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Improvement Report
Dr. Minal Mehta

Topics: HIV counseling and testing, HIV/AIDS basic care and support, HIV/AIDS

Region and Country: India, Asia

Organization: Private Charitable Hospital in Central Suburb of Mumbai India
The Report

 This improvement report refers to the period Jan 2003- December 2005.  The facilities were  private charitable hospitals running a clinic for HIV AIDS. ( Name of the organization, funding agency and sample studied are concealed in line with the ethical principles of anonymity and confidentiality ). Two clinics hired PLHIV staff as nurse, receptionist, outreach workers, and an accountant. I was offering honorary counseling service in these clinics.

 The problem that was faced was Neuro-cognitive impairment in the varying degree in the staff of the two clinics. Examples were – toilet taps of the two facilities were often found soiled with the blood or vaginal secretions, used needles were found uncapped in the positions which exposed others to get needle stick injury.
While counseling is integral part of HIV AIDS program. It is limited to pre and post test counseling with no correlation with the disease progression. Very little attention is given to the psychotherapeutic needs of PLHA in advanced stage of the disease. It is proposed that intensive counseling and psychotherapy may become integral part of the HIV AIDS management. The report also highlights outcome of intensive sessions of cognitive retraining, positive imagery and positive suggestion sessions conducted for 10 PLHA under study at weekly interval during the study period Jan 2003- December 2005.

Report draws on a case study of a care and support program run by a charitable hospital in Mumbai The 10 PLHA under study were in the age group of 25 to 35 years married with spouse alive or dead. One PLHA was transgender, One was Male and 8 PLHA were women. They all formed the staff of the care unit of the hospital/clinic and will be referred hereafter in this text as informants. They were employed by the hospital/clinic under GIPA principle. 

Informants were interviewed initially as part of the history taking session which lasted for two hours. The subsequent counseling sessions were conducted on monthly basis for one year. Thereafter the informants were subjected to intensive cognitive retraining, positive imagery and positive suggestions method of psychological intervention over next one year on a weekly basis.
History taking interview were recorded in a text format. Counseling sessions were digitalized and transcripts were prepared which were then subjected to Thematic Content Analysis. ( Reference- by an independent statistician in private practice ). Goal of the preliminary data analysis was to identify the psychological coping mechanism used by PLHA to handle their life situation. Data analysis was done manually.

Forms of Neuro Cognitive  impairment observed in the PLHA –

HIV infection in advance stage is known to affect neurological function. However, this is rarely emphasized  and addressed. It was observed that cognitive impairment was shown by 7/10 PLHA under study. One informant wrote in the daily diary – “ she used the common toilet in the work place and sticky secretions from her vagina were applied intermittently to the tap. She used to hope that some one could get the infection in the process”- However, during counseling session she expressed that she had no control over her behaviour and she needs help. Second informant was nurse by profession. In the counseling session she shared - “In the ward after the blood collection she used to leave the needle open on the edge of the table in the hope that someone could get infected by needle prick.”. she precipitated this behaviour only when she felt threatened by any event, episode or situation. However, the threshold of the perceived threat was too low and hence behavior was repeated once in two or three days. Behavior change was observed immediately after the intensive counseling session. One informant had developed cervical cancer and used to have profused bleeding during menses and would leave the toilet uncleaned. Most of the non-PLHA staff were threatened by her behavior at the same time would not want her job terminated on the grounds of illness so accommodated her with supportive intensive counseling. However, this informant eventually succumb to death. This was severe case of total cognitive dysfunction which remained unreported in the clinical case history of the informant. One informant shared in the counseling session she gets boutes of revengeful fellings and then she takes to unprotected sexual relationships. Once the drive for revenge dies down she feels guilty and depressed. One informant under study was a case of failed counseling in the study period. She is having unprotected sex with her husband to get pregnant as well as HIV infection. She is a case of cognitive impairment in absence of HIV. She delivered a baby boy after two years of unprotected sex with her sero positive husband. She and her baby are   non-reactive. She took PPTCT support during and after delivery. However, she continued unprotected sex till the study period was over. This case also confirms that sexual mode of transmission is comparatively slower and varies with individual.
Improvement  seen - Empathy, cognitive retraining, positive imagery on weekly, monthly and quaterly basis  resulted in  increased awareness in the informant. In six months time the informants were able to experience  partial control and in one  year time 5/10 informants  reported regaining cognitive health.  4 informant died with improvement in cognitive function but deterioration of other systems. One case failed the counseling.

1)Neuro-cognitive impairment is common but often neglected in the HIV AIDS care setting. Senior medical officials were   asked to intervene but administration feared that PLHIV networks may call it a strategy to discontinue the service of the HIV infected staff and media may give negative publicity.

2) National and International forum were used to create greater awareness through scientific publication but the publication was denied on the grounds of technical insufficiency.
3) 4 informants under study expired towards the end of the study,4 changed the job and 2 informants are continuing the job in the same facility.
4) Till date the HIV AIDS  counseling(ART,TESTING OR PPTCT) offered in the public  sector  or charitable clinic/hospital remains insufficient and needs urgent attention.
5) Cognitive retraining, positive imagery and positive suggestion sessions are very useful but are very demanding technically to be monitored for informant numbers as large as 10.
6)Case progress recording system in private practice is challenging due to limited funding.