Today’s Agenda

India’s National AIDS Control Programme

Reversing the Tide

International AIDS ConferenceWashington D.C., U.S.A

July 2012

Aradhana JohriAdditional Secretary,

National AIDS Control OrganizationGovernment of India

1

Reversal of the Epidemic

The Route

Looking Forward

1

2

3

Today’s Agenda

2

0.31% adults infected2.3 million people living with HIV

20-25 million people projected to be living with AIDS by 2010 (highest number in any country in the world)

Early 2000’s….projections Today…

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Age

-adj

uste

d H

IV p

reva

lenc

e (%

)

Source: HIV Estimations, 2010 & NACO’s ANC Sentinel Surveillance data. Consistent ANC sites for the age group 15-24 were analysed

Source: National Intelligence Council (2002) 'The Next wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China', September, p.3

56% reduction

in new infections over the

last decade!

HIV in India...grim projections earlier, but a global success story today

3

Reduced Deaths & More Efficient Case Detection

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684528177

64116

134928

217781

375204

0

50000

100000

150000

200000

250000

300000

350000

400000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Annual Deaths Pts. On ART

Decline in estimated annual AIDS-related deaths with scale-up of ART

Declining AIDS-

related deaths

Significant increase in

baseline CD4 count

at detection

4

Source: HIV Estimations, 2010

The Road Map

NACP I (1994-1999)Initial

Interventions

NACP II (1999-2006)

-Decentralisation to states - Limited

coverage of services

NACP III (2007-2012)

Massive scale up with quality assurance

mechanisms 56% reduction

in new infections achieved

NACP IV (2013+)

Consolidate gains

Focus on MARPSQuality

assurance5

Quadrupling of budget for HIV under NACP III ($ Million)…

1990

-199

2

1992

-199

9

1999

- 20

04;

exte

nded

to

2007

2007

-201

2

Medium term plan NACP I NACP II NACP III

- 200 400 600 800

1,000 1,200 1,400 1,600 1,800 2,000

4 113

459

1,783

Additional 800m of extra budgetary support

6

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Targeted Interventions

No. of Tis % Coverage of MARPS

No.

of T

Is

% C

over

age

of M

ARPS

Ambitious Targets, Impressive

Achievements

7

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STI/ RTI Services

No. of STI CentresSTI episodes treated annually (Millions)

No.

of S

TI C

entr

es

STI e

piso

des t

reat

ed a

nnua

lly (M

illio

ns)

8

Ambitious Targets, Impressive

Achievements

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Condom Social Marketing

No. of Districts with CSMPCondom Sales (Millions)

No.

of D

istr

icts

with

CSM

P

No.

of C

ondo

ms D

istr

. (M

illio

ns)

9

Ambitious Targets, Impressive

Achievements

10

Ambitious Targets, Impressive

Achievements

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HIV Counseling & Testing Services

No. of Stand-alone ICTCNo. of FICTCNo. Tested Annually (Million)

No.

of I

CTCs

No.

Tes

ted

Annu

ally

(Mill

ions

)

10,515

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01

02

03

04

05

06

07

08

09

10

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02

09 11,460

13,013

PPTCT Programme

No. of Pregnant Women tested (million)No. of MB Pairs Received NVP

No.

of P

regn

ant W

omen

Tes

ted

(mill

ion)

No.

MB

Pairs

Rec

d. N

VP

11

Ambitious Targets, Impressive

Achievements

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Anti-Retroviral Treatment (ART)

No. of ART CentresNo. of Link ART CentresNo. of PLHIV on ART ('000)

No.

of A

RT C

entr

es

No.

of P

LHIV

on

ART

(‘000

)

12

Ambitious Targets, Impressive

Achievements

TG IDU MSM FSW Truckers Migrants ANC0

1

2

3

4

5

6

7

8

9

10

8.824

7.170

4.430

2.670 2.592

.986.415

HIV Prevalence (%)

Source: 2010-11 NACO HIV Sentinel Surveillance – Provisional Findings

13

India continues to portray

a concentra

ted epidemic

New Evidence…HSS 2010-11

New Evidence…HSS 2010-11

03-05 04-06 05-07 06-08 07-100tan3a56603

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IDU FSW MSM ANC

ANC

HIV

Prev

alen

ce (%

)

Declining trends at national level among general

population, FSW & MSM

Stable trends at national level

among IDU

Need to study trends among

Migrants, Truckers and TG

Source: 2010-11 NACO HIV Sentinel Surveillance – Provisional FindingsNote: 3-yr moving averages based on consistent sites; ANC–385 sites, FSW–89 sites, MSM–22 sites, IDU–38 sites 14

Further decline in HIV prevalence among different risk groups

ANC

IDU

FSW

MSM

HIV Epidemics among FSW

States with higher vulnerability among FSW

Declining trends among FSW at national level and in all the states

Greater need to sustain the reach and quality of FSW interventions to consolidate the gains

Vulnerability due to FSW also extends to source states for migration

Large size of FSW with higher HIV prevalence in high prevalence states

Source: NACO HIV Sentinel Surveillance 2010-11 – Provisional Findings; NACO Mapping of HRG 2008-09;

HIV Epidemics among MSM

States with higher vulnerability among MSM

Large size and higher levels of HIV among MSM in high prevalence states and low prevalence states of Gujarat, MP, West Bengal, Chhattisgarh, Delhi etc.Need to saturate coverage among MSM through effective prevention services

Source: NACO HIV Sentinel Surveillance 2010-11 – Provisional Findings; NACO Mapping of HRG 2008-09;

HIV Epidemics among IDU

States with higher vulnerability among IDU

Higher levels of HIV among IDU in Punjab, Chandigarh, Delhi and Mumbai, in addition to North EastEmerging epidemics among IDUs in low prevalence states of Kerala, Orissa, MP, Bihar and UPFocus on saturation with Needle-Syringe Exchange Programme and Scale-up of OST

Source: NACO HIV Sentinel Surveillance 2010-11 – Provisional Findings; NACO Mapping of HRG 2008-09;

HIV Epidemics due to Migration

States with higher vulnerability due to Migration

Rising trends in low prevalence states among ANC attendees despite low level, stable epidemics among HRG in these states

Mapped migration corridors with large volumes of out-migration to high prevalence destinations

HIV prevalence – higher among rural ANC than urban; higher among those whose spouse is a migrant

Need to increase coverage of migrants at destinations & along with their spouses at source

Source: NACO HIV Sentinel Surveillance 2010-11 – Provisional Findings; Source: Population Council Study -- Reference: Saggurti N, Mahapatra BB, Swain SN, Jain AK. Male out-migration and sexual risk behavior in India: Is the place of origin critical for HIV prevention programs?. BMC Public Health. 2011. 11:S6;

Emerging Vulnerabilities

Jharkhand

Maharashtra

Tamil Nadu

Madhya Pradesh

Average

Gujarat

Andhra Pradesh

Karnataka

West Bengal

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001

002

002

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003

003

003

003

004HIV Prevalence (%) among Truckers

Mumbai

Chennai

Average

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009

HIV Prevalence (%) among TGs

Greater vulnerability among Truckers and Trans-gendersNeed to generate more evidence on epidemic trends and transmission dynamicsNeed to scale up and strengthen prevention interventions for Truckers & TG

Source: 2010-11 NACO HIV Sentinel Surveillance – Provisional Findings

TRUCKERS TRANS-GENDERS (TGs)

Targeted Interventions Proven Cost-Effective

Characteristic Value

Cumulative Costs of implementing FSW TI (1995-2015)

USD 1991 Million

Cumulative HIV infections averted by FSW TIs (1995-2015)

2.7 Million

Cost per HIV infection averted

USD 105.5

Cost per DALY averted USD 10.9

Districts with higher TI intervention intensity show greater declines than those with lower TI intensity2.7 million lives saved through TIs, cost of ~$100/ infection averted

Source: Impact of Targeted Interventions on Heterosexual Transmission of HIV in India, Kumar R, Mehendale SM, Panda S; Sex Transm Infect 2011;87:354e361. doi:10.1136/sti.2010.047829, Prinja et al

20

HIV prevalence according to TI intensity among young ANC attendees (15-24 yrs) in Tamil Nadu, Karnataka,

Maharashtra and Andhra Pradesh, India.

0.00

0.25

0.50

0.75

1.00

1.25

1.50

1.75

2.00

2.25

2001 2002 2003 2004 2005 2006 2007 2008

% H

IV p

reva

lenc

e

High TI intensity districts Low TI intensity districts

Reversal of the Epidemic

The Route

Looking Forward

1

2

3

Today’s Agenda

21

Guiding Principles

22

COMMUNITY and high risk groups at centre

PREVENTION focused

Increased access to

TREATMENT, care and support

Expanded service delivery

with AMBITIOUS TARGETS

The Route

Consultative

processManagement focus

Listening to data – Real time

23

Consultative process for planning and implementation

A community-centric approach

Communities of

MARPS and PLHIV

Technical experts

and resource groups

Civil Society

Development

Partners

Other governme

nt departme

nts

24

The Route

Consultative

processManagement focus

Listening to data – Real time

25

Leveraging Expertise

Guidelines, policy & planning

Fund release,

administration,

programme implementat

ion

Managing in-sourced units, coordinating

technical inputs

Technical inputs into

guideline and tool

development

Supportive

supervision --

‘feel on the

street’ quality

assuranceIn-sourced supportGovernment programme delivered

Core capabilities of government• Build on core health systems capabilities• Supplement with technical staff on contract• Partner with SACS• Contracts with management agencies

Leveraging external skills through:• Technical Resource

Groups• Technical Support Units• Academic partnerships

26Resulting in large improvements in service delivery… Eg: TI

Management Focus…

Standardization for scaleSome Examples…

27

Operational &

Technical Guideline

s

Uniform Training Modules

Structured

Monitoring

Mechanisms

Unit Costing

for Intervent

ions

Management Focus…

PHASE-1 (2007)• Focus on outreach• No services

PHASE-2 (2010)• Addition of services (Counseling & testing)

• Convergence with the health system• External Evaluation

PHASE-3 (2012)• Focus on Knowledge of HIV Services & Vulnerabilities – Youth & Migration

• Convergence and outreach strengthened; Greater focus on mid-media, folk arts, bus campaigns etc.

• Day-to-day monitoring, Pre-Post & Concurrent Evaluation

Flexible Modeling-Greater ImpactEg. Red Ribbon Express

28

RRE-1 RRE-2 RRE-30tan28a566028

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Reach of RRE

No. of People Reached (Million)Projected

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Pre-RRE Post-RRE

The Route

Consultative

processManagement focus

Listening to data – Real time

29

Evidence-driven recasting of Migrant Strategy

Higher HIV Prevalence among Pregnant Women with a Migrant Spouse

Migrants over-represented (80%) among HIV+ men (Ganjam)

…resulting in re-scoping and

reshaping of Migrant Strategy under NACP-

III

Adding transit

and source interventions

to migrant packag

e

Tracking

migrant routes

for better focus

Reverse mappin

g to identify sources

and address spouses

of migrant

s

Source: Population Council Study -- Reference: Saggurti N, Mahapatra BB, Swain SN, Jain AK. Male out-migration and sexual risk behavior in India: Is the place of origin critical for HIV prevention programs?. BMC Public Health. 2011. 11:S6; NACO HIV Sentinel Surveillance

Linkages

between source

& destinat

ion

30

RAJ UP BIH WB JHAR ORI CHHT MP.000

.200

.400

.600

.800

1.000

1.200

Migrant Non-Migrant

HIV Positive Cases HIV Negative Controls0%

10%20%30%40%50%60%70%80%90%

100%

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Non-Migrants Returned Migrants Active Migrants

Roll out of OST ProgrammeSetting up of Link ART Centres

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Proven impact of OST on reduced HIV risk

BaselineAfter OST

31

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Percentage

Patients who travel >100 Kms/visit

Patients who don’t come to ARTC due to long distance

Patients who spend > Rs.100 / visit

Patients who don’t come due to finan. reason

Setting up of Link ART Centres

9

Monitoring of PLHA on ART

Screening of HIV TB Coinfection

Enrollment of PLHA in HIV Care and basic investigations

Pre-ART Management

Treatment of OIs

Psycho–socialSupport to PLHA

LAC

2010 2012 2014*0tan28a566028

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Scale-up of OST

No of OST CentresIDUs on OST

* Projected as per scale-up plan

OR to study Factors affecting ART Adherence

Evidence Led…

Reversal of the Epidemic

The Route

Looking Forward

1

2

3

Today’s Agenda

32

Challenges and the way forwardHigher

domestic funding

Balancing prevention

and treatment

Convergence with health system

Progressive policy

initiatives

Maintaining political

will

33

1. Increased reliance on domestic financing in view of dwindling donor

resources

Domestic Budget; 006

External Aided Component; 094

NACP-III

Domestic Budget; 077

External Aided Component; 023

2012-13

NACP-III: Expenditure till 31.03.2012; 2012-13: Budget Estimate

2. Balancing Prevention & TreatmentSTI

PPTCT / ICTC

Condom Promotion

MARPS

HIV-TB

Treatment of OIs

EID & Pediatric ART

Free First & Second Line ART

Sustaining Prevention Focus & Addressing Emerging Epidemics

Vs

Growing need for ART

3. Convergence for Higher Impact

-

1,000,000 272,263

585,459 803,551 812,743 242,021

568,430 796,667 797,291 PPTCT Scale up in Karnataka

No. of ANCs registered No. of ANCs tested for HIVSource: NACO-CMIS

ICTC, PPTCT, STI,

Blood Safety,

Condom

MARPS, ART

Social Protection

IEC

CHALLENGESCompeting priorities at state level Scaling up integration initiativesEnsuring availability of trained counselors / staffStigma in health care settings

Launch of PMTCT integration – mid-

2008

Complete integration

Partial integration

Coordination

Value addition / linkages

4. Taking the lead…Policy Initiatives

Mainstreaming harm reduction policy for

IDUs

Decriminalizing

homosexuality

Roll out of more

efficacious regimen

(Option-B) for PPTCT

Scale up of free Second

Line ART

37

“Some of the key priority areas will be preventing new infections in hitherto low prevalence states while consolidating efforts in the high prevalence states”The Prime Minister, Dr. Manmohan Singh, at the Parliamentary Forum on HIV/AIDS, 2011

5. Sustained political will

38

You must be the change you wish to see in the world…

-- Mahatma Gandhi

39

Thank You!and we march on…

40

Resulting in large improvements in TI service delivery levels

  2010 2011 GrowthCore groups

attending STI clinics

2.3 mn 2.7 mn 16%

Core groups tested for HIV 0.8 mn 1.1 mn 35%

Condoms distributed to core groups

282 mn 298 mn 6%

Needle/syringe distribution to

IDUs44.5 mn 56.4 mn 27%

41