National AIDS Control Programme - NACP

1. National AIDS Control Programme Dr. Rizwan S A, M.D., …India’s answer to HIV/AIDS 1

2. Outline EPIDEMIOLOGY OF HIV/AIDS IN INDIA THE EARLY RESPONSE TO THE EPIDEMIC NACP I & II CURRENT PROGRAMME – NACP III Programme components of NACP III Achievements of NACP III Evaluation of NACP III THE FUTURE – NACP IV COMMENTS 2

3. Epidemiology of HIV/AIDS in India 3

4. Indian Scenario of HIV/AIDS HIV epidemic in India shows a stable trend at national level , However, some low prevalence and vulnerable states show rising trends HIV trends in India 2002 - 2009 4

5. Burden of HIV in India Based on HIV Sentinel Surveillance 2008-09, Annual report of NACO 2010-11 Parameter All India Adult prevalence 2009 0.31 % PLHA 2009 23.9 lakh Subgroup All India # (%) 2008 IDU 9.86 MSM 6.90 FSW 4.80 STD clinic attendees 2.90 ANC 0.47 5

6. Incidence of HIV HIV infection has declined by more than 50% during the last decade. It is estimated that India had approximately 1.2 lakh new HIV infections in 2009, as against 2.7 lakh in 2000 This is one of the most important evidence on the impact of the various interventions under NACP and scaled-up prevention strategies 6

7. Classification of States High prevalence >5% in HRG & >1% in ANC MR, TN, Andhra, Manipur, Karnataka, Nagaland Moderate prevalence > 5% in HRG & <1 % in ANC Gujarat, P uducherry , Goa Low prevalence <5 % in HRG & <1% in ANC All other states/UTs 7

8. Classification of districts - 1 Districts are classified into four categories A to D 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 8

9. Classification of districts - 2 Based on 2004-2006 HSS Category A; 156 Category B; 39 9

10. Dynamics of Transmission females Male Clients males MSM IDUs FSW Children Spouses Others in Gen. Population Past SW & MSM Iatrogenic (Adapted from Tim Brown’s) 10

11. Rationale for T argetted Intervention HRG 11

12. Routes of transmission 12

13. The early response to the epidemic 13

14. The beginnings - 1 HIV infection first detected in India in 1986, when 10 HIV positive samples were found from a group of 102 female sex workers from Chennai There were two essential questions to be answered What was the geographical extent of the infection in India? What are the main routes of transmission of the infection in the country? To answer these a chain of 62 AIDS surveillance centres was gradually established nationwide 14

15. The beginnings - 2 Results from these centres indicated infection was widespread in the country but limited to those with high risk behaviour or to recipients of infected blood not so far spread into the general community Main mode of transmission was heterosexual although injecting drug use was responsible in the northeast 15

16. The beginnings - 3 In 1986 , G overnment set up an AIDS Task Force under ICMR and established a National AIDS Committee (NAC) chaired by Secretary , Department of Health and Family Welfare In 1987, National AIDS Control Programme was initiated, with help from the World Bank In the next four years, the programme’s main activity was the screening of the “sexually promiscuous population”, and blood donors and carrying out some educational programmes 16

17. The beginnings - 4 In 1989, a Medium Term Plan for AIDS Control was developed with the support of the WHO It focused only on Maharashtra, Tamil Nadu, West Bengal , Manipur and Delhi , areas that surveillance data indicated were at high risk of HIV infection State AIDS Cells were established in these states and awareness activities and some early targeted interventions were field tested 17

18. NACP – I (1992-1999) In 1991, several international donors expressed their willingness to support the NACP UK Department for International Development Norwegian Agency for Development Cooperation USAID Ford Foundation International Development Association U nited Nations Development Programme (UNDP ) United Nations Drug Control Programme (UNDCP ) Accordingly , the Strategic Plan for Prevention and Control of AIDS in India was developed for the period 1992-97, now called NACP-I. This first phase was extended to 1999 because only half of earmarked funds had been utilised The cost of NACP-I was US$27.5 million from GOI , $ 2.2 million from WHO, and IDA credit of $84.2 million . (114 million) 18

19. NACP - I India’s first effort to develop a national public health programme for HIV/AIDS prevention and control A ims were Prevent HIV transmission Decrease the morbidity and mortality associated with HIV infection M inimise the socio-economic impact of HIV infection 19

20. NACP - I National AIDS Committee - headed by health minister for overall policy making and overseeing the programme’s performance. The National AIDS Control Organisation (NACO ) - established in June 1992 under the Department of Health for implementation. A National AIDS Control Board - constituted for approval of NACO policies, expediting sanctions and for approval of major financial and administrative decisions. State AIDS Cells (SACs) - constituted in all 32 states and union territories (UT) to implement. The state programme was supported by technical and support staff and used the administrative machinery of the state health departments. Programme was hindered by administrative and financial bottlenecks. As an experiment, the SACs in Tamil Nadu and Pondicherry were converted into registered societies under the chairmanship of the secretary of health. 20

21. NACP – I Services Mass “information, education and communication ” programmes Starting to talk about sex in a society which didn't like to talk about such things Early awareness messages with fear-provoking images such as skull and crossed bones . Such campaigns lead to AIDS phobia, stigma and discrimination later on Revamping of the entire blood collection , processing, storage and distribution system following Supreme Court judgment in 1996 National Blood Transfusion Policy was formulated and guidelines were issued Professional blood donation was banned Condoms Popularise the use of condoms, improve quality and increase availability . NGOs were engaged to promote and distribute condoms through “social marketing ” Annual sentinel surveillance system Initially, 180 sites were set up to monitor HIV prevalence among ANC clinic attendees and STD clinics Control of STDs Upgrade 504 existing STD clinics with equipment , and laboratory facilities and drugs Train doctors to provide “ syndromic ” treatment of STDs Some elementary treatment facilities Pilot projects on targetted interventions Multi- sectoral approach – pvt and corporate sector, national and international organisations 21

22. NACP-II ( 1999-2007) Total outlay – Rs . 2064.65 crore GOI share was 196 crore Aims Reducing spread of HIV infection in India Strengthen India's capacity to respond to HIV epidemic on long term basis State AIDS Cells of all 32 states/UT converted to societies registered under the Charitable Societies Act For greater flexibility Effective programme management 22

23. NACP-II Services - 1 1. Targetted intervention > 1,000 targetted interventions, mostly through NGOs, for CSWs, MSM, IDUs, street children, prisoners, truck drivers and migrant labourers Use peer educators to counsel, provide condoms through social marketing and provide information to encourage a change in behaviour (“ behaviour change communication ”). Some 845 clinics providing STD treatment were upgraded during this programme 2. Mass education campaigns Sex education programmes in schools, colleges and youth forums such as the National Service Scheme, Nehru Yuva Kendras and the Village Talk AIDS programmes . 23

24. NACP-II Services - 2 3. Blood safety Licenced blood banks increased to 1,230 including 82 blood component separation centres All donated blood tested for Hepatitis C and an external quality assurance system for HIV testing HIV transmission through blood was reduced to <2% (from 8% when surveillance first started 4. VCTCs Enabled those at risk to know their HIV status and seek treatment Referrals to services for treatment and care Prevention of mother to child transmission of HIV, and for the provision of antiretroviral drugs to people with AIDS, linked to the VCTCs 24

25. NACP-II Services - 3 5. Programme for Prevention of Mother (Parent ) to Child Transmission (PPTCT) Prevent the transmission of HIV from pregnant, HIV-positive women to their children They offer pregnant women testing for HIV and provide drugs and advice to those who are HIV-positive Towards the end of the programme, PPTCT centres were combined with VCTCs to form Integrated Counselling and Testing Centres (ICTCs). By November 2006, there were 3,396 such ICTCs in the country 25

26. NACP-II Services - 4 6. Annual sentinel surveillance Unlinked blood samples from HRG from targetted intervention projects, STD clinic attendees and pregnant women from designated sentinel sites To provide information on trends in the HIV epidemic in the country and to estimate the HIV burden of the country Reported AIDS cases were also tracked 7. Treatment and prophylaxis for opportunistic infections Beyond prevention and start providing medical services For advanced illness, the “continuum of care” model with home-based care and hospital referral 122 community care centres or hospices for the care of terminally ill AIDS patients 8. Antiretroviral therapy (ART) programme Started in April 2004 in the high prevalence states. By December 2006, about 56,000 patients were receiving drugs from 107 ART centres 26

27. Current programme – NACP III 27

28. NACP-III (2007-2012) Based on the experiences and lessons drawn from NACP- I & II Built upon their strengths Its priorities and thrust areas are drawn up accordingly >99% of the population is infection free So, NACP-III places the highest priority on preventive efforts at the same time, seeks to integrate prevention with care, support and treatment Total budgetary outlay – Rs . 11,585 crore Direct budget Rs . 2861 crore Rs . 7,786 crore for prevention and Rs . 1,953 crore for CST 28

29. NACP – III Goals Halt and reverse the epidemic in India over the next five years by four pronged strategy Prevent new infections Increasing CST for PLHA Strengthen the infrastructure, systems and human resources Strengthening strategic information systems (SIMS ) Objective Reduce the rate of incidence by 60% in the first year of the programme in high prevalence states to obtain the reversal of the epidemic, A nd by 40% in the vulnerable states to stabilise the epidemic. 29

30. NACP – III Guiding principles Unifying credo of 3 ones (one agreed Action Framework , one National HIV/AIDS Coordinating Authority , one agreed National Monitoring and Evaluation ) Equity is to be monitored by relevant indicators in both prevention and impact mitigation strategies i.e. percentage of people accessing services disaggregated by age and gender. Respect for the rights of PLHA Civil society representation Creation of an enabling environment wherein PLHA can lead a life of dignity . Provide universal access to HIV prevention, care, support and treatment services. HRD strategy of NACO and SACS is based on qualification, competence, commitment and continuity 30

31. Key actors in NACP III 31

32. Administrative structure of NACO 32

33. Programme components of NACP III 33

34. 34

35. 1. Prevent new infections 35

36. 1. Prevent new infections Saturation of coverage in high risk group through targeted interventions Scaling up interventions among general population 36

37. Saturating coverage of high risk group through Targeted I nterventions Strategy BCC to increase demand for product & services Provide STI services Promote condom , ensure availability and easy access Create enabling environment for safe behaviours (legal, policy, structural modification) Increase programme sustainability through CBO and increase ownership among HRGs For MSM and transgender – advocacy at national and state level OST intervention for IDUs NSEP for IDUs 2100 TIs were proposed to reach 1 million FSWs, 1.15 mil MSMs, 1.9 lakh IDUs by 2012. 37

38. Targetted Intervention Indicators To saturate 80% population of HRG with special focus on IDU, MSM 50-60% of core group reporting condom use during last sexual intercourse 80% of current IDUs using clean needles 38

39. Scaling up interventions in Bridge Population 110 lakh migrants and truckers Mapping by NACO in 17 states identified high, medium, and low priority locations Interventions will focus on high priority locations Eg . Trans-shipment locations where 5000 or more long distance truckers halt every month. Intervention in the form of BCC , interpersonal communication, condoms, STI services LWS for HRG and Bridge population – cover highly vulnerable villages by mapping with 5000 population. They are supported by village level v olunteers 39

40. Scaling up interventions for General Population Indicator 95% of population recall three modes of transmission and two methods of prevention Strong IEC campaign Condom promotion Promotion of voluntary blood donation and access to safe blood Scaling up ICTC Scaling up PPTCT Management of STI & RTI PEP Promotion of safe practices and infection control Inter- sectoral coordination and mainstreaming 40

41. IEC - 1 Integral part, special emphasis on youth and women Focus on behaviour change for promotion of safe behaviours , reduction of stigma & discrimination, promotion of counselling and testing , increasing condom use voluntary blood donation At the national level - the IEC division of NACO devises policy and guidelines and supervises the IEC activities of states At the state level – decentralised to respond to local priorities and language 41

42. IEC - 2 Channels – mass media, exhibitions , film shows, folk troupes , adolescent education progamme in schools, formation of Red Ribbon Clubs in colleges, Red Ribbon Express Family Health Awareness Campaigns To raise awareness and provide service delivery for STI/RTI services 42

43. Integrated counselling and testing - 1 Is a key entry point for a range of interventions like Diagnostic facilities for HIV infection, counselling by trained counsellors . prevention of infection from mother to child, referral for STD treatment, condom promotion, care for opportunistic infections, management of HIV-TB co-infection, referral to ART centres ICTC provides people the opportunity to learn and accept their HIV status in confidential environment 43

44. Integrated counselling and testing - 2 Conselling Pretest Posttest Terminally ill AIDS patients Testing Policy No individual will be subjected to mandatory testing No mandatory testing for employment Adequate voluntary testing facility throughout the country Disclosure to spouse depends on the person but should be encouraged In case of marriage – should be done to the satisfaction of the person concerned Testing strategies Mandatory – blood banks, Unlinked and anonymous – surveys and surveillance, Voluntary and confidential, Need based 44

45. Integrated counselling and testing - 3 Currently there are 5135 centres located in medical colleges and district hospitals, some CHCs and PHCs Under NACP III ICTC will become a hub for all HIV related services All CHCs to have centres 24 hr PHCs and pvt. hospitals also involved Mobile ICTC in hard to access areas via NRHM Internal/external qualtiy assurance Target of 10-15 tests per day Linkage, referral, feedback mechanism between ICTC and ART centres , HIV-TB cross referral mechanism In 2009-10 community based HIV screening through ANMs and use of DNA PCR in high volume ICTCs for early infant diagnosis was a landmark 45

46. Integrated counselling and testing - 4 Types of ICTCs Fixed facility Stand alone (full time staff) in medical colleges, district hospitals Facility integrated (existing staff of the facility) 24 hr PHCs, pvt sectors, Mobile ICTCs for hard to reach areas Staffing – MO, Counsellor, LT Opt-in and opt-out testing EQA Each ICTC assigned to SRL Sending coded samples from SRL to ICTC 20% of Positives and 5% of negatives form ICTC to SRL in the first week of every quarter 46

47. PPTCT - 1 Primary prevention in young people & women of child bearing age Promotion of free/subsided/commercially marketed condoms , Management of STIs BCC to reduce risk behaviour , Information about risk during pregnancy, delivery, BF, Encouraging to visit VCT counsellor or health provider for information on how to prevent HIV/AIDS among infants & young children Prevention of unintended pregnancies in HIV positive women Prevention of transmission from HIV women to infant through antiretroviral prophylaxis and safer delivery practices Care and support services to HIV infected women 47

48. PPTCT - 2 Provided in AN clinics of all Medical college hospitals and district hospitals of high prevalence states. The aim is to offer HIV testing to all pregnant women in the country Of the 27 million pregnancies occurring every year, 0.187 million occur in HIV infected mothers leading to 56,700 infected babies. Up-scaling of use of NVP to cover atleast 80% of such mothers 48

49. HIV/AIDS response in the ‘world of work’ Specific guidelines to strengthen the response of workplace to mitigate the impact of HIV Key areas Prevention of HIV/AIDS Care and support for infected workers Stigma and discrimination 49

50. Universal precautions and PEP Accidental contact of open wounds, needle stick injury, mucous membrane Medical care and counselling after exposure Chemoprophylaxis 50

51. Management of STI 4-6% of adult population is affected by STIs The services are provided through designated STI/RTI clinics, TI clinics, a network of pvt. providers and NRHM at sub-district facility STD increases the chance of acquisition and transmission of HIV Preventive measures are similar to that of HIV STD clinical services are important access point for persons at risk for both HIV/STD 51

52. STD Control Programme - 1 NACO took over STD Control Programme 1992, which was running from 1946. Treatment based on principles of ‘syndromic management’ and referral STI/RTI management of RCH II will be integrated with NACP-III Mass mobilization campaigns - demand generation and service provision through ‘Family Health Awareness Campaigns’ conducted annually 52

53. STD Control Programme - 2 Objectives – reduce STD cases and thereby control HIV and prevent long term/short term morbidity and mortality Strategies Develop adequate and effective program management Promote IEC activities Comprehensive case management – diagnosis, treatment, conselling , partner notification, screening for other diseases Strengthening existing facilities, and creating new facilities where required Facilities for diagnosis and treatment of asymptomatic infections 53

54. Condom promotion - 1 Issues Sensitize people for using condoms not only for the family planning but also for prevention HIV/STDs Convince CSWs and clients about the importance of condom as a means for preventing HIV Provision of low cost good quality condoms 54

55. Condom promotion - 2 Strategies Technical assistance to companies to manufacture quality condoms Strengthening the existing social marketing structure in the Dept. of Family Welfare Collaborating with the existing IEC program of the Dept. of Family Welfare for promoting use of condoms for achieving the dual purpose of averting conception and protecting from STD/HIV Strengthening monitoring systems 55

56. Condom promotion - 3 NACO in collaboration with Dept. of Family Welfare is providing subsidized condoms to SACS thru three schemes Distribution scheme Social marketing Commercial brand scheme General availability in drug stores, highways, road and railway jns ., public places etc., Indicators % reporting consistent u se of condoms with non-regular partners in last 30 days % reporting condom availability within 500 metres % increase in non-traditional outlets for condoms 56

57. Condom promotion - 4 Despite awareness and availability, use remains low To increase use social marketing is used Female condom use has been scaled up by NACO in AP, TN, Maharastra , WB to saturate all female sex workers via TIs 57

58. School AIDS Education Programme To raise awareness levels in school children Help resist peer pressure Develop a safe and responsible lifestyle Reinforces family values and respect for opposite sex Activities include – training of teachers, peers educators, role play, debates, Training modules 58

59. University Talk AIDS Project October 1991 Collaboration between NSS, Dept. of Youth Affairs & Sports and NACO. Raise awareness among thru workshops, seminars, materials Includes drug abuse, relationships, courtship, marriage 59

60. Blood Safety - 1 Aim To develop and strengthen National blood transfusion system, Ensure adequate supply of safe blood to all blood banks and health facilities Ban on professional donation since Jan 1 st 1998 National blood policy and Action plan Testing of blood is mandatory for Hep B&C, malaria, syphilis, HIV I & II 60

61. Blood Safety - 2 NACP III aims to ensure provision of safe and quality blood to remote areas of the country in the shortest time possible through a well coordinated National Blood Transfusion Service The specific objective is to ensure reduction in the transfusion assoc. infection to 0.5 % by Ensuring voluntary donation as the main source of blood supply Blood storage centres in the PHC for remote areas Vigorously promoting appropriate use of blood, blood components and blood products among the clinicians Capacity building for efficient and self sufficient blood transfusion services Four metro blood banks proposed as Centres of Excellence 61

62. 2. Increasing CST for PLHA 62

63. 2. Increasing CST for PLHA Comprehensive management of PLHA by management of opportunistic infections ART psychological support home based care impact mitigation 63

64. ART - 1 Free of cost thru select Govt. and non-profit pvt. hospitals Proposed 250 ART centres with 650 link ART centres to cover 3 lakh adults and 40000 children, ensure high degree if adherence (95%) As of Jan 2010, there were 239 ART centres giving treatment to 2,17,781 patients Priority group Seropositive women, esp from PPTCT program CLHA below 15 years PLHA referred from TIs Ensure treatment adherence IEC Individualise adherence Social support Direct observation 64

65. ART - 2 Proposed 350 ART centres , by January 2010 a total of 287 centres were operational . 10 CoE have been established to provide state of the art services for PLHAs, acting as knowledge hubs, resources centres , and for training of doctors on HIV The National Paediatric AIDS Initiative was launched in Nov 2006. Free ART to around 40000 children by end of NACP III 65

66. ART - 3 Paediatric ART services Provide facilities for diagnosis and treatment DNA PCR made available in selected national reference centres Quality of ART centres Ensuring high level of adherence to prevent emergence of resistance Effective monitoring and evaluation Every ART centre linked to NGO or PLHA network to provide psychosocial support 66

67. ART - 4 Management of drug resistance 4-8% of case develop resistance to first line drugs per year Strategy Improve adherence Monitoring resistance Policy for affordable generic second line drugs Making available second line drugs to those in need 67

68. Thru partnership with non-profit organisations Community Care Centres will provide social support, counselling , treatment and patient management including referrals These centres will act as bridges between ARTs and PLHA households focusing on management of opportunistic infections as well as counselling for ART One centre per 5 districts in high prevalence states and one per 10 in low prevalence states Care and support for PLHA - 1 68

69. Protection of right to privacy and human rights Proper support in hospital and community Confidentiality and rights of employment Positive women have complete choice of pregnancy and childbirth Sensitization of medical and paramedical workers Home based care and community based services Adequate supply of bio-safety equipment and infection control during treatment of HIV patients Care and support for PLHA - 2 69

70. Care and support for PLHA - 3 Home and neighbourhood Village health workers, community volunteers, traditional health workers family members Trained for palliative treatment, psychosocial support and education Health sub-centres These workers should be trained to deal with day to day problems of PLHAs PHCs Staff trained for comprehensive care based on syndromic approach District hospitals Clincial and nursing specialist care Regional hospitals Wide range of expertise and extensive lab support 70

71. 3. Strengthen the infrastructure, systems and human resources 71

72. Programme management For effective management, decentralization evolved during NACP II with the setting up of SACS will be further carried out upto district level through DAPCU District AIDS Prevention and Control Units They will be operate within the Dist. Health Society sharing the administrative and financial structure of NRHM NACO has established 14 technical resource groups , technical support groups for various technical aspects of the epidemic including for social marketing of condoms, financial management team and others 72

73. Capacity building All cadres of health care providers at national, state and district levels will be trained Augmenting capacity in management, finance Collaborating with partners, working on performance and quality based contractual arrangement, expertise to establish CBOs, training in ART, engaging services of procurement agencies to procure medical supplies and other goods required under the programme 73

74. Inter- sectoral collaboration NACO is providing support to 31 ministries and has identified 11 depts. for mainstreaming NACO will collaborate with ministries of defence , industry, labour , railways to use their medical infrastructure for prevention and treatment including treatment of STIs, c ondom promotion, ICTCs, PPTCT, treatment of opportunistic infections and ART Partnership with PLHA networks to create enabling environment by addressing issues of stigma, discrimination, legal and ethical concerns Collaboration with RCH (for condom, RTI/STI, PPTCT), RNTCP , IDSP (data sharing) 74

75. 4. Strengthening SIMS, M&E 75

76. 4. Strengthening SIMS, M&E Information is available from many sources like sentinel surveillance, BSS, research studies, CMIS. To effectively use all available information and for evidence based planning a Strategic Information Management Unit has been established at the national and state levels It will provide information for planning, M&E, surveillance and research 76

77. 4. Strengthening SIMS, M&E 77

78. CIMS - 1 User friendly to all states Community friendly information systems to collect data Develop indicators for monitoring progress Training of M&E personnel Biannual review Publication of M&E data for transparency 78

79. CIMS - 2 Challenges MIS data is sparingly used for planning Programme managers are required at the state level to start using this data Quality and completeness of data needs refinement 5000 primary data generating units SACS NACO Data flow 79

80. Surveillance of HIV/AIDS AIDS case surveillance HIV sentinel surveillance STD surveillance Behavioural surveillance 80

81. AIDS case surveillance All medical institutions will participate in the identification of suspected cases, but only referral hospitals will finally confirm the diagnosis and report the cases. Confirmation is done by VCT at the microbiology dept. of medical colleges and tertiary care hospitals Provide data on clinical profile like opportunistic infections, also supplements HIV sentinel surveillance data, also used for planning care for AIDS patients 81

82. HSS - 1 Objectives and uses of HSS To determine the level ( magnitude ) of the epidemic To monitor the epidemic trends over time To describe the distribution in different geographical areas and population sub groups Advocacy/ Planning Estimation of burden 82

83. HSS - 2 Brief history 1985 – First started by ICMR in Delhi, Pune and Vellore 1986 – Expanded to 9 cities of high vulnerability 1992 – NACO Formed; Initiated HSS using Unlinked Anonymous Testing strategy in 60 sites 1998 – Expanded to 180 sites across the country: Mainly ANC attendees (proxy for general population) and STD patients (proxy for HRG) and limited number of HRG sites 2003 – expansion of HRG sites and ANC sites in peri urban/rural settings 2006 – Major expansion to cover all districts 2008 – DBS strategy and random sampling with informed consent in HRG sites introduced Currently testing around 400,000 samples annually 83

84. HSS – 3 (Methods) High Risk / Bridge Groups General Population IDU/ MSM/ FSW / SMM/ LDT STD pts Pregnant Women attending Antenatal Clinics Sentinel Site Drop-in-centers/ NGO service points STD & Gynae clinics ANC clinic Sample Size 250 250 (100 + 150) 400 Durtion/ Frequency 3 mo /Once a yr 3 mo / Once a yr. 3 mo / Once a year Sampling Consecutive (/Random) Consecutive Consecutive Age Group 15-49 years 15-49 years 15-49 years Testing Method UAT with informed consent Unlinked Anonymous Testing (UAT) UAT 84

85. HSS - 5 Initially the purpose was to determine the geographic spread and modes of transmission, currently – to monitor the trends of infection Data is collected form sentinel sites, annually for a period of 3 months In ANC sites, consecutive women attending the designated ANC sites who meet the inclusion criteria are included till 400 sample size is reached or until the end of surveillance In STD sites, samples are collected from two sources, STD & OG clinics located in the same hospital , 150 from STD clinics, 100 from OBG clinics. Only consecutive new cases of STDs diagnosed syndromically are recruited 85

86. HSS - 6 HRG and Bridge population members are recruited from service points like de-addiction centres , drop-in centres , satellite points until 250 are reached or until end of surveillance period. DBS method is adopted for HRG sites and venous blood for rest. Two test protocol is adopted to determine positivity There is a system of external quality assurance for field work and lab testing The number of sites has gone up from 176 in 1998 to 1359 in 2010 86

87. HSS - 4 Data acquisition and interpretation Surveillance should be flexible and move with the needs and stage of the epidemic Use surveillance data to improve understanding of the epidemic and to plan prevention and care Method of data collection is based on frequency, quality and resources 87

88. year 2010 – 1359 Sites year 2003 – 699 Sites HIV Sentinel Surveillance - Scale up 88

89. Expansion of sentinel surveillance Site Type 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2010 STD 76 75 98 133 166 163 171 175 251 248 217 184 ANC 92 93 111 172 200 266 268 267 470 484 498 506 ANC (Rural) - - - - - 210 122 124 158 162 162 182 ANC (Youth) - - - - - - - - 8 8 8 8 IDU 5 6 10 10 13 18 24 30 51 52 61 79 MSM - - 3 3 3 9 15 18 31 40 67 96 FSW 1 1 2 2 2 32 42 83 138 137 194 261 Migrant - - - - - - - 1 6 3 8 20 Eunuchs - - - - - - - 1 1 1 1 3 Truckers - - - - - - - - 15 7 7 20 TB 2 2 - - - - 7 4 - - - - Fisher-Folk/ Seamen - - - - - 1 - - 1 - - - Total 176 177 224 320 384 699 649 703 1122 1134 1215 1359 89

90. HSS - 7 Data sources used for HSS 2010 An expanded HIV Sentinel Surveillance spread over 1,212 sentinel surveillance sites and covering all districts in the country (Data from 1998 to 2009 rounds of HSS was used ) NFHS-3 Size estimates of high risk group population based on High Risk Groups mapping exercise Indian Census Coverage data from ART Programme and PPTCT Programme Other Demographic and Epidemiological evidence Used for estimating such as HIV burden, new infections and deaths due to AIDS, need for ART & PPTCT 90

91. STD surveillance A recent activity to assess the magnitude of the problem Collect etiological information Thru STD clinics having lab support Syndrome based information Thru peripheral health institutions Community based studies to generate data on prevalence of STDs in rural and urban areas 91

92. Behavioural surveillance survey - 1 Assess the magnitude of risk behaviour through periodic repeat surveys Baseline survey completed in 2001 Second survey done in 2006 92

93. Behavioural surveillance survey - 2 A set of indicators used Knowledge Behaviour STI/RTI prevalence Risk perception 93

94. Achievements of NACP III 94

95. Targetted Intervention Currently , there are 1,385 TIs providing prevention services to overall 31.32 lakh population covering 78% FSW, 76% IDUs, 69% MSM, 32% Migrants and 33% Truckers State   Training  and  Resource  Centres   established  in  14  state ensure  the   capacity  and  technical   skills  of  the  TI staff The Link Worker Scheme addresses  population  with  high risk   behaviours  and young people in highly  vulnerable villages. Mapping  has been completed  in all  the districts and  during mapping process, 200   most  vulnerable  villages were identified in  each district  and estimated  number of  high risk   population At present,  the  scheme  covers 186 districts in 20 states during 2010-11 95

96. TI numbers 96

97. Management of  STI/RTI - 1 An  estimated 3  crore  episodes of  STI/RTI occur every  year in the  country Syndromic Case Management are provided through 1,038 designated STI/RTI clinics , including 90 new clinics established during 2010-11 Around 3,891 Private Preferred Providers were identified for providing STI services to high risk population. Overall, 84.9 lakh STI episodes were treated during 2010-11, till January 2011 NACO has branded the STI/RTI services as “ Suraksha Clinic” NACO  is  supporting 894  designated  STI/RTI clinics located at District & Teaching hospitals 1,281 STI clinics  in TIs 8,515 Preferred Pvt. Providers for community based STI service delivery  26,415  PHC/CHCs  under  NRHM 7 regional STI training, reference and research centres till December 2009 NACO  is coordinating with NRHM and has proposed  to procure colour coded drug kits for the PHCs and CHCs under NRHM.  97

98. Management of  STD/RTI - 2 98

99. Condom promotion Till January 2011 , 25.5 crore pieces of condom were distributed though 5.46 lakh condom outlets. Against NACP‐III target for condom distribution of 3.5 billion pieces by 2012 , achievement has been 2.2 billion pieces by November, 2009 99

100. Blood Safety Programme A network of 1,127 Blood Banks including 155 Blood Component Separation Units and 28 Model Blood Banks and 685 blood storage centres . Around 79.2 lakh blood units were collected during 2010-11 till January 2011, 79.4 percent of them through voluntary donation in NACO-supported blood banks. It is planned to raise voluntary donation to meet 90 % of blood unit requirement by  2012 New initiatives includes  4 Metro Blood  Banks- New Delhi, Mumbai , Chennai  & Kolkata  as Centres of  Excellence in Transfusion Medicine and one large Plasma Fractionation Centre at  Chennai. 100

101. ICTCs - 1 Against the 11 th Plan target of counseling and testing 75,00,600 pregnant women , 104.96 lakh women had already been tested between April 2007 and August 2009 In 2009‐10, there are 5,089 ICTCs which tested 91.9 lakh persons against the target of 155.3 lakhs  till November  2009 So far,  12 lakh  out of an estimated  23  lakh HIV  positive persons have been  diagnosed In   2009‐10 -   22,585, HIB‐TB   co‐infected patients  were  diagnosed During  2009‐10,  ICTCs  provided  counseling  and  testing to   38.8  lakh  pregnant  women, of whom 13,496 were found HIV positive. A total of 8158 mother-baby pairs were given prophylaxis of NVP 101

102. ICTCs - 2 102

103. IEC   Campaigns   reaching  youth  through  music  &  sports  in Mizoram,  Nagaland , Manipur; on-ground mobilisation 3 radio programmes launched thru radio clubs Zindagi Zindabad  campaign  ( IEC van, folk theatre & condom demo ) conducted in 12 states in 2008-09 covering 84 distt. 31 lakh people reached thru 11,000 performances Special episodes on HIV in tele ‐serial Kyon ki Jina Isi ka Naam Hai ; Kalyani Health Magazine from 9 regional networks of Doordarshan during 2009‐10 The Adolescence Education Programme conducted for class 9 and 11 covered 92,000 out of 1,52,000 schools 5,034 RRC were formed against a target of 6,008 103

104. Mainstreaming HIV/AIDS mainstreamed into the agendas of Ministries, corporate sector and civil society organisations 8.39 lakh front line workers and personnel from various Government Departments, Civil Society Organisations and corporate sector were trained 1,300 companies have adopted workplace on HIV/AIDS 104

105. CST for PLHA - 1 ART programme launched on 1 st April ,  2004 has been scaled  up to  230  centres and 2,87,968 patients are receiving free ART as of November 2009 The capacity of laboratories for CD4 testing has been strengthened Presently 152 CD4 machines are installed . Under  the  National  Paediatric   HIV/AIDS  Initiative, 62,777 CLHA have been registered and more than 18,020 are currently receiving treatment Seven  ART  centres   are  being upgraded as Regional Centre of Excellence Roll out of  Second  line ART  has now been expanded  to  the 10 centres of excellence from Jan 2009. 744  patients are receiving second  line drugs 287  Community  Care  Centres   (CCC)  are  operational  as  of Dec 2009  for  reinforcing adherence counseling. ART Plus Scheme: Second Line ART expanded to 10 centres in January 2009 105

106. CST for PLHA - 2 It is planned  to have 350 CCC by  2012 300  Link ART  centres  have been developed at ICTC or CCC (against the target of 650 by 2012 ) Smart card system 106

107. CST for PLHA - 3 State support to PLHA: Innovative social security measures like pension schemes for PLHA has been in 6 states, 7 states are providing concession to PLHA for commuting to ART centres by road; 9 states supporting nutritional care for PLHA 208   Drop In Centres (DICs ) run by Networks of People living  with HIV   with support from NACO promote  Positive living PLHIV and improve the quality of life of the infected, build their capacity and coping skills and link them with the existing services 107

108. Convergence with NRHM Counseling of non HIV pregnant women on nutrition , birth spacing and family planning by ICTC counselors Training of ASHA on module “Shaping Our Lives” developed by NACO for frontline workers Inclusion of HIV screening in routine ANC check up Expansion of ICTC and PPTCT services to all 24x7 health facilities Incentives to Health Care Providers for conducting deliveries of HIV positive pregnant women in public health facilities Training of Family Planning counselors on, PPTCT, ANC , STI & nutrition For National STI programme , NACO will continue to monitor & supervise Establishing 29 district level blood banks with NACO and NRHM support Strengthening of Health facilities for OST 108

109. Monitoring and Evaluation - 1 NACO collects routine information on components from all states and UTs from blood banks, ICTCs, STD clinics, ART centres and from NGOs implementing targeted intervention and CCCs Information is collected monthly thru CMIS, installed in all SACS Out of 195 category A and B districts 149 have established DAPCU as on 2009 DAPCUs have trained personnel for implementing and monitoring 109

110. Routine data collection under the programme is done through CMIS. Monthly reports are received from 35 SACS with 292 ART Centres , 1,127 Blood Bank, 255 CCCs, 5,233 ICTCs, 1,038 STI clinics and 1,385 TIs. Strategic Information Management System (SIMS), a web-based integrated monitoring and evaluation system is being developed as a mechanism for improving efficiency of the CMIS. SIMS was launched in August 2010 and is scheduled to be fully implemented during 2011. Monitoring and Evaluation - 2 110

111. 111 Special initiatives in HSS in 2010 Technical and User-specific Operational Manuals Site-specific job-aids (Wall charts etc) Training standardized and PPTs provided Supervision strengthened (CTMs, RIs & SSTs) Mop-up & on-site training for those who missed the training Introduction of Bi-lingual data forms with instructions (Hindi & 7 regional languages) Lab and data QA strengthened SIMS modules for HSS for Data entry, Data monitoring & in-built validation checks Expansion of HRG sites : 194 new sites added including 154 HRG sites 53 poor performing sites deleted including 30 STD sites

112. Evaluation and  Operational   Research Network  of Indian Institutions for  HIV/AIDS Research ( NIIHAR ) set up in 2007 undertakes operational, epidemiological, and bio-medical research NACO fellowship scheme for capacity building of young researchers NACO ethics committee 112

113. Evaluation of NACP III 113

114. Mid-term review of NACP III - 1 Conce p tual framework 114

115. Mid-term review of NACP III - 2 Conducted from 16 Nov to 3 Dec 2009 Mission team with representatives form world bank, DFID and other development partners Comprehensive evaluation of strategies, plans, resources and activities Several  studies  were  initiated  that  inform  MTR on the effectiveness and impact of strategies, progress against the set targets and areas  that need  mid‐course corrections 115

116. Mid-term review of NACP III - 3 Development  objective  of NACP‐III  are well within reach ,   many targets reached and even surpassed. BSS  coverage estimates for 6 states validate  this. Prevalence among ANC attendees, STI patients, FSWs and   MSMs is  declining . Vast majority of new infections and existing burden of disease concentrated in 5-15% of districts Impressive  gains  have  been  made  in  ART services Up scaling of ICTCs, TIs, condom distribution increased More emphasis needed on quality in areas with high  HIV prevalence  & high  vulnerability More   progress is required in  areas like supply  chain management and  laboratory services 116

117. The future – NACP IV 117

118. NACP IV - 1 The Guiding principles for NACP IV will continue to be the same as in NACP III with the addition of Five cross-cutting themes namely Quality Innovation Integration Leveraging Partnerships Stigma and Discrimination 118

119. Conceptual framework for NACP IV 119

120. NACP IV - 2 Proposed Goal Accelerate Reversal Integrate Response Proposed Objectives Reduce new infections by 60% (2007 Baseline of NACP III) Comprehensive care, support and treatment to all persons living with HIV/AIDS Total budget - Rs . 12,824 crore 120

121. Key Strategies of NACP IV To achieve the goal and objectives the following key strategies have been identified. Strategy 1: Intensifying and consolidating prevention services with a focus on HRG and vulnerable population. Strategy 2: Increasing access and promoting comprehensive care, support and treatment Strategy 3: Expanding IEC services for (a) general population and (b) high risk groups with a focus on behavior change and demand generation . Strategy 4 : Building capacities at national, state and district levels Strategy 5: Strengthening and use of Strategic Information Management Systems 121

122. Proposed Targets for NACP IV - 1 122

123. Proposed Targets for NACP IV - 2 123

124. comments 124

125. Comments Political commitment Legislation to stop discrimination HSS – pitfalls ART programme – financial issues, coverage, short supply No importance to prevent, rescue, rehabilitate, reintegrate endangered persons of sex-work VCT – surgical patients being tested w/o consent and refused surgery if found positive Underutilisation of funds – CAG audit report ( J uly 2004) Blood banks – w/o licence Inadequate information on condom effectiveness Vertical programme – not cost effective, inefficient Sex education – M aharastra , Karnataka, Chattisgarh , M adhya P radesh, have banned sex education 125

126. Concerns about HSS - 1 Implementation of surveillance among MARPS through NGOs implementing TIs: Conflict of interest & selection bias Inadequate coverage UAT sans consent in TI sites: An ethical dilemma Relevance of HIV surveillance among STD patients Sample size in ANC is 400: Is it sufficient? Reporting of AIDS and STI cases: Clinic based, incomplete and delayed ANC attendees may not adequately represent general population due to referrals & predominance of low SE status popn . Periodic population surveys are needed to calibrate data from ANC clinic attendees PMTCT program data: promising but not suitable for immediate replacement of ANC surveillance 126

127. Concerns about HSS - 2 To conduct and regularly report EQAS To switch to DBS for surveillance after feasibility study Explore possibility of HIV incidence surveillance by Using stored NFHS samples Stored HIV SS samples For such incidence assays Develop guidelines Ensure laboratory logistics Explore HIV SS sample storage issues 127

128. Concerns about HSS - 3 Dried Blood Spot for HIV testing Technique of venepuncture Fear/reservation among patients regarding venepuncture Drawing venous blood Lack of expertise especially at TI sites Sera separation Availability of equipments required for sera separation Bio-medical waste management inappropriate at TI sites Logistics: Storage and transportation of sera under cold chain 128

129. Concerns about AIDS case surveillance Was important early in epidemic Not useful because Data are incomplete, poor representation Not designed to collect information on High risk behaviours Do not monitor current transmission pattern - represent 8-10 year old infections Can not use to estimate current program needs Complex mathematical models needed to estimate ART needs Other potential sources with scale up HIV infection reporting from VCTC, PMTCT, ART center Data from TB sites and HIV prevention and care sites 129

130. Concerns about STI surveillance Current STI surveillance is: Incomplete, Irregular & Non-representative Hardly used to monitor HIV and STI epidemic Captures mainly the public health system Recommendations Implement basic STI survll in STI, TI & ANC clinics Involve private sector Simplified reporting formats Ensure analysis and usage of data 130

131. MDG for HIV/AIDS GOAL-6 COMBAT HIV/AIDS, MALARIA AND OTHER DISEASES Target-6.A Have halted by 2015 and begun to reverse the spread of HIV/AIDS Indicators HIV prevalence among population aged 15-24 years Condom use at last high-risk sex Proportion of population aged 15-24 years with comprehensive correct knowledge of HIV/AIDS Ratio of school attendance of orphans to school attendance of non-orphans aged 10-14 years

132. Target-6.B Achieve , by 2010, universal access to treatment for HIV/AIDS for all those who need it Indicator 6.5 Proportion of population with advanced HIV infection with access to antiretroviral drugs