National AIDS Control Program - IV

NATIONAL AIDS CONTROL PROGRAMME(NACP)-IV

Dr. Bharat Paul

CONTENTS

• Introduction• Epidemiology of HIV/AIDS• AIDS Control Programme in India• NACP I,II & III• NACP-IV

– Objectives– Strategies– Key initiatives– Guiding Principles– Services– Monitoring framework– Challenges

• References

INTRODUCTION

HIV is the Human Immunodeficiency Virus- lentivirus -retrovirus

Leads to Acquired Immune Deficiency Syndrome, or AIDS.

Destroy specific blood cells, called CD4+ T cells, which are crucial for fighting diseases.

No cure for HIV infection.Currently, people can live much longer - even decades -

with HIV before they develop AIDS. “Highly active” combinations of medications that were

introduced in the mid 1990s.

Modes of transmission

Heterosexual 87.4

Parent to Child5.4

others3.3

Injecting Drug Use1.6

Homosexual/Bisexual1.3

Blood and BloodProducts1

Risk of transmission

ROUTE EFFICIENCY (%)

Sexual 0.01 to 1

Transfusion of blood products >90

Sharing needles/syringes 3-5

Percutaneous exposure 0.4

Mucocutaneous exposure 0.05

Mother to child transmission 25-30

ADULTS --Positive test for HIV antibody by 2 separate test using

2 different antigens +Any one of the following

Weight loss >10% of bw Chronic diarrhoea >1 month Chronic cough >1 month Disseminated ,miliary or

extrapulmonary TB Neurological impairment Esophageal candidiasis Kaposi sarcoma

Major –Weight loss,Failure to thrive,Candidiasis,Tuberculosis,Herpes zoster

Minor—Generalised lymphadynopathy,Oropharyngeal candidiasis,Persistant cough for >I month , Generalised dermatitis, Confirmed maternal HIV infection

CHILDREN—At least 2 major signs + 2 minor signs

Case definition of AIDS

Epidemiology of HIV/AIDS in India

• The HIV epidemic in India is concentrated among High Risk Groups and is heterogeneous in its distribution.

• Overall trends of HIV portray a declining epidemic at national level, though regional variations exist.

• The total number of people living with HIV/ AIDS in India was estimated at around 20.9 lakh in 2011, 86% of whom were in 15-49 years age-group.

Epidemiology of HIV/AIDS in India

• According to HSS 2012-2013, the overall HIV prevalence among ANC attendees continued to be low at 0.35% in the country, with an overall declining trend at the national level.

• According to HIV Estimations 2012, the adult (15-49 years) HIV prevalence at national level continued its steady decline from the estimated level of 0.41% in 2001 to 0.27% in 2011

Epidemiology of HIV/AIDS in India

• India has demonstrated an overall reduction of 57% in estimated annual new HIV infections (among adult population) during the past decade from 2.74 lakh in 2000 to 1.16 lakh in 2011.

Classification of 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

Classification of districts

• 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

Haryana

• Category A – Bhiwani• Category B – None• Category C –

Ambala,Faridabad,Fatehabad,Gurgaon,Hisar, Jhajjar, Jind, Kaithal, Karnal, Kurukshetra, Mewat, Panchkula,Panipat, Rewari, Rohtak, Sirsa, Sonipat, Yamunanagar

• Category D - Mahendergarh

AIDS Control Programme in India

• 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.

• In 1986 Government 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 1989, a Medium Term Plan for AIDS Control was

developed with the support of the WHO.

AIDS Control Programme in India

• First National AIDS Control Programme (NACP-I) was launched in 1992.

• NACP-II launched in 1999: decentralization of programme implementation to State level and greater involvement of NGOs.

• NACP- III implemented during 2007-2012: scaling up HIV prevention interventions for HRG and general population, and integrate them with Care, Support & Treatment services.

• NACP-IV has been developed for the period 2012-2017

NACP-I

OBJECTIVE Slow and prevent the spread of HIV through a major effort to prevent HIV

transmission.

KEY STRATEGIES Focus on raising awareness, Blood safety, Prevention among high-risk populations, Improving surveillance

ACHIEVEMENTS National AIDS response structures at both the national and state levels and provided critical

financing. Strong partnership with the World Health Organisation(WHO) and later helped mobilize

additional donor resources. Established the State AIDS Control Cells Improved blood safety. Expanded sentinel surveillance and improved coverage and reliability of data. Improved condom promotion activities. National HIV testing policy.

NACP-II

OBJECTIVE

Reduce the spread of HIV infection in India through behavior change and increase capacity to respond to HIV on a long-term basis.

KEY STRATEGIES

Targeted Interventions for high-risk groups Preventive interventions for general

populations Involvement of NGOs Institutional strengthening

NACP-II

ACHIEVEMENT

At the operational level 1,033 targeted interventions set up, 875 Voluntary counseling and testing centers (VCTC) and 679 STI clinics at the district level.

Nation-wide and state level Behaviour Sentinel Surveillance (BSS) surveys were conducted

Prevention of parent-to-child transmission (PPTCT) programme was expanded.

A computerized management information system (CMIS) created. HIV prevention and care and support organizations and networks

were strengthened. Support from partner agencies increased substantially

NACP-III

OBJECTIVE Reduce the rate of incidence by 60 per cent in the first year of the programme in

high prevalence states to obtain the reversal of the epidemic, and by 40 percent in the vulnerable states to stabilise the epidemic.

STRATEGIES Prevention – Targeted intervention (TI), ICTC, blood safety, communication,

advocacy and mobilisation, condom promotion. Care, support and treatment – ART, Pediatric ART, Center for

excellence, Community Care Centers. Capacity building – establishment, support and capacity

strengthening, training, managing programme implementation and

contracts, mainstreaming/private sector partnerships. Strategic information management – monitoring and evaluation.

NACP-III

ACHIEVEMENTS

There were 306 fully functional ART Centres against the target of 250 by March 2012

Nearly 12.5 lakh PLHIV were registered and 420000 patients were on ART. 612 Link ART centre (LAC) had been established wherein, 26023 PLHIV

were taking Services There were 10 Centres of Excellence, 7 Regional Pediatric centres also functional. 259 Community Care Centres across the Country 6000 condoms & 6000 village information centres established 3000 Red ribbon clubs established Link Workers training module updated

NACP-IV

• Launched on 12 February 2014• Total budget outlay Rs 14295 crores.• Goal: Accelerate Reversal and Integrate

Response

NACP-IV

• Objective 1:• Reduce new infections by 50% (2007 Baseline

of NACP III)• Objective 2:• Provide comprehensive care and support to all

persons living with HIV/AIDS and treatment services for all those who require it.

STRATEGIES UNDER NACP-IV

Key Strategies under NACP-IV

Intensify &consolid

ate preventive services

Increase access

&promote

comprehensive care,

support & treatment

Expanding IEC

services

Capacity building

Strengthening

Strategic Informati

on Managem

ent system

Strategy 1: Intensifying and Consolidating Prevention Services

• Prevention will continue to be the core strategy of NACP-IV as more than 99% of the people are HIV negative

• It is planned to cover 90% of HRGs through Targeted Interventions (TI) implemented by NGO and CBOs

• High risk migrants, their spouses, truckers and other vulnerable population will be accessed by collaborating with other departments, voluntary groups, civil society networks, women groups and youth clubs.

Activities

• Saturating quality HIV prevention services to all HRG groups, based on emerging behavior patterns and evidence.

• Strengthening needle exchange Programme, drug substitution programme and providing Opioid Substitution Therapy (OST).

• Reaching out to MSM and Transgender communities.

Activities

• Addressing the issue related to coverage and management of rural interventions.

• Providing quality STI/RTI services.• Strengthening management structure of blood

transfusion services.• Expand the ICTC services and strengthen

referral linkages.

Strategy 2:Comprehensive Care,Support and Treatment

• Additional Centres of Excellence (CoEs) and upgraded ART Plus Centres will be established to provide high quality treatment

• Treatment of HIV/AIDS will include: (i) anti-retroviral treatment (ART), including second line (ii) management of opportunistic infections including TB in PLHIV, (iii) positive preventions and (iv) facilitating social protection and insurance for PLHIV.

Activities

1. Scale up ART Centres, LACs, and COEs ART services.

2. Strengthening follow up of patients on ART and improving quality of counseling services at ART service delivery points.

3. Comprehensive care and support services for PLHIV through linkages.

4. Provide guidelines and training for integration in health care settings to NRHM.

Strategy 3: Expanding IEC services for (a)general population and (b) high risk groups with a focus on

behavior change and demand generation

1. Increasing awareness among general population ,in particular women and youth.

2. Behavior change communication strategies for HRG and vulnerable groups.

3. Continued focus on demand generation of services.

4. Reach out to vulnerable populations in rural settings.

5. Extending services to tribal groups and hard-to-reach populations.

Strategy 4:Strengthening institutional capacities

• The programme management structures established under NACP will be strengthened.

• Programme planning and management responsibilities will be enhanced at national, state, district and facility levels.

• Phased integration of the HIV services with the routine public sector health delivery systems, streamlining the supply chain mechanisms and quality control mechanisms and building capacities of governmental and non-governmental institutions.

Strategy 5: StrategicInformation Management System

• This will ensure– high quality of data generation systems such as

Surveillance, Programme Monitoring and Research.

– strengthening systematic analysis, synthesis, development and dissemination of Knowledge products in various forms.

– emphasis on Knowledge Translation as an important element of policy making and programme management at all levels.

Key initiatives under SIMS

• National Integrated Biological & Behavioural Surveillance(IBBS) among HRG & Bridge Groups

• National Data Analysis Plan• National Research Plan• Advanced analytic and Geographic

Information System(GIS)

Guiding Principles of NACP-IV

1.Continued emphasis on three ones - one Agreed Action Framework, one National HIV/AIDS Coordinating Authority and one Agreed National M&E System.

2. Equity

3. Gender

4. Respect for the rights of the PLHIV

5. Civil society representation and participation.

6. Improved public private partnerships.

7. Evidence based and result oriented programme implementation.

CROSS CUTTING AREAS OF FOCUS

1. Quality

2. Innovation

3. Integration

4. Leveraging Partnerships

5. Stigma and Discrimination

KEY PRIORITIES UNDER NACP-IV

1. Preventing new infections by sustaining the reach of current interventions and effectively addressing emerging epidemics.

2. Prevention of Parent to Child transmission

3. Focusing on IEC strategies for behavior change in HRG, awareness among general population and demand generation for HIV services.

KEY PRIORITIES UNDER NACP-IV

4. Providing comprehensive care, support and treatment to eligible PLHIV

5. Reducing stigma and discrimination through Greater involvement of PLHA (GIPA)

6. De-centralizing rollout of services including technical support

7. Ensuring effective use of strategic information at all levels of programme

KEY PRIORITIES UNDER NACP-IV

8. Building capacities of NGO and civil society partners especially in states with emerging epidemics

9. Integrating HIV services with health systems in a phased manner

10. Mainstreaming of HIV/ AIDS activities with all key central/state level Ministries/ departments will be given a high priority.

PACKAGE OF SERVICES

PREVENTION SERVICES

• Targeted Interventions for High Risk Groups and Bridge Population.

• Needle-Syringe Exchange Programme (NSEP) and Opioid Substitution Therapy (OST) for IDUs

• Prevention Interventions for Migrant population at source, transit and destination

• Link Worker Scheme (LWS) for HRGs and vulnerable population in rural areas

PREVENTION SERVICES

• Prevention & Control of Sexually Transmitted Infections/Reproductive Tract Infections (STI/RTI)

• Blood Safety• HIV Counseling & Testing Services• Prevention of Parent to Child Transmission• Condom promotion• Information, Education & Communication (IEC)

& Behavior Change Communication (BCC).

Care, Support & TreatmentServices

• Laboratory services for CD4 Testing and other investigations.

• Free First line & second line Anti-Retroviral Treatment (ART) through ART centres and Link ART Centres (LACs), Centres of Excellence (COE) & ART Plus Centres

• Pediatric ART for children.• Early Infant Diagnosis for HIV exposed infants

and children below 18 months.

Care, Support & TreatmentServices

• HIV-TB Coordination (Cross referral, detection and treatment of co-infections)

• Treatment of Opportunistic Infections• Drop-in Centres for PLHIV networks

New Initiatives under NACP-IV

• Differential strategies for districts based on data triangulation with due weightage to vulnerabilities.

• Scale up of programmes to target key vulnerabilities– Scale up of Opioid Substitution Therapy(OST) for

IDUs– strengthening of Migrant Interventions at

Source,Transit & Destinations

New Initiatives under NACP-IV

• Scale up of Multi-Drug Regimen for Prevention of Parent to Child Transmission(PPTCT).

• Social protection for marginalized populations through mainstreaming and earmarking budgets for HIV among concerned government departments.

• Establishment of Metro Blood Banks and Plasma Fractionation Centre.

New Initiatives under NACP-IV

• Launch of Third Line ART and scale up of first and second Line ART.

• Demand promotion strategies specially using media, e.g., National Folk Media Campaign & Red Ribbon Express and buses.

MONITORING FRAMEWORK

IMPACT INDICATORS

• Reduction of new HIV infections (HIV Incidence): Estimated number of Annual New HIV Infections (HIV incidence)

• Reduction in mortality among people living with HIV/AIDS: Estimated number of annual AIDS-related deaths

• Survival of AIDS patients on ART

OUTCOME INDICATORS

• Behavioural Change among Female Sex Workers: Percentage of female sex workers who report using a condom with their last client(Target: 80% to 85% increase by 2017; 5% increase over the baseline of IBBS 2012-13).

• Behavioural Change among Men who have Sex with Men: Percentage of men who have sex with men who report using a condom during sex with their last male partner (Target: 45% to 65% increase by 2017; 20% increase over the baseline of IBBS 2012-13).

OUTCOME INDICATORS

• Behavioural Change among Injecting Drug Users :Percentage of injecting drug users who do not share injecting equipment during the last injecting act (Target: 45% to 65% increase 2017; 20% increase over the baseline of IBBS 2012-13

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, in close collaboration with NRHM, to prevent mother to- child transmission in the community

PROGRAMME TARGETS

• Supply of 90 lakh units of safe-blood and enhanced use of blood products will be ensured.

• It is estimated that there will be 10,05,000 people on ART (including 50,000 children who require 1st line ART and nearly 50,000 PLHIV who require 2nd line drugs) by 2017.

NACP-IV BUDGET

NACP-IV Challenges

• Need to consolidate successes gained, by sustaining prevention focus besides effectively addressing the challenges.

• Given the experience of previous phases where the programme focused on saturating the coverage, NACP- IV needs to advance towards focusing on ensuring higher quality of services under interventions while sustaining the coverage.

NACP-IV Challenges

• Emerging Epidemics in certain low prevalence states and districts due to Migration to high prevalence areas.

• Major challenge for the programme will be to ensure that the treatment requirements are fully met without sacrificing the needs of prevention

• Regions with different maturity levels of the epidemic will require different resources and services

NACP-IV Challenges

• International finances for HIV/AIDS programme are shrinking.

• Stigma and Discrimination that is still prevailing against the vulnerable population, persons and families infected and affected with HIV.

REFERENCES

• NACP – IV strategy document – National AIDS Control Organisation

• Annual report of NACO,2013-14• National AIDS Control Program –Health

Programs in India – Dr. D.K Taneja• National AIDS Control program- National

Health Programs of India – Dr.J.Kishore