National AIDS Control Programme - NACP

1

National AIDS Control Programme

Dr. Rizwan S A, M.D.,

…India’s answer to HIV/AIDS

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

3

EPIDEMIOLOGY OF HIV/AIDS IN INDIA

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

5

Burden of HIV in India

Based on HIV Sentinel Surveillance 2008-09, Annual report of NACO 2010-11

Parameter All India

Adult prevalence2009

0.31%

PLHA 2009

23.9 lakh

SubgroupAll India# (%) 2008

IDU 9.86

MSM 6.90

FSW 4.80

STD clinic attendees 2.90

ANC 0.47

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

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, Puducherry, Goa

• Low prevalence– <5% in HRG & <1% in ANC

– All other states/UTs

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

9

Classification of districts - 2

• Based on 2004-2006 HSS

• Category A; 156 • Category B; 39

10

Dynamics of Transmission

females

Male ClientsmalesMSM IDUs

FSW

Children

Spouses

Others in Gen. Population

- Past SW & MSM

- Iatrogenic

(Adapted from Tim Brown’s)

11

Rationale for Targetted Intervention

HRG

12

Routes of transmission

13

THE EARLY RESPONSE TO THE EPIDEMIC

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

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

16

The beginnings - 3

• 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 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

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

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

– United 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)

19

NACP - I

• India’s first effort to develop a national public health programme for HIV/AIDS prevention and control

• Aims were – Prevent HIV transmission– Decrease the morbidity and mortality associated

with HIV infection– Minimise the socio-economic impact of HIV

infection

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.

21

NACP – I Services1. 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

2. 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

3. Condoms– Popularise the use of condoms, improve quality and increase availability. – NGOs were engaged to promote and distribute condoms through “social marketing”

4. Annual sentinel surveillance system– Initially, 180 sites were set up to monitor HIV prevalence among ANC clinic attendees

and STD clinics

5. Control of STDs– Upgrade 504 existing STD clinics with equipment, and laboratory facilities and drugs– Train doctors to provide “syndromic” treatment of STDs

6. Some elementary treatment facilities

7. Pilot projects on targetted interventions

8. Multi-sectoral approach –pvt and corporate sector, national and international organisations

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

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.

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

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

26

NACP-II Services - 46. 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

27

CURRENT PROGRAMME – NACP III

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

29

NACP – III• Goals

– Halt and reverse the epidemic in India over the next five years by four pronged strategy

1. Prevent new infections

2. Increasing CST for PLHA

3. Strengthen the infrastructure, systems and human resources

4. 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,

– And by 40% in the vulnerable states to stabilise the epidemic.

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

31

Key actors in NACP III

32

Administrative structure of NACO

33

PROGRAMME COMPONENTS OF NACP III

34

35

1. PREVENT NEW INFECTIONS

36

1. Prevent new infections

• Saturation of coverage in high risk group through targeted interventions

• Scaling up interventions among general population

37

Saturating coverage of high risk group through Targeted Interventions

• 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.

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

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 volunteers

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

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

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

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

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

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

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

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

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

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

50

Universal precautions and PEP

• Accidental contact of open wounds, needle stick injury, mucous membrane

• Medical care and counselling after exposure• Chemoprophylaxis

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

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

53

STD Control Programme - 2

• Objectives – reduce STD cases and thereby control HIV and

prevent long term/short term morbidity and mortality

• Strategies

1. Develop adequate and effective program management

2. Promote IEC activities

3. Comprehensive case management – diagnosis, treatment,

conselling, partner notification, screening for other diseases

4. Strengthening existing facilities, and creating new facilities

where required

5. Facilities for diagnosis and treatment of asymptomatic

infections

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

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

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 use of condoms with non-regular partners in last 30

days

• % reporting condom availability within 500 metres

• % increase in non-traditional outlets for condoms

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

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

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

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 1st 1998• National blood policy and Action plan• Testing of blood is mandatory for Hep B&C, malaria,

syphilis, HIV I & II

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

62

2. INCREASING CST FOR PLHA

63

2. Increasing CST for PLHA

• Comprehensive management of PLHA by management of – opportunistic infections

– ART

– psychological support

– home based care

– impact mitigation

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

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

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

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

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

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

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

71

3. STRENGTHEN THE INFRASTRUCTURE, SYSTEMS AND HUMAN RESOURCES

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

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

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, condom 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)

75

4. STRENGTHENING SIMS, M&E

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

77

4. Strengthening SIMS, M&E

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

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

80

Surveillance of HIV/AIDS

• AIDS case surveillance• HIV sentinel surveillance• STD surveillance• Behavioural surveillance

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

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

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) 400Durtion/ 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 yearsTesting Method UAT with

informed consent

Unlinked Anonymous Testing (UAT)

UAT

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

88year 2010 – 1359 Sitesyear 2003 – 699 Sites

HIV Sentinel Surveillance - Scale up

89

Expansion of sentinel surveillance

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

- - - - - 1 - - 1 - - -

Total 176 177 224 320 384 699 649 703 1122 1134 1215 1359

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

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

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

93

Behavioural surveillance survey - 2

• A set of indicators used– Knowledge– Behaviour– STI/RTI prevalence– Risk perception

94

ACHIEVEMENTS OF NACP III

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

96

TI numbers

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. 

98

Management of STD/RTI - 2

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

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.

101

ICTCs - 1

• Against the 11th 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

102

ICTCs - 2

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

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

105

CST for PLHA - 1• ART programme launched on 1st 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

106

CST for PLHA - 2

• It is planned to have 350 CCC by 2012• 300 Link ART centres have been develo

ped at ICTC or CCC (against the target of 650 by 2012)

• Smart card system

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

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

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

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 e ciency of the ffi CMIS.

• SIMS was launched in August 2010 and is scheduled to be fully implemented during 2011.

Monitoring and Evaluation - 2

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

113

EVALUATION OF NACP III

114

Mid-term review of NACP III - 1

Conceptual framework

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

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

117

THE FUTURE – NACP IV

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

119

Conceptual framework for NACP IV

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

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

122

Proposed Targets for NACP IV - 1

123

Proposed Targets for NACP IV - 2

124

COMMENTS

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 (July 2004)

• Blood banks – w/o licence

• Inadequate information on condom effectiveness

• Vertical programme – not cost effective, inefficient

• Sex education – Maharastra, Karnataka, Chattisgarh, Madhya Pradesh, have

banned sex education

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

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

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

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

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

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 yearsCondom use at last high-risk sexProportion of population aged 15-24 years with comprehensive correct knowledge of HIV/AIDSRatio of school attendance of orphans to school attendance of non-orphans aged 10-14 years

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

Indicators of HIV/AIDS in MDG in INDIA

134

Thank you