National AIDS Control Programme

The goal is to HALT AND REVERSE the epidemic in India over next 5 years by integrating programmes for preventions & care, support & treatment.

1. NATIONAL
AIDS CONTROL
PROGRAMME
Dr Lipilekha Patnaik
Professor, Community Medicine
Institute of Medical Sciences & SUM Hospital
Siksha ‘O’ Anusandhan deemed to be University
Bhubaneswar, Odisha, India
Email: [email protected]

2. INTRODUCTION
•AIDS(acquired immunodeficiency syndrome)
•Caused by-HIV (Human immunodeficiency virus)
•Family-Retroviridae
•Disease characterized by profound immunosupression that leads
to opportunistic infections, secondary neoplasms, neurological
manifestations

3. Problem statement
•World
•According to WHO, HIV continues to be a major global public
health issue
•Globally Total Cases -36.9million
•Death -9,40,000
•Newly infected -1.8 million
•Adult receiving ART -59%
•Children on ART -52%
•Pregnant women on ART -80%
•According to report between 2000-17, new HIV infection fell
by 36%, HIV related deaths fell by 38% with 11.4 million lives
saved due to ART.

4. INDIAN SCENARIO

5. Milestones of the programme
•1986-First case of HIV detected. AIDS task force set up by ICMR.
National AIDS Committee by Ministry of Health.
•1990 –Medium term plan for states and 4 metros.
•1992 –NACP I launched
National AIDS control board constituted. NACO set up.
•1999 –NACP II began, SACS established
•2002 -National AIDS control policy
National blood policy
•2004 –Antiretroviral treatment initiated
•2006 -National council on AIDS under chairmanship of Prime Minister .
National policy on Pediatric ART
•2007 –NACP III launched for 5 years (2007 –2012)
•2012 -NACP IV launched for next 5 years

6. NACP I
OBJECTIVE:
Slow & prevent spread of HIV through a major effort to
prevent its transmission
STRATEGIES:
•Focus on raising awareness, blood safety , prevention
among high risk populations
•Improving surveillance
ACHIEVEMENTS:
•Strong partnership with WHO
•Establishment of the state AIDS control cells
•Improved blood safety
•Expanded sentinel surveillance & improved coverage and
collection of data
•Improved condom promotion activities
•Development of national HIV testing policy

7. NACP II
OBJECTIVES:
Reduce the spread of HIV infection in India through behavioral changes
& Increase capacity to respond to HIV on a long term basis
STRATEGY:
•Target interventions for high risk groups
•Preventive interventions for general populations
•Involvements of NGOs
•Institutional strengthening
ACHIEVEMENTS:
1.1033 TIs, 875 VCTC, 679 STI clinics started at district level
2.Nation wide behavioral sentinel surveillance were conducted
3.PPTCT program was expanded
4.Computerized management information system was created
5.HIV prevention & care and support networks were strengthened
6.Supports from partner agencies increased

8. NACP III
OBJECTIVES:
Reduce the rate of incidence by 60% in 1
st
year of program in high
prevalence states and by 40% in vulnerable states
STRATEGY:
•Prevention by TI, ICTC, Blood safety, Communication, and condom
promotion
•Care ,support & treatment-ART, CoEs, Community center
•Capacity building
•Strategic information management by monitoring & evaluation
ACHIEVEMENTS:
1.306 fully functional ART center & 612 LINK ART center , 10 CoE, 259
Community cares were established
2.12.5 lakhPLHIV were registered & 4.2 lakhpatients were on ART
3.3000 Red ribbon clubs were established
4.Link workers training module updated & condom promotion program
was strengthened

9. NACP –IV
GOAL:
TO HALT AND REVERSE the epidemic in India over next 5 years
by integrating programmes for preventions & care, support &
treatment.
OBJECTIVE:
1.Reduce new infection by 50%(ac. To NACP III base line)
2.Provide care, support & treatment to all living with HIV/AIDS
and treatment service for all who needs it.
.

10. Key strategies
Strategy 1: Intensifying and consolidating prevention services
Strategy 2: Comprehensive care, support and treatment
Strategy 3: Expanding IEC services
Strategy 4: Strengthening institutional capacity
Strategy 5: Strategic Information Management System

11. PACKAGE OF SERVICES
PREVENTION SERVICES
•Targeted Interventions For High Risk Groups and
bridge population
•Needle Syringe Exchange Program and opoid
substitution therapy for IDUs
•Prevention interventions for Migrant population at
source, transit and destonation
•Link worker scheme for HRGs and vulnerable
popoulation in rural areas
•Prevention & Control Of STI/RTI
•Blood Safety
•HIV counselling and testing services
•Prevention Of Parent To Child Transmission
•Condom Promotion
•IEC & BCC
•Social Mobilization, Youth Interventions and
adolescent education programme
•Mainstreaming HIV/AIDS
•Workplace interventions
CARE, SUPPORT & TREATMENT
SERVICES
•Lab services for CD4 testing and other
investigations
•Free first line and second line ART
•Pediatric ART for children
•Early infant diagnosis for HIV exposed infants and
children below 18 months
•Nutritional and psychosocial supports through care
ans support centres
•HIV/TB coordination (cross referral, detection and
treatment of co-infections)
•Treatment of oppurtunistic infection
•Drop-in centres for PLHIV networks

12. Country scenario: Classificationof states
•High prevalence
>5% in HRG & >1% in ANC
Maharashtra, TN, Andhra, Manipur, Karnataka, Nagaland
• Moderate prevalence
>5% in HRG & <1% in ANC
Gujarat, Puducherry, Goa
• Low prevalence
<5% in HRG & <1% in ANC
All other states/UTs

13. Classificationof districts
Districts are classified into four categories A to D
• Category A:
More than 1% ANC/PTCT prevalence in district in any of the sites in the last 3
years.
• Category B:
Less than 1% ANC/PTCT 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 than1% 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:
Lessthan1%ANCprevalenceinallsitesduringlast3yearswithlessthan5%inall
HRGsiteswithnoknownhotspotsORnoorpoorHIVdata

14. HIV SURVEILLANCE
•Surveillances are being carried out to detect spread of the disease &
to make appropriate strategy for prevention and control i.e by area
specific Targeted Interventions & Best Practice Approach.
•Types of surveillances
HIV sentinel surveillance
HIV sero surveillance
AIDS case surveillance
STD surveillance
Behavioural surveillance
Integration with surveillance of other diseases like TB etc.
•Out of the above most effective one is HIVsentinel surveillance
•The main aim of the surveillance is confined to monitor the trend of
HIV infection.

15. Objectives of the surveillance
1.To determine the level of HIV infection among general
population as well as HRGs in different states
2.To understand the trend of HIV epidemic among general
population as well as HRGs in different states
3.To understand the geographical spread of infection and to
identify emerging pockets
4.To provide information for prioritization of the programme
resources & evaluation of program impact
5.To estimate prevalence & HIV burden in the country.
•It is done in the same place over a few years by anonymous
serological tests.
i.e HIV testing is done without identification of name of
samples collected for other purposes eg. VDRL, STD clinics

16. •The demerit of the test is that +ve person is not identified
•In 1994 it was started with55 sentinel sites and became180 in
1998
•The number of HRG of people increased with increase in HIV
sentinel sites .
•THE KEY FEATURES OF THIS SURVEILLANCE ARE
1. Inclusion of data from high risk population through targeted
intervention sites
2. Adding rural samples through antenatal clinics
•THE STRATEGYADOPTED WAS
Whatever be the sentinel site and amount of sample collected-the
duration , frequency and age group of people in the surveillance
should be same in all HRG , bridge population and general
population.

18. COUNSELLING and HIV TESTING SERVICES
These services started in India since 1997
•Components: 1. ICTC, 2. Prevention of parent-to-child transmission of
HIV (PPTCT) 3. HIV/TB collaberativeactivities
Integrated Counselling and Testing Centres
•This is available to increase access to HIV diagnosis
•It includes testing services & community approaches at various level of
health system in India like state, district, sub district, & village/community
level.
FUNCTIONS
1.Early detection of HIV,
2.Provision of basic information on modes of transmission, prevention
of HIV for promoting behavioral change and reducing vulnerability
and linking the PLHIV to care, support & treatment.
A person is counselled and tested for HIV at ICTC, either of his own free will (client
initiated) or as advised by a medical provider (provider initiated).

19. Two Types of ICTC
1.Fixed facility ICTC 2. Mobile ICTC
1. Fixed facility ICTC: are located within an existing healthcare
facility/hospital/health centre
•are of of 2 types 1. Standalone ICTC (SA-ICTC)
2. Facility-integrated ICTC (F-ICTC)
SA-ICTC:The client load is high in the center with full time
counsellor and lab technician who provide HIV counselling & testing
services
F-ICTC:
•These are set below the block level in 24x7 PHCs
•Staffs are trained in counselling and testing services of HIV
•Similar to this Public Private Partnership ICTCs are also established
in private facilities
•The above center are supported by SACS & DACS

20. 2. MOBILE ICTC:
•It is a van with a room to conduct general examination ,
counselling and collection and processing of blood and blood
products
•These are set in hard to reach areas as temporary clinics
•They also provide counselling and services about regular
health check up, antenatal check up & immunization.
•Community based HIV screening is done by ANM at sub centre
level to provide HIV testing to all pregnant women .
•It is done to prevent transmission of HIV from parents to child .

22. PREVENTION OF PARENT-TO-CHILD
TRANSMISSION OF HIV
•The prevention of parent-to-child transmission of HIV/ AIDS (PPTCT)
programme was started in 2002.
•Currently there are more than 15,000 ICTCs in the country which
offer PPTCT services to pregnant women.
•The aim of the PPTCT programme is to offer HIV testing to every
pregnant woman (universal coverage) in the country, so as to cover
all estimated HIV positive pregnant women and eliminate
transmission of HIV from mother-to-child.
•In India, PPTCT interventions under NACP was started in 2002, using
SD-NVP prophylaxis for HIV positive pregnant women during labour
and also for her new born child immediately after birth.

23. •With the department of AIDS control adopting “Option B” of the
World Health Organization recommendations (2010), India has also
transitioned from the single dose Nevirapinestrategy to that of multi-
drug ARV prophylaxis from September 2012.
•The national strategic plan for PPTCT services using multi-drug ARVs in
India was developed in May-June 2013 for nationwide implementation
in a phased manner.
•Based on the new WHO guidelines (June 2013) and on the suggestions
from the technical resource groups during December 2013,
department of AIDS control has decided to initiate lifelong ART (using
the triple drug regimen) for all pregnant and breast-feeding women
living with HIV, regardless of CD4 count or WHO clinical stage, both for
their own health and to prevent vertical HIV transmission, and for
additional HIV prevention benefits.
•The PPTCT services provide access to all pregnant women for HIV
diagnostic, prevention, care and treatment services.

24. HIV/TB COLLABERATIVE ACTIVITIES
•NACP IV covers the HIV testing of TB patients
•It is combined work of NACP & RNTCP
•State with high HIV prevalence covers about 90% of TB
patients for HIV testing.
•There is expected detection of HIV within 2-4 weeks of TB
positivity.
•This service was started in October 2012 in Karnataka
followed by Maharastra, Andhra Pradesh & Tamil Nadu.

26. CARE, SUPPORT & TREATMENT
The care, support and treatment (CST) component
of NACP aims to provide comprehensive services
to people living with HIV (PLHIV) with respect to
•free Anti-Retroviral Therapy (ART)
•psychosocial support
•prevention and treatment of opportunistic
infections (OI) including tuberculosis
•and facilitating home-based care and
•impact mitigation

27. •These services are provided through ART center across the
country
•Some are linked to Centre of Excellence (CoE) & ART Plus
center at selected institutions.
•Some are linked through Link ART centerlike linking to ICTC,
STI clinics, PPTCT services & with RNTCP.
ART CENTERS-519
LINK ART CENTERS-1073
Centre of Excellence -10
PEDIATRIC CoE-7
ART PLUS CENTERS-52
CST CENTERS -350

28. Services provided
1)ANTI RETROVIRAL THERAPY :
A)1
st
line ART-Provided free of cost to PLHIV through
ART centers.
•Patients are provided counselling on treatment and nutrition.
•Follow up is done by assessing drug adherence, regularity of
visit, periodic examination & CD4 count testing in every 6
months
•Till 2017 –7.68 lakh PLHIV were on 1
st
line ART
•After launching of Pediatric HIV/AIDS initiative ,till march
2017 -1,06,824 cases were registered and out of that 42,015 are
on 1
st
line ART

29. B. Alternative first-line ART:
•It has been observed that a small number of patients
initiated on first-line ART, experience acute/chronic
toxicity/intolerance to first-line.
•ARV drugs, thus necessitating change of ARV drugs
to alternative first-line drugs.
•Presently, the provision of alternative first-line ART
is done through the Centres of Excellence and ART-
Plus centres across the country.

30. C. Second line ART:
•The second-line ART began in January 2008 at two sites -
GHTM, Tambaram, Chennai and JJ Hospital, Mumbai on a pilot
basis, and was then further expanded tothe other CoEs in January
2009.
•Some ART centers were upgraded to plus centers
•Till march 2017 –8,897 patients were on 2
nd
line ART
•All ART centres are linked to CoE/ART-Plus centres.
•For the evaluation of patients for initiation on second-line and
alternate first-line ART, a State AIDS Clinical Expert Panel
(SACEP) has been constituted by DAC at all CoEs and ART-Plus
centres.
•This panel meets once in a week for taking decisions on patients
referred to them with treatment failure/major side effects.

31. National paediatric HIV/AIDS initiative:
•The national paediatric HIV/AIDS initiative was launched on 30
November 2006.
•Till March 2014, nearly 1,06,824 children living with HIV/AIDS
(CLHIV) were registered in HIV care at ART centres, of whom
42,015 were receiving free ART.
•Paediatric formulations of ARV drugs are available at all ART
centres.
Paediatric second-line ART:
•While the first-line therapy is efficacious, certain proportion of
children do show evidence of failure.
•There is not much data available on the failure rate of Nevirapine-
based ART in children.
•Currently, second-line ART for children has been made available
at all CoE and ART-Plus centres.

32. Early infant diagnosis:
•In order to promote confirmatory diagnosis for HIV exposed
children, a programme on Early Infant Diagnosis (EID) was
launched by DAC. All children with HIV infection confirmed
through EID have been linked to ART services.
TARGETED INTERVENTIONS FOR HIGH RISK GROUPS:
The main objective of targeted interventions (TI) is
•To improve health-seeking behaviour of high risk groups
(HRG) and
•To reduce their risk of acquiring sexually transmitted
infections (STI) and HIV infections.

33. The services offered through targeted
interventions include:
•Detection and treatment for sexually transmitted infections
•Condom distribution (except in TIs for bridge population)
•Condom promotion through social marketing (for HRG
and bridge population)
•Behaviour change communication
•Creating an enabling environment with community
•involvement and participation
•Linkages to integrated counselling and testing centres
•Linkages with care and support services for HIV positive
•HRGs
•Community organization and ownership building

34. Specific interventions for IDUs
•Distribution of clean needles and syringes
•Abscess prevention and management
•Opioid substitution therapy
•Linkage with detoxification/rehabilitation services
Specific interventions for MSM/TGs
•Provision of lubricants
•Specific interventions for TG/hijra populations
•Provision of project-based STI clinics

35. Link worker scheme:
•The Link worker scheme is a community-based outreach
strategy to address HIV prevention and care needs of HRG
and vulnerable population in rural areas.
•The specific objectives of the scheme include reaching out to
these groups with information and knowledge on prevention
and risk reduction of HIV and STI, condom promotion and
distribution, providing referral and follow-up linkages for
various services.
•It includes counselling, testing and treatment of STI and
opportunistic infections through link workers, creating an
enabling environment for PLHIV and their families, and
reducing stigma and discrimination against them.
•In partnership with various development partners, the link
worker scheme has been expanded and is being implemented
in 17 states covering 163 highly vulnerable districts.

36. Blood transfusion services:
•Only licensed blood banks are permitted to operate in country and
voluntary blood donation is encouraged since 1
st
Jan 1998.
•The strategy is to ensure safe collection, processing, storage and
distribution of blood and blood products.
•Zonal blood testing centres have been established to provide
linkage with other blood banks.
•As per national blood safety policy, testing of every unit of blood
is mandatory for detecting infections like HIV, hepatitis B,
hepatitis C, malaria andsyphilis.
•NACO is supporting 1167 blood banks, including 304 Blood
Component Separation Units (BCSU) and 34 Model Blood
Banks, 260 major blood banks and 613 district level blood banks.
•Blood storage centres were established at First Referral Units
(FRUs), at sub-district levels, for wider availability of safe blood,
particularly for emergency obstetric care and trauma care services.

37. Condom promotion:
•Condom promotion strategies will be strengthened through free
distribution and social marketing channels, non-traditional
outlets, female condoms, etc. aided by an effective
communication strategy.
•On the basis of HIV prevalence and family planning needs, the
districts have been mapped and classified into four categories:
(a) High prevalence of HIV and high fertility (HPHF); (b) High
prevalence of HIV and low fertility (HPLF); (c) Low prevalence
of HIV and low fertility (LPLF); and (d) Low prevalence of HIV
and high fertility (LPHF).
•During 2014 the coverage of condom social marketing
programme implementation was spread across 395 districts,i.e.
141 HPHF, 84 HPLF and 170 LPHF districts in 11 states.

38. OBJECTIVES:
1.Increase demand for condoms among high risk, bridge &
general population
2.Maximize access of free condoms with minimize wastage
3.Increase sells in rural areas
4.To make it available within 15 minutes of walking distance from
any location
•This prevents HIV infection as well as decreases STD.
•Free condoms NIRODH are procured by Ministry of Health &
Family Welfare and distributed by NACO/SACS to HRGs
through TI/NGOs/ICTC/ART centers for HIV prevention

39. STD CONTROL PROGRAMME
•STD control is linked to HIV/AIDS control as behaviour resulting
in the transmission of STD and HIV are same.
•HIV is transmitted more easily in the presence of another STD.
•Hence, early diagnosis and treatment of STD is now recognized as
one of the major strategies to control spread of HIV infection.
Following measures are taken for STD control
A) Management of STDs through syndromic approaches by colour
coded kits
B) Integration of services for treatment of reproductive tract
infections & STDs at all levels of health care
STDs Clinics at district / block/ First Referral Unit (FRU) level
would function as referral centres for treatment of STDs referred
from peripheries. All STDs clinics would also provide counselling
services and good quality condoms to the STD patients.

40. •NACO has branded the STI/RTI services as “Suraksha
Clinic”, and has developed a communication strategy for
generating demand for these services.
•PRE-PACKEDSTI/RTI COLOUR CODED KITS: Pre-
packed colour coded STI/RTI kits have been provided for
free supply to all designated STI/RTI clinics. These kits are
being procured and supplied to all State AIDS Control
Societies.
•The colour code is as follows:
•Kit 1 -grey, for urethral discharge, ano-rectal discharge and cervicitis.
•Kit 2 -green, for vaginitis.
•Kit 3 -white, for genital ulcers.
•Kit 4 -blue, for genital ulcers.
•Kit 5 -red, for genital ulcers.
•Kit 6 -yellow, for lower abdominal pain.
•Kit 7 -black, for inguinal bubo

42. Information, education and communication
Communication is the key to generating awareness on
prevention as well as motivating access to testing, treatment,
care and support. Communication in NACP-IV is directed at:
a.To increase knowledge among general population
(especially youth and women) on safe sexual behaviour
b.To sustain behaviour change in high risk groups and bridge
populations
c.To generate demand for care, support and treatment
services and
d.To make appropriate changes in societal norms that
reinforce positive attitude, beliefs and practices to reduce
stigma and discrimination.

43. Adolescence Education Programme:
•This programme runs in secondary and senior secondary
schools to built up life skills of adolescents to cope with
the physical and psychological changes associated with
growing up.
•Under the programme, 16 hour sessions are scheduled
during the academic terms of class IX and XI.
•State AIDS control society have further adapted the
modules after state level consultations with NGOs,
academicians, psychologists and parent-teacher bodies.
•This programme is beingimplemented in 23 states and by
March 2014, 49,000 schools have been covered.

44. Red Ribbon Clubs:
•The purpose of Red Ribbon Club formation in colleges
is to encourage peer-to-peer messaging on HIV
prevention and to provide a safe space for young people
to seek clarifications of their doubts and myths
surrounding HIV/AIDS.
•The RRCs also promote voluntary blood donation
among youth.

45. ACHIEVEMENTS
•Capacities of State AIDS control societies & District AIDS
prevention and control units have been strengthened.
•Technical support units were established at National & State
level to assist in program monitoring.
•State training resource centers were set up.
•Strategic information management system (SIMS) has been
established with 15,000 reporting units across country
•ART centers , ART link centers , CoEs , ICTCs were
established & Support agencies were increased.

46. •The 2016-21 strategy by UNAIDS is a bold call to reach
all those people who were left.
•It is a call to reach 90-90-90treatment targets to protect
the health of people living with HIV.
•90% of people should be aware of there infection à
90% of that population should start on ARTà90% out of
those taking ART should have undetectable HIV in their
body till 2020.
Target-
1.75 % reduction in incidence of infection from 2010-20.
2.Reduce in annual death rates to less than 5,00,000 till
2020.