dr. b.b. rewari who national consultant (art) national aids control organisation new delhi
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Overcoming Barriers: Road Map for Universal Access to Care, Support and Treatment in India Satellite Session XVI International Aids Conference Toronto, Canada,16 th August 2006. Dr. B.B. Rewari WHO National Consultant (ART) National AIDS Control Organisation New Delhi. - PowerPoint PPT PresentationTRANSCRIPT
Overcoming Barriers:Road Map for Universal Access to Care, Support and Treatment
in India
Satellite SessionXVI International Aids ConferenceToronto, Canada,16th August 2006
Dr. B.B. Rewari WHO National Consultant (ART)
National AIDS Control OrganisationNew Delhi
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Pondichery
Gujarat
Karnataka
Goa
Lakshwadeep
Dadra Nagar HaveliMaharashtra
Madhya Pradesh
Kerala
Tamil Nadu
Andhra Pradesh
Punjab
Rajasthan
Daman & Diu
J & K
Haryana
Uttar Pradesh
Himachal Pradesh
Delhi
Chandigarh
Bihar
West Bengal
Orissa
Andaman & Nicobar
Mizoram
Meghalaya
Assam
Sikkim
Manipur
Tripura
Arunachal Pradesh
Nagaland
HIV/AIDS Epidemic in India-2005HIV/AIDS Epidemic in India-2005
>1%in Antenatal mothers
>5% in High Risk Groups
<5% in High risk groups
2
Total: 5.206 m
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High Prevalence
Moderate Prevalence
Highly Vulnerable
Vulnerable States
Tamil NaduAndhra PradeshMaharashtraKarnatakaNagaland Manipur
Gujarat GoaPondicherry
AssamBiharDelhiHimachal PradeshKeralaMadhya PradeshPunjabRajasthanUttar PradeshWest BengalChhattisgarhJharkhandOrissaUttranchal
Arunachal PradeshHaryanaJammu & KashmirMeghalayaMizoramSikkimTripuraAndaman & Nicobar IslandsChandigarhDadra & Nagar HaveliDaman & DiuLakshadweep
HIV Prevalence : States Reclassified
•Targeted interventions
•STD care and condom programming
•Blood safety
•Voluntary counselling and testing
•Adolescents
•IEC and social mobilisation
•PPTCT
•Community Care
•Treatment of Opportunistic Infections
•Prevention of Occupation Exposure
•Scaling up Scaling up of ARTof ART
•Workplace interventions
•Inter-ministerial links
•Public Private Partnerships
•Surveillance
•Training
•Monitoring and evaluation
•Technical resource group
•Operations research
•Programme management
•AIDS Vaccine Initiative
Prevention
High risk populations
Low risk populations Care &
supportInter-sectoral
collab.Institutional
Strengthening
CareCollaborate Build capacities
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4 Pillars of Management
1. General management
2. Treatment of Opportunistic Infections
3. Chemo-prophylaxis against various O.Is
4. Anti-retroviral therapy (ART).
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Benefits of Antiretroviral Therapy
• Delays disease progression
• Prevents severe OIs
• Decreases rates of hospitalization
• Decreases transmission of HIV
• Increases survival and quality of life
And…
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Benefits of Antiretroviral Therapy
Restores Hope for Both Patients and Health Care Providers!
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FOUR CLASSES OF ANTIRETROVIRAL DRUGSFOUR CLASSES OF ANTIRETROVIRAL DRUGS
NNRRTTII
NNNNRRTTII
PPII
Zidovudine(AZT)
Lamivudine (3TC)
Stavudine (d4T)
Didanosine (ddI)
Zalcitabine (ddC)
Abacavir (ABC)
Tenofovir (TFV)
Emtricitabine (FTC)
Nevirapine (NVP)
Efavirenz (EFV)
Delavirdine (DLV)
Indinavir (IDV)
Nelfinavir (NFV)
Saquinavir (SQV)
Ritonavir (RTV)
Amprenavir (APV)
Lopinavir (LPV)
Atazanavir (ATV)
Fusion Inhibitor: Enfuvirtide (T-20)Fusion Inhibitor: Enfuvirtide (T-20)
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IMPLEMENTATION OF ART IN INDIA
PRINCIPLES AND GUIDELINES
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Objectives and Targets of National ART Programme:
To provide long-term ARV therapy to eligible patients
To monitor and report treatment outcomes on a quarterly basis
To attain individual drug adherence rates of 95% or more
To increase life span so that 50% of patients on ARV are alive 3 years after starting ARV
To ensure that 50% of patients on ARV therapy are engaged in their previous employment
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Details of the ART Initiative
Provide free access to ART for 100,000 PLHA by 2007;188,000 by 2010 in 6 HP states and Delhi and 300,000 by 2011all over the country
EligibilityChildren below 15 yrs of ageWomenPLHA with full blown AIDS
Access in phases, initially through 25 identified medical institutions, 54 at present,100 by July
2007, 250 by 2011(188 in 6 HP states and Delhi)
ART Policy Package
Government commitment
Detection of eligible cases
Standardized combination ARV therapy
Regular, secure supply of ARV drugs
Monitoring system
Regimen Under National Programme
Zidovudine / Lamivudine / NevirapineOr
Stavudine / Lamivudine / Nevirapine
( Efavirenz in place of Nevarapine if coinfected with TB or side effects with NVP,
Tenofovir under consideration for special situations)
Relative Proportions of different Regimen Under National Programme
The relative proportion of ZDV vs STV based combinations is 60:40.
The relative proportion of STV 30 mg and 40 mg based combinations is 90:10
The relative proportion of NVP vs EFV is 80:20
.
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Number of ART service delivery points (GOI)
8 10
25
40
54
0
10
20
30
40
50
6020
04(A
pri
l)
2004
(No
v)
2005
(Mar
ch)
2005
(O
ct)
2006
(Ju
ne)
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ART centres in India
NACO supported existing centres in India(54)
NACO supported new centres in India(46)
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Access to ART in IndiaGRAND TOTAL of patients on ART as on 30th June 2006
NACO supported ART Centres(54) 33490
State supported ART Centres(9) 766
NGO supported ART Centres(2) 3004
Intersectoral Partners(4) 2327
Private Partners(2) 2399
GFATM Round II Centres(6) 406
Grand Total 42392
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Month-wise distribution of patients on ART(June-06)
4200 53
71 6845
7333 91
68 1025
510
740
1154
912
633
1534
917
999
2378
424
490
2648
528
177
2974
632
744
3349
0
0
5000
10000
15000
20000
25000
30000
35000
40000
Jan
Feb
Mar
Apr
May Jun
July
Aug
Sept Oct
Nov
Dec Ja
nFe
bM
arAp
rM
ay Jun
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Distribution of Patients on ART in India
63%
32%
5%
Male
Female
Children
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1 - Pre-ARTRegister
4 - Patient Care &
Treatment Record
2 - ARTEnrollment
Register
5 - ARV Drug
Dispensing Register
6 - DrugStock
Register
ART Records Reports
MonthlyMonthly Report
New and continuing patients
Adherence
Drug stocks
NGOs
Quarterly/AnnuallyCohort Report
Survival
3 - ART Registration Card (kept by patient)
Ongoing at Facility Regimens
CD4 counts
Defaulters
NACO Recording and Reporting Tools
Distribution of patients in HIV care and patients started on ART (by age and sex)
Men 57.8%
Women37.1 %
Men 64.2%
Children 5.1 %
Women31.2 %
Children 4.6 %
HIV caren=94,698
Started on ART*n=42,047
*Out of 42,047 patients started on ART, D4T+3TC+NVP was used in 61%
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6 months (n=5,241) 12 months (n=2,248) 24 months (n=388)
Treatment outcome of patients at 6, 12 and 24 months after start of treatment
Alive on ART 81%Alive on ART 84% Alive on ART 73%
Died 6% Died
8%Died 13 %
Lost 8%
Lost 13%
Lost 9%
Stopped2%
Stopped1%
Stopped2%
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Initiating ART: Patient education
• It is not curative, but prolongs life• Treatment is lifelong, expensive• High level of adherence is critical (>95%)• Short and long term adverse events• Drug interactions• Safer sex still essential• Do not share drugs with friends , family
members
Start ART when patient is ready
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Role of PLWHA Groups/NGOs in ART programme
• In providing psycho-social support
• In providing treatment literacy to HIV infected persons
• In supporting drug adherence through peer counselling
• Advocacy
• Devising strategies to deliver care at each level of health care
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The value of Adherence
8164
50
256
0
20
40
60
80
100
70% 70-80% 80 - 90% 90 - 95% <95%
Percent adherence to therapy
Unde
tect
able
vir
al lo
ad
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Long Term Efficacy of HAARTNo Magic Bullet , No Miracle
Good Attitude, Knowledgeable DoctorsSimplified and potent HAART
Proper MonitoringCommitted Patients
Adherence, adherence, adherence adherence adherence
Ultimate Goal – Long term viral suppression -- Normalized CD4 counts -- Good quality of life
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Steps being taken to prevent emergence of Drug Resistance
• Simple ART implementation guidelines.
• Patient education & counselling on ensuring maximum levels of adherence.
• Ensuring uninterrupted supply of ARV drugs.
• NGOs linkages with all ART centres.
• ART Centres to be Family counselling centres as well.
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Prevention of emergence of HIV Drug Resistance (HIV DR) is accorded a high priority and is a crucial component of the National ART Programme
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HIV DR Activities undertaken
• National workshop on “Accreditation and Drug Resistance monitoring with special reference to ART” – New Delhi, 27 th –28th Jan., 2005.
• Expert Group meeting at National AIDS Research Institute, Pune; 28th – 29th March, 2005.
• Preparation of HIV DR strategy with WHO assistance (Dr. Don Sutherland), New Delhi – May, 2005.• National consultation on “HIV DR Surveillance &
Monitoring meeting”, Chennai – June 2005 (a WHO supported activity)
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ARV Drugs
• Presently only first-line ARV drugs being procured under the NACP.
• Issue of second-line drugs being examined, expert group meeting held in November, 05.
• Cost of first-line ARV drugs is Rs.550/- per month, while second-line drugs will cost Rs.8,000/- per month(16 times more).
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• Infrastructure including laboratory services strengthening
• Training of Health Care providers
• Assuring 95% adherence
• Country wide provision of ART and continuity of drugs supply
• Drug Resistance Surveillance
Challenges
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• Community mobilization and strengthening Network of People Living with HIV/AIDS
• Capacity for Home based care
• Co ordination of HIV-TB activities
• Additional facilities for admission of people on ART with adverse effects
• Pediatric Formulations and second line drugs
Challenges
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