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Hiv aids in india

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  • 1. Guided by – Dr. Y. D. Badgaiyan Prof. and Head Deptt. of Community Medicine, CIMS, Bilaspur (C.G.) Status & Management of HIV/AIDS in India
  • 2. Background  The Government of India estimates that about 2.40 million Indians are living with HIV (1.93 ‐3.04 million) with an adult prevalence of 0.31% .  Children (<15 yrs) account for 3.5% of all infections, while 83% are the in age group 15-49 years.
  • 3.  Of all HIV infections, 39% (930,000) are among women.  India’s highly heterogeneous epidemic is largely concentrated in only a few states — in the industrialized south and west, and in the north‐east.
  • 4.  The four high prevalence states of South India (Andhra Pradesh – 500,000, Maharashtra – 420,000, Karnataka – 250,000, Tamil Nadu – 150,000) account for 55% of all HIV infections in the country.  West Bengal, Gujarat, Bihar and Uttar Pradesh are estimated to have more than 100,000 PLHA each and together account for another 22% of HIV infections in India.
  • 5. Status of HIV epidemic in India
  • 6.  High prevalent States - States where HIV prevalence in antenatal women is 1% or more.  Moderate prevalent States - States where the HIV prevalence in antenatal women is less than 1% and prevalence in STD and other high risk groups is 5% or more.  Low prevalent States- States where the HIV prevalence in antenatal women is less than 1% and HIV prevalence among STD and other high- risk group is less than 5%.
  • 7. District-wise Scenario of HIV/AIDS Catego ry NACP-III Definition A > 1% ANC prevalence in any of the sites in the last 3 years B < 1% ANC prevalence in all the sites during last 3 years with > 5% prevalence in any HRG site (STD/FSW/MSM/IDU) C < 1% ANC prevalence in all sites during last 3 years with < 5% in all STD clinic attendees or any HRG, with known hot spots D < 1% ANC prevalence in all sites during last 3 years with < 5% in all STD clinic attendees or any HRG OR no or poor HIV data with no known hot spots Category NACP-III A 156 B 39 C 296 D 118 New Districts 30 Total 609
  • 8.  The Indian epidemic is concentrated among vulnerable populations at high risk for HIV.  The concentrated epidemics are driven by unsafe sex between sex workers and their clients and by injection drug user.
  • 9.  Several of the most at risk groups have high and still rising HIV prevalence rates.  According to India’s National AIDS Control Organization (NACO), the bulk of HIV infections in India occur during unprotected heterosexual intercourse.
  • 10.  Consequently, and as the epidemic has matured, women account for a growing proportion of people living with HIV, especially in rural areas.  However, although overall prevalence remains low, even relatively minor increases in HIV infection rates in a country of more than one billion people translate into large numbers of people becoming infected.
  • 11. All the high prevalence states show a clear declining trend in adult HIV prevalence.
  • 12. India 22.5 21.9 21.4 21.1 20.9 0.33 0.31 0.30 0.28 0.27 0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 0.0 5.0 10.0 15.0 20.0 25.0 2007 2008 2009 2010 2011 AdultHIVPrevalence(%) NumberofPLHIV(Lakhs) Estimated Adult HIV Prevalence & Number of PLHIV, India, 2007-11 Number of PLHA (Lakhs) Adult HIV Prevalence (%) Female: 39% of PLHIV; Children: 7% of PLHIV Source: Technical Report India HIV Estimates 2012, NACO & NIMS
  • 13.  However, low prevalence states of Chandigarh, Orissa, Kerala, Jharkh and, Uttarakhand, Jammu & Kashmir, Arunachal Pradesh and Meghalaya show rising trends in adult HIV prevalence in the last four years.
  • 14. However, Regional Variations Exist… 0 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 03-05 04-06 05-07 06-08 07-10 ANC HIV Prevalence (%) Distribution of Estimated New HIV Infections (2011) HP-South-4 HP-NE-3 India LP-North-7 LP-North-6 Declining trends in high prev. states of South & North East, but still at higher levels; Stable to rising trends in low prev. states of Central & North India Source: HSS 2010-11 & HIV Estimations 2012 Note: 3-yr moving averages based on consistent sites; India – 385; HP-South-4 (AP,TN,KR,MH) – 233, HP- NE-3 (MN,NG,MZ) – 31, LP-North-6 (BI,DL,HP,PJ,RJ,UP) – 45, LP-North-7 (AS,CH,GJ,HR,JH,OR, UK) – 33
  • 15.  Most encouraging, the decline is also evident in HIV prevalence among the young population (15-24 yrs) at national level, both among men and women.  Stable to declining trends in HIV prevalence among the young population (15-24 yrs) are also noted in most of the states.  However, rising trends are noted in some states including Orissa, Assam, Chandigarh, Kerala, Jharkhand and Meghalaya.
  • 16. Declining trends, but higher levels… 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 0 2 4 6 8 10 12 03-05 04-06 05-07 06-08 07-10 ANCHIVPrevalence(%) HRGHIVPrevalence(%) ANC MSM FSW IDU Declining trends among general population, FSW & MSM; Stable trends among IDU Note: 3-yr moving averages based on consistent sites; ANC–385 sites, FSW–89 sites, MSM–22 sites, IDU–38 sites Source: HIV Sentinel Surveillance 2010-11 – A Technical Brief, NACO Need to sustain efforts in High Prevalence areas to consolidate gains
  • 17. Risk Factors  Several factors put India in danger of experiencing rapid spread of HIV .  These risk factors include: 1. Unsafe sex. 2. MSM (Men having Sex with Men). 3. IDU (Injection Drug User). 4. Migration & Mobility. 5. Low status of women. 6. Widespread stigma.
  • 18. www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013 Routes of HIV Transmission, 2012-13
  • 19. 1. Unsafe Sex and Low Condom Use  In India, sexual transmission is responsible for 88.2 percent of reported HIV cases and HIV prevalence is high among sex workers (both male and female) and their clients.  A large proportion of women with HIV appears to have acquired the virus from their regular partner.
  • 20. 2. Men Who Have Sex with Men (MSM)  Relatively little is known about the role of sex between men in India’s HIV epidemic,  but the few studies that have examined this subject have found that a significant proportion of men in India do have sex with other men.
  • 21.  As per recent data Chhattisgarh (15 %), Nagaland (13.58%) and Maharashtra (13%) have the highest HIV prevalence among MSM.  Poor knowledge of HIV has been found in groups of MSM.  The extent and effectiveness of India’s efforts to increase safe sex practices between MSM (and their other sex partners) will play a significant role in determining the scale and development of India’s HIV epidemic.
  • 22. 3. Injecting Drug Use (IDU)  Injecting drugs with contaminated injecting equipment is the main risk factor for HIV infection in the north‐east.  Current interventions targeting IDU tend to be inconsistent, and too small and infrequent to yield demonstrable results.  Comprehensive harm reduction programs, including clean needle and syringe exchange is an urgent need.
  • 23. 4. Migration and Mobility:  Migration for work, takes people away from the social environment of their families and community.  This can lead to an increased likelihood to engage in risky behavior.  Concerted efforts are needed to address the vulnerabilities of the large migrant population.
  • 24. 5. Low Status of Women:  Infection rates have been on the increase among women and their infants in some states as the epidemic spreads through bridging population groups.  As in many other countries, unequal power relations and the low status of women, weakens the ability of women to protect themselves and negotiate safer sex both within and outside of marriage, thereby increasing their vulnerability.
  • 25. 6. Widespread Stigma:  Stigma towards people living with HIV is widespread.  The misconception about AIDS perpetuates existing discrimination.
  • 26.  The most affected groups, often marginalized, have little or no access to legal protection of their basic human rights.  Addressing the issue of human rights violations and creating an enabling environment that increases knowledge and encourages behavior change are thus extremely important to the fight against AIDS.
  • 27. National Response to HIV in India
  • 28. HIV/AIDS – India’s Response • 1986: 1st case of HIV detected in Chennai. • 1990: HIV/AIDS Cell set up in MoHFW. • 1992: NACP-I launched. • 1992: National AIDS Control Organisation (NACO) established within MoHFW. • 1999-2006: NACP-II launched. • 2007-2012: NACP-III launched. • NACP IV (2012-2017) on the anvil with projected outlay of more than US$ 2 billion
  • 29.  four-pronged strategy – 1. Prevention of infections through saturation of coverage of high-risk groups with targeted interventions (TIs) and scaled up interventions in the general population. 2. Provision of greater care, support and treatment to larger number of people living with HIV/AIDS (PLHA). NACP STRATEGIES
  • 30. 3.Strengthening the infrastructure, systems and human resources in prevention, care, support and treatment programs at district, state and national levels and 4. Strengthening the nationwide Strategic Information Management System (SIMS).
  • 31.  To meet the above objectives, various interventions were initiated with clearly defined - - technical and operational guidelines and - monitoring indicators. NACP Program Implementation
  • 32.  The National AIDS Control Organisation (NACO) under Ministry of Health and Family Welfare is the overall body for framing policy, guidelines and strategies for program implementation.  It also releases funds to various states and reviews the progress under various components of the program.
  • 33.  State AIDS Control Societies (SACS) have been constituted throughout the country with the responsibility of program implementation.  In high HIV prevalent districts, District AIDS Prevention Control Unit (DAPCU) has been set up for direct supervision at the ground level.
  • 34. 1. Targeted interventions. 2. Management of STI. 3. Condom promotion. 4. Blood safety. 5. Integrated counseling and testing services. 6. Care, support and treatment. 7. Information, education, communication and mainstreaming. 8. Strategic information management system. Program Components
  • 35.  HIV epidemic in India is mainly concentrated in high-risk population like - female sex workers (FSW), - men having sex with men (MSM), - injecting drug users (IDU) and - clients of sex workers. 1. Targeted intervention
  • 36.  Given their special vulnerabilities, prevention strategies include five elements- - behaviour change, - treatment for sexually transmitted infections (STI), - monitoring access to and utilization of condoms, - ownership building and - creating an enabling environment.
  • 37.  STI and Reproductive Tract Infections (RTI) are key determinants of HIV transmission.  An estimated 6% of adult population suffers from STI/RTI annually, accounting for about 30 million episodes per year.  Presence of STI increases the risk of acquisition and transmission of HIV infection five to ten times. 2. Management of STI
  • 38.  Control of STI provides a window of opportunity for prevention of new HIV infection and is the most cost-effective means for preventing HIV transmission.  Provision of standardized package of STI/RTI services through syndromic case management by public health facilities and preferred private practitioners is the cornerstone of the program.
  • 39.  Condom promotion strategy aims to integrate the use for family planning as well as prevention of HIV and STI using various channels of supply, i.e. free, through social marketing and commercial outlets.  In addition, various innovative approaches have been introduced including Condom Vending Machines (CVMs) at strategic sites, female condoms particularly for FSW and special condoms for MSM population. 3. Condom promotion
  • 40.  Blood Safety program under NACP-III aims to ensure provision of safe and quality blood to the far-flung remote areas of the country in the shortest possible time through a well-coordinated National Blood Transfusion Service. 4.Blood safety
  • 41.  Counseling and HIV testing services are being provided through 5223 Integrated Counselling and Testing Centres (ICTC) mainly located in government hospitals.  These services are also being expanded in PHC/CHC in the rural areas, private sector facilities and mobile clinics. 5.Integrated counseling and testing services
  • 42.  The main functions of an ICTC include HIV diagnostic tests, counseling and promoting behavioral change and referral for care and treatment services.  The ICTC services are accessed by voluntary clients (who visit the ICTC on their own), provider initiated client testing including patients with signs/symptoms of HIV infection, patients with STI/RTI/TB and pregnant women visiting antenatal clinics.
  • 43.  The care, support and treatment needs of HIV positive people vary with the stage of the infection.  The HIV infected person remains asymptomatic for 6-8 years. 6. Care, support and treatment
  • 44.  As immunity falls over time, the person becomes susceptible to various Opportunistic Infections (OIs).  At this stage, medical treatment and psychosocial support are needed.  ART and prompt diagnosis and treatment of OIs improve the survival and quality of life.
  • 45.  Information, Education and Communication (IEC) cuts across all program components.  There has been a strategic shift in IEC strategy , with the focus moving on to behavior change communication from just awareness creation. 7. Information, education, communication and mainstreaming
  • 46.  India's response to HIV epidemic is governed by the strategic information derived from HIV Sentinel Surveillance, routine program monitoring, operational research and evaluation studies.  A nationwide web-enabled Strategic Information Management System (SIMS) has been set up to empower program management at various levels with the information required for planning, management and monitoring purposes.  This system also helps in evidence-based policy formulation and program planning. 8. Strategic information management system
  • 47. Diagnosis & Management of HIV/AIDS in India
  • 48. Clinical Diagnosis  WHO case definition for AIDS surveillance- 2 major signs in combination with 1 minor sign.  MAJOR SIGNS 1.Weight loss> 10% body wt. 2. Chronic Diarrhaea for> 1 month. 3. Prolonged fever for > 1 month
  • 49.  MINOR SIGNS  1. persistent cough for > 1 month.  2. generalized pruritic dermatitis.  3. history of herpes zoster.  4. oropharyngeal candidiasis.  5. chronic herpes simplex infection.  6. genaralized lymphadenopathy.
  • 50. Laboratory Diagnosis  A person whose blood contain HIV – antibodies is said to be HIV positive.  The screening test to detect HIV antibody uses normally is ELISA test.  Confirmatory test is WESTERN- BLOT , which is highly specific.
  • 51. Topic Old Guidelines New Guidelines HIV Testing Provider- initiated testing and counselling Community-based HIV testing and counselling with linkage to prevention, care and treatment services is recommended, in addition to old guidelines. Couples Voluntary HIV testing and counselling HIV Testing & counselling
  • 52. Who to test When to test Pregnant women and male partners At first antenatal care visit Re-test in third trimester or peripartum Offer partner testing Infants and children <18 months old At 4–6 weeks for all whose mothers are HIV Positive or status uncertain; Final status after 18 months and/or when breastfeeding ends Children Establish HIV status for all health contacts Tell their HIV status & parents or caregiver’s status Adolescents Integrate into all health care encounters. Annually if sexually active; with new sexual partners
  • 53. Control of AIDS  Four basic approaches to control AIDS- 1. Prevention. 2. Antiretroviral treatment, 3. Specific prophylaxis. 4. Primary Health Care.
  • 54. PREVENTION  1. Health Education - Safe sex - Avoid pregnancy by infected female. - Mass media education  2. Prevention of Blood borne HIV transmission. - Stict sterlization practices. - Testing of blood before transfusion.
  • 55. 2. Antiretroviral Treatment
  • 56. Why to Initiate early ART ?  Reduces risk of progression to AIDS and/or death, TB, non- AIDS-defining illness & increased the likelihood of immune recovery.  Reduces sexual transmission in HIV-serodiscordant couples,  More convenient and less toxic regimens widely available,  Costs and epidemiological benefits  The increased cost of earlier ART would be partly offset by subsequent reduced costs (such as decreased hospitalization and increased productivity) and preventing new HIV infections.
  • 57. GUIDELINES TO START ART  Start ART in all individuals with a CD4 < 500  Priority to severe or advanced HIV disease and CD4 < 350 .  ART at any CD4 count in PLHIV  Active TB disease ,  HBV co-infection with severe chronic liver disease,  HIV-positive partners in sero-discordant couples,  Pregnant and breastfeeding women and  Children younger than five years of age
  • 58. When to start ART in people living with HIV Adults and adolescen ts (≥10 years) Initiate ART if CD4 cell count ≤500 cells/mm3 • As a priority,  Severe/advanced HIV (WHO clinical stage 3 or 4) or  CD4 count ≤350 cells/mm3 Regardless of WHO clinical stage and CD4 • Active TB disease • HBV coinfection with severe chronic liver disease • Pregnant and breastfeeding women with HIV • HIV-positive individual in a serodiscordant partnership (to reduce HIV transmission risk) Infants <1 In all , Regardless of WHO clinical stage and CD4 NE W NE W NE W NE W
  • 59. Children ≥5 yrs to <10 yrs old CD4 ≤500 cells/mm3 • As a priority,  All WHO clinical stage 3 or 4 or  CD4 count ≤350 Initiate ART regardless of CD4 cell count • WHO clinical stage 3 or 4 • Active TB disease Children 1–5 yrs old ART in all regardless of WHO clinical stage and CD4 • As a priority,  All HIV-infected children 1–2 yrs old or  WHO clinical stage 3 or 4 or  CD4 count ≤750 or <25%, whichever is lower Any child < 18 months with presumptive clinical diagnosis of HIV infection. NE W NE W
  • 60. What ART to start ? First-line ART regimens for adults First-line ART = two (NRTIs) + (NNRTI). • TDF + 3TC (or FTC) + EFV (fixed-dose combination) If TDF + 3TC (or FTC) + EFV is contraindicated/not available, options are… • AZT + 3TC + EFV • AZT + 3TC + NVP • TDF + 3TC (or FTC) + NVP Countries should discontinue d4T use in first-line regimens because of its well-recognized metabolic toxicities. NE W Once-daily regimens comprising a non- thymidine NRTI backbone (TDF + FTC or TDF + 3TC) and one NNRTI (EFV) as the preferred choices in adults, adolescents and children >3 yrs.
  • 61. First-line ART Preferred first-line regimens Alternative first-line Regimens Adults (including pregnant and breastfeeding women and adults with TB and HBV coinfection) TDF + 3TC (or FTC) + EFV AZT + 3TC + EFV AZT + 3TC + NVP TDF + 3TC (or FTC) + NVP Adolescents (10 to 19 years) ≥35 kg AZT + 3TC + EFV AZT + 3TC + NVP TDF + 3TC (or FTC) + NVP ABC + 3TC + EFV (or NVP) Children 3 - 10 years and adolescents <35 kg ABC + 3TC + EFV ABC + 3TC + NVP AZT + 3TC + EFV AZT + 3TC + NVP TDF + 3TC (or FTC) + EFV TDF + 3TC (or FTC) + NVP NE W
  • 62. Monitoring of Efficacy of ART 1. Clinical improvement - Weight gain. - Decrease severity of HIV related disease. 2. Increase in Total Lymphocyte count. 3. Improvement in biological markers of HIV. - CD 4 + T – Lymphocyte count. - Plasma HIV – RNA levels.
  • 63. CONCLUSION
  • 64.  National response to HIV/AIDS during the first three years of the NACP-III has been commendable in terms of infrastructure and system development, coverage of targeted population and monitoring systems.  However, there are still challenges to achieve the goal of the reversal of the epidemic.  Key areas which require special attention are TIs for MSM, IDU and migrants and services to HIV positive pregnant women and infants. Conclusion

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