National AIDS control program

National AIDS control program- NACP

1. Presenter: Kartikey , Parnava , Migom Moderator: Dr. Madhu Upadhyay

2. History 1981, cases of Pneumocystis carinii pneumonia (PCP) in 5 gay men in Los Angeles New York and California reported with  Kaposi’s Sarcoma 1981, December- PCP were reported in people who inject drugs.  270 reported cases of severe immune deficiency among gay men - 121 of them had died 1982- initially called gay-related immune deficiency (GRID) In Uganda, doctors reported cases of a new, fatal wasting disease locally known as ‘slim’

3. Suniti Solomon Diagnosed the first indian cases in Chennai in 1985. In 2009, she was awarded , “National Women Bio-scientist Award” by the Indian ministry of Science and Technology. On 25 th January 2017, Govt. of India announced “Padma shri ” award for her contribution towards Medicine “what is killing people with AIDS more is the stigma and discrimination”

4. INDIAN SCENARIO

5. Estimated Adult HIV Prevalence (%) in India

6. Estimated New HIV infections in India

7. State Wise Estimated New HIV Infections among Adults, 2015

8. Annual AIDS-Related Deaths and ART Scale-up, India

9. Routes of HIV Transmission among individuals in 2015-16, SIMS Data 2015-16

10. MILESTONES

11. 1992, IDA Credit of USD 84 million, commitment to combat the disease Objective - slowing down the spread of HIV infections so as to reduce morbidity, mortality and impact of AIDS in the country NACB was constituted and an autonomous NACO was set up to implement the project Focus: awareness generation setting up surveillance system access to safe blood and preventive services for high risk group populations NACP-I

12. NACP II 1999 November, World Bank credit support of USD 191 million Objective: To reduce the spread of HIV infection in India To increase India’s capacity to respond to HIV/AIDS on a long-term basis Key policy initiatives: National AIDS Prevention and Control Policy (2002); Scale up of Targeted Interventions for High risk groups in high prevalence states National Blood Policy Greater Involvement of People with HIV/AIDS (GIPA) National Adolescent Education Programme (NAEP) Introduction of counselling, testing and PPTCT National Anti-Retroviral Treatment (ART) programme Inter-ministerial group for mainstreaming National Council on AIDS Setting up of State AIDS Control Societies in all states

13. NACP-III 2007, July Goal - Halting and Reversing the Epidemic by the end of project period Key pillars: Prevention among HRG and general population Care, support and treatment Key activities: The capacities of  SACS and DAPCUs  have been strengthened Technical Support Units (TSUs) established Dedicated North-East regional Office established State Training Resource Centres (STRC) set up Strategic Information Management System (SIMS) established

14. OBJECTIVES: Objective 1: Reduce new infections by 50% (2007 Baseline of NACP III) Objective 2: Comprehensive care, support and treatment to all persons living with HIV/AIDS NACP-IV

15. Key strategies

16. Guiding principles Continued emphasis on three ones - one Agreed Action Framework, one National HIV/AIDS Coordinating Authority and one Agreed National M&E System. Equity Gender Respect for the rights of the PLHIV Civil society representation and participation Improved public private partnerships Evidence based and result oriented programme implementation.

17. Areas of focus 1. Quality 2. Innovation 3. Integration 4. Leveraging Partnerships 5. Stigma and Discrimination

18. Key priorities Preventing new infections PPTCT Focus on IEC CST GIPA Decentralising rollout of services including technical support Effective use of strategic information Building capacities Integrating HIV services Mainstreaming of HIV/AIDS activities

19. PRIORITISATION OF DISTRICTS FOR PROGRAMME IMPLEMENTATION Category A: More than 1% ANC prevalence in district in any of the sites in the last 3 years Category B: Less than 1% ANC prevalence in all the sites during last 3 years with more than 5% prevalence in any HRG site (STD/FSW/MSM/IDU) Category C: Less than 1% ANC prevalence in all sites during last 3 years with less than 5% in all HRG sites, with known hot spots (Migrants, truckers, large aggregation of factory workers, tourist etc.) Category D: Less than 1% ANC prevalence in all sites during last 3 years with less than 5% in all HRG sites with no known hot spots OR no or poor HIV data

20. Classification of states High prevalence: >5% in HRG & >1% in ANC Moderate prevalence >5% in HRG & <1% in ANC Low prevalence <5% in HRG & <1% in ANC

21. Implementation structure The NACP is implemented through 35 States AIDS Control Societies(SACS) in the states and UTs 3 additional municipal AIDS control societies in Mumbai, Chennai, Ahmedabad District AIDS Prevention and Control Units(DAPCUs) with a team of field funtionaries in A and B category districts for decentralised programme implementation

22. Organogram

23. State AIDS control society (SACS) Autonomous & decentralized A governing body headed by the minister in charge of health/ the chief secretary Representatives from key government departments, the civil society, trade and industry, private health sector and PLHA networks, who meet twice a year It approves new policy initiatives, annual plan and budget, appoints statutory auditors and accepts the annual audit report For better financial and operational efficiency, administrative and financial powers are vested in the executive committee and the programme director Functions: Medical and public health services; Communication and social sector services; and Administration, planning, coordination, monitoring and evaluation, finance and procurement.

24. District AIDS Prevention and Control Units 188 District AIDS Prevention and Control Units (DAPCUs) in A and B category districts spread across 22 states Key Activities: Capacity Building of DAPCU DAPCU led single window approach for PLHIV/HRG linkage with Social incentive/benefit schemes

25. Prevention services Targeted Interventions NSEP, OST for IDUs Migrant population Link Worker Scheme Prevention & Control of STI/RTI Blood Transfusion Services HIV Counselling & Testing PPTCT Condom promotion IEC and BCC Social Mobilization, YIs and AEP Mainstreaming HIV/AIDS Work Place Interventions Care, Support & Treatment Lab services- CD4 Testing, Viral load testing, EID, diagnosis of HIV-2 Free first line & second line ART - ART Centres , link ART Centres , Centres of Excellence & ART plus centres Pediatric ART Nutritional and psycho-social support:-community and support centres HIV-TB coordination Treatment of Opportunistic Infections

26. TARGETED INTERVENTIONS (TI) Core High Risk Groups( FSW, MSM, Transgenders , IDU) Bridge Populations ( Migrants and long distance Truckers) Linkages with care and support services Community mobilization and ownership building Distribution of clean needles and syringes Abscess prevention and management Opioid substitution therapy Linkages with detoxification/ rehabilitation services. Package of services:- Prevention, support and linkage services Screening& treatment of STI Free condom and lubricant distribution Social Marketing of condoms BCC, enabling environment Linkages to ICTC for HIV testing

27. TI

28. New Initiatives under Targeted Interventions 1.“Sustaining the HIV Prevention Impact among Key Populations” 2. Workshop with Law Enforcement Agencies 3. Project Sunrise 4. Project NIRANTAR 5. Migrant Interventions

29. LINK WORKER SCHEME (LWS) To intensify and consolidate prevention services in the rural areas in 163 districts across 18 States Village level workforce - Zonal Supervisors, Cluster Link Workers 20 Cluster Link Workers in each district for clusters of villages ( 5 villages each) Supervised by 2 zonal supervisors in each district

30. SEXUALLY TRANSMITTED INFECTIONS (STI) AND REPRODUCTIVE TRACT INFECTION (RTI) CONTROL & PREVENTION PROGRAMME Pre-packed STI/RTI colour -coded kits

31. CONDOM PROMOTION PROGRAMME Targeted Condom Social Marketing programme Condom Demand Generation Optimization of Free Supply of Condoms Ganpati mandals join hands

32. BLOOD TRANSFUSION SERVICES Current Scenario - 2760 licensed blood banks National Blood Transfusion Council (NBTC) Promotion of Voluntary Blood Donation New initiatives under BTS Model Blood Banks Blood Component Separation Units Major Blood Banks and District Level Blood Banks Blood Transportation Vans Monitoring and supervision of Blood Transfusion Services Metro Blood Banks Plasma Fractionation Centre

33. HIV counselling and testing services I. Integrated Counselling and Testing Centre II. Prevention of Parent-to-Child Transmission of HIV III. HIV/Tuberculosis collaborative activities

34. 1. All HCTS facilities have been divided into two groups: · Screening Facility (F-ICTC, PPP-ICTC, TI-ICTC, OPD, IPD, Emergency wards etc.), and · Confirmatory Facility (SA-ICTC) 2. Community-based HIV screening approaches 3. Public Private Partnership models 4. Standardize pre-test and post-test counselling 5. All individuals accessing ICTCs will now be verbally screened for TB, STI/RTI and other co-infections by the counsellor. 6. Standard operating procedures for all counsellors 7. New sections on (a) HIV-TB collaborative activities, (b) linkages, (c) supply chain management, (d) IEC activities, (e) information management system and (f) testing for syphilis at the HCTS testing facility, have also been added. Key changes

35. ICTC Fixed facility ICTCs Stand alone ICTCs (SA-ICTC) Facility ICTCs (F-ICTC) Mobile ICTC

36. Unique PID code Digits Meaning First 2 digits Type of individual (PW/GI) Second 6 digits Reporting unit Third 2 digits State code Fourth 3 digits District code Fifth 3 digits ICTC Centre number Sixth 2 digits Year Last 5 digits Individual serial number E.g. PW SAICTC DL SED 001 17 12345

37. PPTCT

38. TWO OPTIONS: Providing lifelong ART to all the pregnant and breastfeeding women living with HIV regardless of CD4 count or clinical stage OR Providing ART (ARV drugs) for pregnant and breastfeeding women with HIV during the mother-to-child transmission risk period and then continuing life long ART for those eligible for treatment for their own health

39. GOALS Primary prevention of HIV, especially among women in child-bearing age. Integration of PPTCT interventions with general health services such as basic Ante-natal Care (ANC), Natal and Post –Natal Services, Sexual Reproductive Health and Family Planning, EID, Paediatric ART and Adolescent Reproductive and Sexual Health (ARSH), TB and STI/RTI services. Strengthening post-natal care of the HIV-infected mother and her exposed infant Provide the essential package of PPTCT services

40. Essential package of PPTCT services Routine offer to all pregnant women, ‘opt out’ option ‘ANC Centric’ to ‘Family Centric’ approach Life long ART (TDF+3TC+EFV) Promotion of institutional delivery Provision of nutrition, counselling and psychosocial support Provision of care for associated conditions Provision of ARV prophylaxis with syrup Nevirapine to infants Early infant diagnosis using HIV-DNA PCR at 6 weeks of age, repeat testing at 6 months, 12 months, and 6 months after cessation of BF Integrate follow up of HIV exposed infants into routine healthcare services All babies detected positive <2 years of age to be given Pediatric ARV irrespective of CD4 count Exclusive BF, MIXED FEEDING SHOULD NOT BE DONE

41. HIV TB co-infection Out of 2.1 million PLHIV in India, 95000 co-infected with TB 15-18% of all deaths among HIV infected individuals Active TB is the commonest opportunistic infection All HIV TB co-infected patients regardless of the CD4 count should be ART First priority is to start TB treatment National framework for joint HIV/TB collaborative activities-November 2013

42. Management of special TB/HIV cases TB/HIV patients on Protease inhibitor based ARV TB/HIV in children TB/HIV in pregnant women Drug resistant TB/HIV Prevention Isoniazid preventive therapy Air borne infection control Awareness generation Early detection of TB/HIV 100% coverage of provider initiated testing and counselling PITC in presumptive TB cases Rapid diagnostics for detection of TB and DR-TB in PLHIV Intensified case finding activities at all HIV settings Prompt treatment of TB/HIV Early initiation of ART Prompt initiation of TB treatment

43. HIV TESTING GUIDELINES

44. Initiation of ART based on CD4 count and WHO clinical staging WHO Clinical Stage Recommendations HIV infected Adults & Adolescents (Including pregnant women) Clinical Stage I and II Start ART if CD4 < 350 cells/mm3 Clinical Stage III and IV Start ART irrespective of CD4 count For HIV and TB co-infected patients Patients with HIV and TB co-infection (Pulmonary/ Extra-Pulmonary) Start ART irrespective of CD4 count and type of tuberculosis (Start ATT first, initiate ART as early as possible between 2 weeks to 2 months when TB treatment is tolerated) For HIV and Hepatitis B and C co-infected patients HIV and HBV / HCV co-infection – without any evidence of chronic active Hepatitis Start ART if CD4 < 350 cells/mm3 HIV and HBV / HCV co-infection – With documented evidence of chronic active Hepatitis Start ART irrespective of CD4 count

45. hr 0 min As soon as possible Ideally within 2 hrs , but certainly within 72 hrs 6 months Step 1: Manage exposure site Step 2: Establish eligibility for PEP Step 3: Counsel for PEP Assess source patient’s ARV status Step 5: Laboratory evaluation Step 6: Follow up and monitor adherence Wash wound and surrounding skin with water and soap OR Irrigate exposed eye immediately with water or normal saline OR Rinse the mouth thoroughly , using water or saline and spit again Refer to physician Exposure within 72 hours Assess exposed individual Assess exposure source Assess type of exposure Determine risk of transmission Determine eligibility for PEP Provide information on HIV and PEP Obtain consent for PEP Offer special leave from work Step 4: Prescribe PEP Check for pregnancy if exposed female HCP Explain side-effects of ARVs Explain post-exposure measures against HBV and HBC Provide HIV pre-test counselling Check immunisation status for hepatitis B Offer HIV, HBV, HBC test Draw blood to include CBC, Liver function tests, pregnancy test, if applicable Provide HIV post-test counselling Record- keeping Follow up visits for clinical assessment at 2 weeks and hepatitis B vaccination if needed HIV test at 3 and 6 months Steps for Occupational Exposure

46. Assessing the nature of exposure and risk of transmission Categories of exposure Category Definition and example Mild exposure Mucous membrane/non-intact skin with small volumes e.g. superficial wound (erosion of the epidermis) with a plain or low calibre needle, subcutaneous injection following small- bore needle. Moderate exposure Mucous membrane/non-intact skin with large volumes OR percutaneous superficial exposure with solid needle e.g. a cut or needle stick injury penetrating glove Severe exposure Percutaneous with large volume, e.g. an accident with high calibre needle (>18 G) visibly contaminated with blood; a deep wound ; Transmission of a significant volume of blood ; an accident with material that has previously been used intravenously or intraarterially .

47. Assessing the HIV status of the source of exposure Categories of situations depending on results of the source Source HIV status Definition of risk in source HIV negative Source is not HIV infected but consider HBV AND HCV Low risk High risk Unknown HIV positive and clinically asymptomatic HIV positive and clinically symptomatic ( see WHO clinical staging) Status of the patient is unknown, and neither the patient nor his/her blood is available for testing ( e.g. injury during medical waste management the source patient might be unknown). The risk assessment will be based only upon the exposure ( HIV prevalence in the locality can be considered)

48. HIV post -exposure evaluation for prophylaxis Exposure Status of source HIV+ and Asymptomatic HIV+ and Clinically symptomatic HIV status unknown HIV status negative Mild Moderate Severe Consider 2-drug PEP Start 2-drug PEP Start 3-drug PEP Start 2-drug PEP Start 3-drug PEP Start 3-drug PEP Consider 2-drug PEP Consider 2-drug PEP Consider 2-drug PEP No PEP is required if the source blood is confirmed HIV negative

49. PEP Drug Regimens to be Prescribed by Health Centres Preferred Alternative 2-drug regimen (basic PEP regimen) 1st choice: Zidovudine (AZT) + Lamivudine ( 3TC) 2nd choice: Stavudine (d4T) + Lamivudine (3TC) 3-drug regimen (expanded PEP regimen) – consult expert opinion for starting 3rd drug e.g. Lopinavir/ Ritonavir, Nelfinavir or Indinavir Not recommended Didanosine ( ddl ) + Stavudine ( d4T) Non nucleoside Reverse Transcriptase Inhibitor (NNRTI) such as Nevirapine should not be used in PEP HIV chemoprophylaxis

50. SURVEILLANCE OF HIV AIDS AIDS case surveillance HIV sentinel surveillance STD surveillance Behavioural surveillance

51. Element Summary Sentinel site ANC clinic Sample size 400 Duration 3 months Frequency Once in two years since 2008-09 Sampling method Consecutive Eligibility criteria Pregnant women. 15-49 years, attending the ANC for the first time Exclusion criteria Already visited once at the ANC site Blood specimen Serum Testing strategy Unlinked anonymous Testing protocol Two test protocol HSS methodology

52. National integrated biological and behavioural surveillance To strengthen HIV surveillance among high risk groups and bridge population Objective: To analyse and understand HIV related behaviours and HIV prevalence among key risk groups by linking behaviours with biological findings To measure and estimate the change in HIV related risk behaviours and HIV prevalence among key risk groups, between baseline and end line for NACP-IV 276 Domains – independent/composite FSW, MSM, TG, IDU, MIG, CMW

53. Care, support and treatment Service Delivery Mechanism:- ART Centers, Centers of Excellence Pediatric Centers of Excellence Facility Integrated ART Centers Link ART Centers Link ART Plus Center Care & Support Centers Model of HIV treatment service Public Health Infrastructure & HIV-Relevant Staff HIV-Related Services Medical College ART Centre/ Link ART Centre Link ART Centres Community-Based HIV Screening CCC / NGOs Referral District Hospital Community Health Centre Primary Health Centre (PHC) Sub-Centres & Anganwadi Centres ICTC District with low Sero -positivity may have LAC only. ART Centres + tertiary level care Centres of Excellence - alternate First line & Second line ART

54. CST package: free universal access to ART,CD4 testing services, EID, counseling services, Management of Opportunistic Infections CST Services Referral and Linkage Mechanism Capacity building for CST Endeavors to enhance and ensure the provision of high quality services:- State grievance redressal committee Other initiatives: PG diploma in HIV medicine, - capacity building Computerized online inventory mechanism, airborne infection control, HIV-Visceral Leishmaniasis co infection programme coordination

55. INFORMATION, EDUCATION & COMMUNICATION (IEC) To increase knowledge in general population To sustain behaviour change-at risk populations To generate demand for care, support & treatment services To strengthen the enabling environment Key activities undertaken by IEC Mass Media Campaigns Long Format Programmes Outdoor activities Folk Media and IEC Vans

56. STRATEGIC INFORMATION MANAGEMENT UNIT Four divisions: Monitoring & Evaluation Division Research Division Surveillance & Epidemiology Division Data Analysis & Dissemination Unit Functions: generates and manages crucial information on the entire spectrum of the HIV epidemic and its control promote data use for policymaking, programme planning, implementation and review at national, state, district and reporting unit levels

57. Monitoring framework Impact indicators: Reduction of HIV incidence Reduction in mortality among PLHIV Survival of AIDS patients on ART Outcome indicators: Behaviour change among FSW Behaviour change among MSM Behaviour change among IDU Programme targets: By 2017, NACP- IV will cover 9 lakh FSWs, 4.40 lakh MSMs including TG/ Hijras and 1.62 lakh IDUs through Targeted Interventions. Over 16 lakh long distance truckers and 56 lakh high-risk migrants will be separately targeted as part of bridge population. 140 lakh pregnant women will be targeted. Supply of 90 lakh units of safe-blood and enhanced use of blood products The programme will provide 1st and 2nd line ART to all who require it.

58. Key concerns and challenges for NACP-IV Need to consolidate successes gained Need to advance towards focusing on ensuring high quality services Emerging epidemics in certain low prevalence states and districts Treatment coverage are fully met Regions with different maturity levels of epidemic will require different resources and services Budgetary support Integration with larger health systems Ensuring social protection schemes for people infected and affected with HIV Stigma and discrimination that is still prevailing Need for innovation

59. Key issues in targeted intervention Strategy related: Adaptation of design of Tis to the changing context Budgeting and contracting flexibilities Operational issues: Budget cuts, fund flow and financial uncertainties Community mobilisation and enabling environment Key population size estimates Recent decline in coverage of population Focus, mechanisms and investments for capacity building Context specific BCC and IEC material TSU/NTSU Partnerships with communities and civil society

60. Key issues in HCTS Coverage gaps in testing of target population Gaps in detection and linkage loss of HIV positive cases between ICTC and ART Increasing sero -discordance among spouses

61. Thank you!