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
4. Indian Scenario of HIV/AIDS
HIV trends in India 2002 - 2009
HIV epidemic in India shows a stable trend at national level,
However, some low prevalence and vulnerable states show rising trends
4
5. Burden of HIV in India
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
Based on HIV Sentinel Surveillance 2008-09, Annual report of NACO 2010-11
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, Puducherry, 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
8
data
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,
– 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
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
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)
18
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
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
1.
2.
3.
4.
5.
6.
7.
8.
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 organisations21
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
26
centres
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
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.
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
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 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.
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 volunteers
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
1.
2.
3.
4.
5.
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 use 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 1st 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
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. Care and support for PLHA - 1
• 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
68
69. Care and support for PLHA - 2
•
•
•
•
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
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
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, 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)
74
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
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
5000 primary data
generating units
SACS
NACO
• 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
Data flow
79
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
IDU/ MSM/ FSW /
SMM/ LDT
STD pts
General Population
Pregnant Women
attending Antenatal
Clinics
Sentinel Site
Drop-in-centers/ STD & Gynae
NGO service
clinics
points
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 - 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. 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
89. 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
90. 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
91. Behavioural surveillance survey - 2
• A set of indicators used
– Knowledge
– Behaviour
– STI/RTI prevalence
– Risk perception
93
93. 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
95. 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
97. 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
98. 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 BanksNew Delhi, Mumbai, Chennai & Kolkata as Centres
of Excellence in Transfusion Medicine and one large Plasma
Fractionation Centre at Chennai.
100
99. 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
101
101. 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
102. 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
103. 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
105
104. 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
106
105. 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
106. 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
108
• Strengthening of Health facilities for OST
107. 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
108. Monitoring and Evaluation - 2
• 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 webbased 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.
110
109. 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
111
110. 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. 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
114. 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
116. 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
118. 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
119. 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
123. 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
125
124. 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
125. 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
126. 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
127. 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
128. 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
129. 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
130. 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
