National AIDS Control Program

1. National AIDS Control Program Dr. KANUPRIYA CHATURVEDI

2. Lesson Objectives • To know about the extent of the problem of HIV/AIDS in India • To learn about the evolution of India’s response to HIV/AIDS: phases 1,2, 3 of NACP(National AIDS Control Program) • To know about the goals, objectives, strategies of NACP • To know about the achievements of NACP Dr. KANUPRIYA CHATURVEDI

3. Global estimates for Adults and Children, 2008 Dr. KANUPRIYA CHATURVEDI

4. HIV estimates for India (2007) Dr. KANUPRIYA CHATURVEDI

5. Current Scenario • HIV situation in the country is assessed and monitored through regular annual sentinel surveillance established since 1992. • There are 1.8 - 2.9 million (2.31 million) people living with HIV/AIDS at the end of 2007. The estimated adult prevalence in the country is 0.34% (0.25% - 0.43%) and it is greater among males (0.44%) than among females (0.23%). • The overall HIV prevalence among different population groups in 2007 continues to portray the concentrated epidemic in India, with a very high prevalence among High Risk Groups - IDU (7.2%), MSM (7.4%), FSW (5.1%) & STD (3.6%) and low prevalence among ANC clinic attendees (Age adjusted - 0.48%). Dr. KANUPRIYA CHATURVEDI

6. Overview • In India, after the first case of HIV was detected in Chennai in 1986, the virus spread rapidly across the nation in both urban and rural areas. • Since then, the HIV epidemic has traveled a long way, establishing itself with the greatest speed in the six high prevalence states of Andhra Pradesh, Maharashtra, Manipur, Nagaland, Karnataka and Tamil Nadu. • The natural history of the HIV epidemic has played out in various forms - from the injecting drug use-driven epidemic of the North East seen in Manipur and Nagaland, to the sex work-driven epidemic of the south of India. • Since, every country and every government needs to have a solution to deal with such an issue; the government formulated the National AIDS Control Program. Dr. KANUPRIYA CHATURVEDI

7. National AIDS Control Program( NAPC) • 1985 Govt. of India constituted a taskforce to study the problem of HIV/AIDS as related to India • 1991-1999 A comprehensive HIV/AIDS Control Project Phase I was launched during VIII Plan with an outlay of 222.6 crores with the assistance of World Bank & WHO • 1985 Govt. of India constituted a taskforce to study the problem of HIV/AIDS as related to India • 1991-1999 A comprehensive HIV/AIDS Control Project Phase I was launched during VIII Plan with an outlay of 222.6 crores with the assistance of World Bank & WHO • NAPC Phase II (1999-200 • NAPC Phase III ( 2006- 11) Dr. KANUPRIYA CHATURVEDI

8. National AIDS Control Programme Phase I and II • Phase-I (1992 - 1999) was implemented across the country with objective to slow the spread of HIV to reduce future morbidity, mortality, and the impact of AIDS by initiating a major effort in the prevention of HIV transmission. • Phase-II (1999 - 2006) was aimed at reducing spread of HIV infection in India and strengthen India's capacity to respond to HIV epidemic on long term basis Dr. KANUPRIYA CHATURVEDI

9. Significant Achievements of NACP-I &II • Scaling up PMTCT and VCCTC services especially in the high prevalence states. • Increasing access to free ARV is one of the major achievements of NACP-II. • Recognizing the need of care and support for people living with HIV and AIDS and scaling up of Community Care Centers. Dr. KANUPRIYA CHATURVEDI

10. Contd. • The effectiveness of the condoms as one of the safest methods to prevent and control the spread of HIV and other STIs has been well established. • Initiating the process for developing draft legislation on HIV and AIDS. • Focus has shifted from raising awareness to behavior change, from a national response to a decentralized response and an increasing engagement of NGOs and networks of people living with HIV/AIDS. • The National AIDS Prevention and Control Policy and the National Council on AIDS (NCA), chaired by the Prime Minister, provide policy guidelines and political leadership to the response. Dr. KANUPRIYA CHATURVEDI

11. Phase-III (2007-2012) • Phase-III (2007-2012)is based on the experiences and lessons drawn from NACP-I and II, and is built upon their strengths. Its priorities and thrust areas are drawn up accordingly and include the following: • Considering that more than 99 percent of the population in the country is free from infection, NACP-III places the highest priority on preventive efforts while, at the same time, seeks to integrate prevention with care, support and treatment. Dr. KANUPRIYA CHATURVEDI

12. Contd. • Sub-populations that have the highest risk of exposure to HIV receive the highest priority in the intervention programs. These would include sex workers, men-who-have-sex-with-men and injecting drug users. Second high priority in the intervention programs is accorded to long-distance truckers, prisoners, migrants (including refugees) and street children. • In the general population those who have the greater need for accessing prevention services, such as treatment of STIs, voluntary counseling and testing and condoms, will be next in the line of priority. Dr. KANUPRIYA CHATURVEDI

13. Contd. • NACP-III ensures that all persons who need treatment would have access to prophylaxis and management of opportunistic infections. People who need access to ART will also be assured first line ARV drugs. • Prevention needs of children are addressed through universal provision of PPTCT services. Children who are infected are assured access to pediatric ART. • NACP-III is committed to address the needs of persons infected and affected by HIV, especially children. Dr. KANUPRIYA CHATURVEDI

14. Contd. • NACP-III also plans to invest in community care centres to provide psycho-social support, outreach services, referrals and palliative care. • Socio-economic determinants that make a person vulnerable also increase the risk of exposure to HIV. NACP-III will work with other agencies involved in vulnerability reduction such as women's groups, youth groups, trade unions etc. to integrate HIV prevention into their activities Dr. KANUPRIYA CHATURVEDI

15. Lesson learnt from Phase I &II • The epidemic continues to progress with the following characteristics • High risk groups to low risk groups • Urban to rural areas • High prevalence states to all states • High vulnerability of young persons and women • MSM and IUDs have not received appropriate attention • Growing number of people living with HIV/AIDS has increased the need for care , support and treatment Dr. KANUPRIYA CHATURVEDI

16. Goals and Objectives of NACP-III • The overall goals of NACP-III is to halt and reverse the epidemic in India over the next five years by integrating programmes for prevention, care and support and treatment. This is achieved through a four-pronged strategy • The specific objective is to reduce the rate of incidence by 60 per cent in the first year of the programme in high prevalence states to obtain the reversal of the epidemic, and by 40 percent in the vulnerable states to stabilise the epidemic. Dr. KANUPRIYA CHATURVEDI

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

18. Guiding principles • The unifying credo of Three Ones, i.e., one Agreed Action Framework, one National HIV/AIDS Coordinating Authority and one Agreed National Monitoring and Evaluation System. • Equity is to be monitored by relevant indicators in both prevention and impact mitigation strategies • Respect for the rights of people living with HIV/AIDS (PLHA). Dr. KANUPRIYA CHATURVEDI

19. Contd. • Civil society representation and participation in the planning and implementation of NACP-III is essential for promoting social ownership and community involvement. • Creation of an enabling environment wherein those infected and affected by HIV can lead a life of dignity. This is the cornerstone of all interventions. Dr. KANUPRIYA CHATURVEDI

20. Contd. • Provide universal access to HIV prevention, care, support and treatment services. • For making the implementation mechanism more responsive, proactive and dynamic, the HRD strategy of NACO and SACS is based on qualification, competence, commitment and continuity. Dr. KANUPRIYA CHATURVEDI

21. 1: Prevent new infections Dr. KANUPRIYA CHATURVEDI

22. Objective 1:To prevent new infections • Saturation of coverage of high risk group through targeted interventions. • Scaling up interventions among general population Dr. KANUPRIYA CHATURVEDI

23. 1.1 Saturation of coverage of high risk group through targeted interventions • Essential elements of targeted interventions are: • Access to behavior change communication • Prevention services ( condoms, STI services, needles and syringes • Treatment services( STI services, drug substitution for IDU • Creation of enabling environment at project sites. Dr. KANUPRIYA CHATURVEDI

24. 1.2 Scaling up interventions among general population • STD control program • Voluntary counseling and testing • PPTCT program • Universal precautions and Post exposure prophylaxis • Blood safety • Improved access to quality condoms Dr. KANUPRIYA CHATURVEDI

25. Contd. • Focused efforts on women,children and Young people • Expanding HIV/AIDS response at workplace • Focused efforts on migrants, mobile populations and in cross border areas Dr. KANUPRIYA CHATURVEDI

26. STD Control Program • An estimated five percent adult population affected by STDs, also has HIV infection..Limited diagnostic facilities to manage complicated STDs and drug resistance to major STDs are the other issues of concern that NACP-III addresses • Under NACP-III, a demand for STD services is generated through its awareness on one hand and on the other STD services are expanded through its integration with the Reproductive and Child Health Programme.. Dr. KANUPRIYA CHATURVEDI

27. Voluntary counseling and testing • HIV counselling and testing services were started in India in 1997. There are now more than 4000 Counselling and Testing Centres, mainly located in government hospitals. • Under NACP-III, Voluntary Counselling and Testing Centres (VCTC) and facilities providing Prevention of Parent to Child Transmission of HIV/AIDS (PPTCT) services are remodelled as a hub or ‘Integrated Counselling and Testing Centre’ (ICTC) to provide services to all clients under one roof. • An ICTC is a place where a person is counselled and tested for HIV, of his own free will or as advised by a medical provider. The main functions of an ICTC are: Dr. KANUPRIYA CHATURVEDI

28. PPTCT Program • The Prevention of Parent to Child Transmission of HIV/AIDS (PPTCT) programme was started in the country in the year 2002 following a feasibility study in 11 major hospitals in the five high HIV prevalence states. • Currently, there are more than 4000 Integrated Counselling and Testing Centres (ICTCs) in the country, most of these in government hospitals, which offer PPTCT services to pregnant women. • Of these ICTCs, 502 are located in Obstetrics and Gynaecology Departments and in Maternity Homes where the client load is predominantly comprised of pregnant women Dr. KANUPRIYA CHATURVEDI

29. Blood safety • NACO is committed to bridge the gap in the availability and improve quality of blood under NACP-III. To achieve these objectives NACO plans to: • Raise voluntary blood donation to 90 percent • Establish blood storage centres in Community Health Centres • Expand external quality assessment services for blood screening • Quality management in blood transfusion services • Sensitise clinicians on optimum use of blood, blood components and products • Add 39 blood banks in districts that do not have blood transfusion facility • Establish blood storage centres in 3222 community care centres • Provide refrigerated vans in 500 districts for networking with blood storage centres Dr. KANUPRIYA CHATURVEDI

30. Blood safety contd. • Establish additional model blood banks in 22 states; 10 are functional already • Set up additional Blood Component Separation Units (BCSU) in 80 tertiary care hospitals and separate at least 50 percent of the collection at all BCSUs (162) into components • Promote autologous blood donation • Liaise with Indian Red Cross Society and Ministry of Youth Affairs and Sports to promote voluntary blood donation among the youth • Set up 32 model blood banks in various states • Liaise with the Indian Medical Council (IMC) to mandate the requirement of a department of transfusion medicine in all medical colleges and appropriate transfusion practices in the syllabus of MD/MS clinical subjects • Establish one additional plasma fractionation facility in the country • Establish four Centres of Excellence in blood transfusion services in the four metros in order to cater to any region of the country in time of a crisis • Introduce accreditation of blood banks Dr. KANUPRIYA CHATURVEDI

31. Post exposure prophylaxis • Post exposure prophylaxis (PEP) refers to comprehensive medical management to minimise the risk of infection among Health Care Personnel (HCP) following potential exposure to blood-borne pathogens (HIV, HBV, HCV). • This includes counselling, risk assessment, relevant laboratory investigations based on informed consent of the source and exposed person, first aid and depending on the risk assessment, the provision of short term (four weeks) of antiretroviral drugs, with follow up and support Dr. KANUPRIYA CHATURVEDI

32. Improved access to quality condoms • Under NACP-III condom promotion continues to be an important prevention strategy. The programme seeks to: • Increase condom use during sex with non-regular partner, which is the key to limiting HIV spread through sexual route. • Increase the number of condoms distributed by social marketing programmes. • Increase the number of free condoms distributed through STI and STD clinics, reaching those who are at the highest risk of acquiring or transmitting HIV. • Increase access to condoms, especially to men who have sex with non-regular partners. • Increase the number of commercial condoms sold. • Increase the number of non-traditional outlets for socially marketed condoms, e.g., paan shops, lodges, etc. in strategically located hotspots of solicitation Dr. KANUPRIYA CHATURVEDI

33. Care, support and treatment Dr. KANUPRIYA CHATURVEDI

34. Objective 2: Care support and treatment • Improved treatment access for opportunistic infections and continuation of care • Children affected and infected by HIV • Integration of prevention with care, support and • Community care and support programs • Collaboration with PLHA network • Impact mitigation and linking it with livelihood support. • Improving access to ART for PLHA, Children, quality of services Dr. KANUPRIYA CHATURVEDI

35. ART • Adherence to ART is Critical • ART is Accessible to All • Criteria for ART: • CD4 (cell /mm3)Actions< 200 Treat irrespective of clinical stage 200 – 350 Offer ART for symptomatic patients Initiate Rx before CD4 drop below 200   cells/mm3For Asymptomatic people *>350Defer treatment in asymptomatic persons • There are 127 ART centres operating in the country as of June 2007. By 2012, 250 ART centres will become functional across the country in order to provide people living with HIV/AIDS better access to treatment. Dr. KANUPRIYA CHATURVEDI

36. Strengthen the infrastructure, systems and human resources Dr. KANUPRIYA CHATURVEDI

37. Objective 3:Strengthen the infrastructure, systems and human resources • State AIDS control societies • District aids prevention and control units • Strengthening of the National AIDS control organization • Capacity building • Sustained technical training support to public and private agencies • Mainstreaming HIV and partnership development • Convergence with RCH, TB and MoHFW • Coordination and partnership with donors Dr. KANUPRIYA CHATURVEDI

38. Strengthening strategic information systems (SIMS Dr. KANUPRIYA CHATURVEDI

39. Objective 4: Strengthening strategic information systems (SIMS) • One nationwide strategic information system • Strengthening the comuterised management system (CMIS) and making it more appropriate and userfriendly • Developing community friendly information systems • Developing indicators for the state plans and instiutitonal arrangement for collecting, analyzing and monitoring progress • Hardware and software procurements Dr. KANUPRIYA CHATURVEDI

40. Key Achievements under NACP • Promotion of voluntary blood donation has enabled reducing transmission of HIV infection through contaminated blood from about 6.07% (1999), 4.61% (2003), 2.07% (2005), 1.96% (2006) to 1.87% (2007). • The number of integrated counseling and testing centres increased from 982 in 2004, 1476 in 2005, 4027 in 2006, 4567 in 2007 and 4817 in 2008 (till September, 2008). The number of persons tested in these centres has increased from 17.5 lakh in 2004 to 37.9 lakhs in 2008-09 (August, 2008). • . Dr. KANUPRIYA CHATURVEDI

41. Contd. • The number of STI clinics being supported by NACO has increased from 815 in 2005 to 895 in 2008. The reported number of patients treated for STI in 2005 was 16.7 lakh, in 2006, 20.2 lakh and in 2007, it has increased to 25.9 lakh. • . In the year 2007, a total of 3.2 million pregnant women accessed PPTCT services at ICTCs across the country of which 18449 pregnant women were diagnosed to be HIV +ve. Of these 11460 (62%) pregnant women and the infants born to them received prophylactic single dose Nevirapine to prevent parent to child transmission of HIV. Dr. KANUPRIYA CHATURVEDI

42. Contd. • As of September 2008, 5,61,981 patients have been registered at ART centers and 1,77,808 clinically eligible patients are receiving free ART in Govt. & inter-sectoral health sector. • This is achieved through 179 ART centers across 31 states. Total 159 Community Care Centers are established across country of providing Care & Support Services to PLHA's. • The Targeted Intervention (TI) projects aim to interrupt HIV transmission among highly vulnerable populations. Such population groups include - commercial sex workers, injecting drug users, men who have sex with men, truckers and migrant workers. • As on date, 1132 Targeted Interventions are operational in various states and UTs in the country Dr. KANUPRIYA CHATURVEDI