national aids control programme – an overview

National AIDS Control Programme

– An Overview


By the end of the session the participant will understand:

• Epidemiology of HIV in the world and in India

• National AIDS Control Programme (NACP) and the National response to HIV in India

• Details on NACP phase III

– Goal, Objectives & Key Components

– Care, Support and Treatment services

– Linkages between different services


Session Objectives

2

Estimated Range

People living with HIV 34.2 million 31.8 – 35.9 million

New HIV infections in 2011 2.5 million 2.2 – 2.8 million

Deaths due to AIDS in 2011 1.7 million 1.6 – 1.9 million

Global estimates for Adults and Children 2011

National AIDS Control Programme 3

Adults and children estimated to be living with HIV, 2011


Total: 34.2 million (31.8 million – 35.9 million)

Western & Central Europe

860 000[780 000 – 960 000]

Middle East & North Africa330 000

[250 000 – 450 000]

Sub-Saharan Africa23.5 million

[22.2 million – 24.7 million]

Eastern Europe & Central Asia1.5 million


South & South-East Asia4.2 million


Oceania53 000

[43 000 – 60 000]

North America1.4 million

[1.1 million –2 million]

Latin America1.4 million


East Asia830 000

[590 000 – 1.2 million]

Caribbean230 000

[200 000 – 250 000]

Declining Trend of HIV Epidemic in India


Female: 38.7% of PLHIV; Children: 4.4% of PLHIV

Source: HIV Estimations, 2008-09

Estimated Annual New infectionsTrend in India

National AIDS Control Programme 6 Source: HIV Estimations, 2008-09

Decline in Estimated Annual DeathsTrend in India


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176968189872 196466 199502 193257 185870

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0

50000

100000

150000

200000

250000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

• Provisional estimates place the number of people living with HIV in India in 2009 at 23.95 lakhs with an estimated adult HIV prevalence of 0.31 percent

• Available evidence on HIV epidemic in India shows a declining trend at national level

• The epidemic is concentrated among high risk group populations and is heterogenous in its spread

• Heterosexual route of transmission accounts for 87% of HIV cases detected

Disease Burden of HIV in India


District-wise Scenario of HIV/AIDSCategory / Districts NACP-III Definition

A 156 >1% ANC prevalence in any of the sites in the last 3 years

B 39

<1% ANC prevalence in all the sites during last 3 years with >5% prevalence in any HRG site (STD/FSW/MSM/IDU)

C 296

<1% ANC prevalence in all sites during last 3 years with <5% in all STD clinic attendees or any HRG, with known hot spots

D 118

<1% ANC prevalence in all sites during last 3 years with <5% in all STD clinic attendees or any HRG OR no or poor HIV data with no known hot spots

New Districts: 30

Total Districts: 609


Routes of Transmission of HIV

NACO Annual Report 2009-2010

10 National AIDS Control Programme

HIV among various population groups in India, 2008-09

National AIDS Control Programme Source: HIV Estimations, 2008-09 11

National Response


PHASE I 1992-1999

PHASE II 1999-2006

PHASE III 2007-2012


National AIDS Control Programme Phase III (2007-2012)

Objectives:• Prevention of new infections (Saturation of HRG coverage

and scale up of interventions for General population)

• Increased proportion of PLHIV receiving care, support and treatment

• Strengthening capacities at district, state and national levels

• Building Strategic information management systems

Goal : Halt and reverse the epidemic in India over the next five years


NACP Phase III: Strategies in detailPrevention

High risk populations

Low risk populations

People living with HIV/AIDS

Care, Support and Treatment

• Targeted Interventions for High Risk Groups (FSW, MSM, IDU, Truckers & Migrants)

• Link Worker Scheme for rural population

• Prevention & Control of Sexually Transmitted Infections

• IEC, Social Mobilisation & Mainstreaming

• Condom promotion

• Blood safety

• Counselling & Testing Services (ICTC, PPTCT, HIV/TB)

• First line & second line ART

• Community Care Centres

• HIV-TB Coordination

• Treatment of Opportunistic Infections


Implemented by NGOs and focuses on saturating the High Risk Groups (FSW, IDUs & MSM) and bridge population (migrants and truckers)

Services offered under TI include:

• Condom promotion

• Management of Sexually transmitted infections

• Needle Exchange Programme / oral substitution therapy (for injecting drug users)

• Creating an enabling Environment

• Behaviour Change Communication (BCC)

• Referral services for counselling and HIV testing and treatment

Targeted Interventions (TI)


Revised Migrant HIV Strategy


• Ten times higher prevalence rates in migrants than General Population; Highest prevalence after the HRG – 3.6 %

• Low prevalence districts with high migration to and from high prevalent destinations are rapidly increasing HIV epidemic

• Example: from high to low (Ganjam to Surat)

• 230 destination site interventions among migrants in 21 States cover 117 districts with high in-migration across country, covering 19.11 lakh high risk migrants

• 122 districts identified with high out-migration – source districts across 11 States

Link Workers Scheme


• Reaches out to HRGs and vulnerable men & women in rural areas

– Range of vulnerable population has expanded to widows, out of school youth, people who have multiple sexual partners and spouses / partners of HRGs

– NACP–NRHM Convergence covers pregnant women

– Information provided on risk reduction, knowledge, skills & services on STIs / HIV prevention

– Addresses the potential, outgoing and returnee migrants

• Implemented in 127 districts in partnership with partner agencies

– GFATM (60 districts), UNICEF (26), UNDP (25) & USAID (16)

Provision of STI / RTI case services is an important strategy to prevent HIV transmission and promote sexual and reproductive health under NACP-III and RCH-II. These include:

• Training of preferred private practitioners for syndromic management

• Diagnosis and treatment of sexually transmitted infections through syndromic cases management by providing colour coded packs

• Linkages with HRGs

• Referral services from STI clinics to Integrated Counselling and Testing Centres

Sexually Transmitted Infections (STI Clinics)


Information Education and Communication (IEC)


• IEC campaigns for behaviour change, demand generation linked to services

• Theme-wise campaign to promote HIV counselling & testing, ART, treatment for STIs, condoms, voluntary blood donation & address stigma and discrimination

• Multimedia approach (use of mass media, mid-media, out door and inter-personal communication)

• Special episodes on HIV on Doordarshan

• IEC toolkits prepared for High Risk Groups, Integrated Counselling & Testing Centres, ART & STI centres

Condom Promotion

Free Condoms - Procured by MoHFW• Distributed by NACO through TI NGOs/ICTC/ART

centre for HIV/AIDS Prevention• Distributed by MoHFW through PHC, CHC, health

workers for Family Planning

Socially Marketed Condoms - 8 SMOs• Distributed by Social Marketing Organisations,

provided by MoHFW on subsidised rates

Commercial Condoms• Distributed by Commercial Organisations like

JK Ansell, Men pharma, TTK LIG, etc.


Blood Safety


• Adequate supply of safe and quality blood

– Screening of donated blood for HIV, syphilis, hepatitis B & C and malaria before transfusion

• Promoting voluntary blood donations:

– Target: 80%; Achievement in 2010: 77.8%

• Blood Components Separation Units (BCSU):

– Facilities made functional in 60 Blood Banks (Target: 80)

– 41.1% whole blood converted into components in BCSU by December 2010 (Target: 80%)

• Increasing access to blood in rural areas through blood storage units

Blood Safety: New initiatives


• Setting up of Metro Blood Banks as Centre of Excellence in Transfusion Medicine

– 4 Metro Blood Banks as Centres of Excellence, in New Delhi, Mumbai, Kolkata & Chennai (budget of Rs. 468 crores)

– Blood Banks will have State of the Art facilities with 100% Voluntary Blood Donation

– 100% blood components preparation and capacity to process more than 100,000 units of blood annually

• Plasma Fractionation Centre (PFC)

– To set up PFC with a processing capacity of more than 150,000 litres of plasma in Chennai with budget of Rs. 250 crores over 5 years

Linkages of ICTC: Gateway to HIV CareSTI

ServicesWalk-in Clients

Prevention Services

Targeted Interventions

TB Services

Integrated Counselling and Testing Centres (ICTC):HIV Counselling and Testing

PLHIV linked to care, support and treatment services

through referrals to

ART Centres CD4 testing,

Care, support & treatment

Antenatal Care

Referral to home and community based care

Onsite Services: PPTCT, TB/HIV, Basic OI Management, TB and STI Care, Reproductive

and Child Health, Routine and Emergency Medical Care


Single window service for:• Pre-test counselling before HIV testing• HIV testing and providing results of the test• Post-test counselling to both positive and negative persons• Condom promotion and distribution • Identification for HIV+ pregnant women • Providing prophylaxis (Nevirapine tablet and syrup and

mother and new born) for prevention of transmission from mother to child

• Prophylactic (Co-trimoxozole) to exposed children • Education regarding infant feeding • Referral to ART Centre for investigation and treatment• Cross referral between RNTCP and ICTCs

Integrated Counselling & Testing Centres


Voluntary Counselling

Testing

ICTC is the entry

point

Secondary HealthCare

NGOsYouth Groups

Volunteers

DistrictHospitals

HIV ClinicsSocial/legal

SupportHospice

Specialistsand SpecialisedCare facilities

Palliativeemotional &

spiritual supportself care

Primary HealthCare

Community CareTertiary Health

Care

Home care

Peer

support

-Health posts-Dispensaries-Traditional-Orphan care

PLHIV

Continuum of Care for PLHIV


Care Support & Treatment


Comprehensive HIV Care:

• The overall goal is to improve the survival and quality of life of PLHIV with Comprehensive HIV care package of services including condoms and prevention education

ART Policy Package:

• Free Universal Access to ART

• Free Diagnostic services

• Standardised combination ARV therapy

• Regular and secure supply of ARV drugs

• Robust Monitoring & Evaluation system

Model of HIV Treatment ServicePublic Health Infrastructure

Selected Medical colleges

Medical college and

District Level Hospital

Sub-District level

hospitals & CHC

Care Support & Treatment ProgrammeThree tier Structure


CST Services: Referrals & Linkages


RNTCP

Care & Support ( CCC & DLN)

• Capacity building of good quality, skilled and knowledgeable healthcare providers in chronic patient management, including treatment failures

• Training HIV Care personnel (Training centre)

• Operational Research and scientific publications

• Fellowship Programmes for doctors

• Mentoring ART centres in the region / state

• Distance Education / consultation: Telemedicine

• Repository of information related to HIV/AIDS

Centres of Excellence


ART Plus Centres: Rationale

• Patients experiencing treatment failure with First Line ART are referred to the Centres of Excellence for further evaluation and Second Line treatment.

• Many patients are reportedly facing problems due to long distance, travel, time and costs.

• Based on the existing number of patients on Second Line ART & distance from CoE, it has been decided to expand the network of ART centres that would be capacitated to start Second Line treatment following the same referral procedure as adopted for the Centres of Excellence.


• Integrate ART services with the Primary / Secondary Health Care system

• Build capacity of the health care staff at the Primary Health Care Level in ART treatment

• Increase access to ART services

• Improvement in the adherence of patients to ART

• Improve quality of services at ART Centres by decongestion and decentralisation

• Reduce the travel cost and travel time of PLHIV to access services

Link ART Centre: Objectives


• LAC Plus scheme is being implemented in the existing LACs, as and when the patient load (PLHIV on ART) crosses 70

• Manpower:

• Currently, the LACs are utilising the existing human resources of the ICTC and the institution

• However, for LAC Plus, a contractual nurse is being recruited to handle the additional functions and work load

LAC Plus Scheme


Functions of LAC & LAC Plus


LAC LAC PlusARV Drug dispensing All the functions of LAC

Monitoring of PLHIV on ART Enrolment of PLHIV into HIV care and ART Care

Counselling on Adherence, nutrition and positive prevention

Pre-ART management including basic investigations and CD4 testing through linkage

Treatment of Minor OIsFollow up of Pre-ART patients not eligible for ART

Identification of side effectsReferral of eligible patients to Nodal ART Centre for ART initiation

Tracing of MIS / LFU (on ART) patients Line listing and reporting of HIV-TB cases to Nodal ART centre

Psycho-social support to PLHIVTracing LFU (Pre-ART & on ART) & MIS patients

Screening of HIV-TB co infection

Back referral to Nodal ART Centre

Community Care CentresA Community Care Centre is a community based facility for

Accessible, Affordable and Sustainable counselling, support and treatment of PLHIV


• Psycho-social support to PLHIV

• Drug Adherence and nutritional counselling

• Support to new patients on ART

• Follow-up of PLHIV including tracing missed cases and those lost to follow-up

• Home-based care and services

• Treatment of minor OIs (Out-patient / Inpatient Care)

• Palliative treatment to terminal cases

Care Support & Treatment Programme

• National ART programme was started on April 1, 2004 at 8 institutions in India

• Target under NACP-III:

– 250 ART Centres

• ART Target NACP-III:

– 3 lakh adult PLHIV

– 40,000 children (CLHIV)

NACP: Update of CST Activities 35

Scale up of CST Facilities


Facility forCST

Baseline (March 2007)

NACP-III Target

(March 2012)

January2012

ART Centres 107 250 342

Centres of Excellence

0 10 10

Regional Paediatric ART Centres

0 7 7

ART Plus Centres 0 28 Functional: 20

Link ART Centres

-- -- 685

Community Care Centres

122 350 253

ICTC–ART Linkages

0

200000

400000

600000

800000

1000000

1200000

1400000

1600000

1800000

2007 2008 2009 2010 2011Not linked 361018 398639 416339 426206 302310Linked to ART 366641 611754 893567 1122351 1468440

PLH

IV id

entif

ied

at IC

TC

7,27,659

13,09,906

10,10,393

17,70,750

72.5%

50.4 %

60.5%

68.2%


83%

15,48,557

ART Scale up in India


Registered in HIV Care

Ever started on ART

PLHIV alive and on ART

CLHIV alive and on ART

Male 7,59,558 4,55,179 2,57,371 16,837

Female 6,08,414 3,04,921 1,99,725 11,388

Transgender 3,260 1,388 852 -

Total 13,71,232 7,61,488 4,57,948 28,225

As Assessed at the end of January 2012

ART Scale up in India

0 500000 1000000 1500000

Registered under HIV Care

Ever Started on ART

PLHIV alive and on ART

1371232

761488

457948 60% of Ever started on ART


56% of Registered In HIV Care

January 2012 data

Issues and Challenges• Low referrals from ICTC to ART centres

• Early Infant Diagnosis

• Enrollment of children under ART care

• Pre-ART care and Follow up

• Timely and Early initiation of ART

• Ensuring optimal (>95%) adherence to ART

• Tracking patients Lost to follow up (LFU)

• Second line ART initiation

• Linkages with RNTCP and other local networks

• Irrational ART Prescriptions outside National Programme


• The estimated number of people living with HIV in India in 2009 is placed at 23.95 lakhs

• NACP phase III aims to halt and reverse the epidemic in India, to scale up care and support services and to strengthen capacity at all levels

• ICTC is the entry point for providing comprehensive care and support to the HIV-infected persons

• ART services are being expanded to provide treatment nearer to patients' homes

• Process of decentralisation and appropriate referral and linkage services ensure PLHIV of comprehensive care in the existing health delivery system


Key Points

41

national aids control programme – an overview

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