ART centre. There could be a visit register with signing in and signing out to ensure accountability
- Fast tracking of patients who are pregnant, children, elderly, sick and those suspected with tuberculosis.
- Nodal officer, regional co-ordinator, DAPCU and APD to have clarity on roles and responsibilities and not give conflicting messages to staff.
- Regular monitoring visits to be made by KSAPs authorities.
- Grievance redressal mechanisms to be instituted for patients. Patient grievances to be addressed urgently and seriously
- Admission – Good communication and co-ordination between ART centre and ward. Regular rounds to be conducted by the ART staff. Patients should not be kept in separate wards as it amounts to discrimination.
- Counseling to include problem due to defaulting, nutrition, sexual health and adherence