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EPIDEMIOLOGY OF HIV/AIDS WITH
UPDATE IN THE PROGRAMME AND
RECENT ADVANCES
Name of the Presenter
Dr.Rama Shankar
PG Residen...
CONTENTS
• Introduction
• Epidemiology of HIV/AIDS
• Global and National fact sheet
• AIDS control Programme in India
• HI...
INTRODUCTION
• AIDS also called slim disease caused by retrovirus known as HIV.
• Destroy specific blood cells, called CD4+...
EPIDEMIOLOGICAL DETERMINANTS
• Agent:HIV virus is 1/10000th of a mm
in diameter.
• The virus replicates in T4 lymphocytes
...
5
• NRTI!
• ABC- Abacavir 300
mg BD!
• ddl-Didanosine
200mg BD!
• FTC- Emtricitabine
200 mg BD!
• 3TC- Lamivudine 150
mg B...
6
EPIDEMIOLOGICAL DETERMINANTS
• Mode of transmission
• Sexual transmission
• Blood Contact
• Maternal to foetal transmissio...
WHO CASE DEFINITION OF AIDS SURVEILLANCE
• For adults & adolescent (>12 yrs of age): 2 major signs and one
minor signs
• M...
WHO CLINICAL STAGING OF HIV DISEASE IN ADULTS, ADOLESCENTS AND
CHILDREN
• Clinical stage 1
(Adults)
• Asymptomatic
• PGL
•...
2013 WHO GUIDELINES ON WHEN TO START
ART
• Treat adults, adolescents & children with CD4 count of 500 cells/mm3 or less, w...
2015 WHO GUIDELINES ON WHEN TO START ART
Recommendation 1: When to start ART among people living with HIV
Target
Populatio...
SUMMARY OF FIRST/SECOND/THIRD LINE ART REGIMEN FOR ADULTS,
ADOLESCENTS, PREGNANT AND BREASTFEEDING WOMEN AND CHILDREN
Firs...
Targeted viral load
monitoring clinical or
immunological failure
Routine viral load
monitoring ( early detection
of virolo...
POST EXPOSURE PROPHYLAXIS FOR HIV
Preferred regimen
Preferred third drug or
alternative regimen
For adults and
Adolescents...
GLOBAL HIV TRENDS
Numberinmillion
0
4
8
12
16
NumberinMillion
32
33.25
34.5
35.75
37
Years
2007 2008 2009 2010 2011 2012 2...
Adult HIV Prevalence (%) in India, with uncertainty
bounds
Percentage
0
0.105
0.21
0.315
0.42
Years
2007 2008 2009 2010 20...
Annual AIDS-Related Deaths and ART Scale-up
India 2007-14
PLHIV(Alive&OnART
0
2.25
4.5
6.75
9
AnnualARDinlakhs
0
0.375
0.7...
HIV "SENTINEL" SURVEILLANCE
HSS is defined as "a system of monitoring HIV epidemic
among specified population groups by coll...
OBJECTIVES OF HIV SENTINEL SURVEILLANCE
To understand the trends of the HIV epidemic among
the general population, bridge ...
HIV SENTINEL SURVEILLANCE IN INDIA
20
One of the world largest and most robust HSS systems.
Since 1998, it has helped GOI ...
EXPANSION OF HSS SITES IN INDIA
21
Site type 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008-09 2010-11 2012-13 201...
22
NACO
Technical resource Group on Surveillance & Estimation
( Nodal Agency: Policy, Strategy & Plan)
NIHFW
( Nodal Agenc...
WHY SURVEILLANCE AMONG ANC CLINIC ATTENDEES?
Pregnant women represent the sexually segment of the general population
and h...
24
HIV prevalence (%) among ANC clients (2014-2015) & other
risk groups (2010-11).
HIV prevalence (%) at ANC sites India
a...
THREE GROUPS OF STATES/UT
Group 1 ( High Prevalence states)
MHA, TN, KTN, AP, MAN
& NGN
HIV infection crossed 5%
mark in H...
26
INTEGRATED BIOLOGICAL AND BEHAVIOURAL SURVEILLANCE (IBBS)
It is one of the largest bio-
behavioural surveys among
HRGs ...
INTEGRATED COUNSELLING
AND TESTING CENTRES (ICTC)
HIV Counselling:It is a confidential dialogue
between a client and counse...
DIFFERENT TYPES OF ICTCS
Fixed-facility ICTCs: those located within existing health-care facility/hospital/
centre. It is ...
OUTCOME
On a site wise analysis, it is noted overall that 70 sentinel sites have shown HIV
prevalence of 1% or more among ...
PPTCT
In India the PPTCT intervention under NACP started in 2001-02 using SD-NVP
prophylaxis for HIV-positive pregnant wom...
ESSENTIAL PACKAGE OF PPTCT SERVICES
Routine offer of HIV counselling and testing to all pregnant women through ANC
with "o...
Provide antiretroviral prophylaxis to infant from birth up to
minimum period of six weeks.
Integrate follow up of HIV expo...
33
Pregnant women visiting HSC
ANC registration by HSC ANM
HSC:Routine ANC & PNC
HSC: Screen Pregnant women for HIV,
Syphi...
AIDS CONTROL PROGRAMME IN INDIA
• HIV infection 1st detected in 1986 when 10 HIV positive samples were found from a group
...
NACP-I
• OBJECTIVE
• Slow and prevent the spread of HIV through a major effort to prevent HIV transmission.
• KEY STRATEGI...
NACP-II
• OBJECTIVE
• Reduce the spread of HIV infection in India through behaviour change and increase capacity to
respon...
• Reduce the rate of incidence by 60% in the first year of the programme in high
prevalence states to obtain the reversal o...
NACP-IV PROJECT DESIGN
Key strategies
under NACP-IV
Strengthening
SIMS
Intensify and
consolidate
preventive
services
Incre...
INTENSIFYING AND CONSOLIDATING PREVENTION
39
•Prevention the core strategy as 99% of the people are HIV negative.
!
•It is...
COMPREHENSIVE CST
Additional CoEs and upgraded ART plus Centres will be established to provide high quality
treatment
Trea...
EXPANDING IEC SERVICES FOR (A) GENERAL POPULATION AND
(B) HIGH RISK GROUPS WITH A FOCUS ON BEHAVIOUR CHANGE
• Increasing a...
STRENGTHENING INSTITUTIONAL CAPACITIES
• The programme management structures established under NACP will be
strengthened
•...
KEY PRIORITIES UNDER NACP-IV
• Prevention new infections by sustaining the reach of current interventions
• PPTCT. Focusin...
KEYS INITIATIVES UNDER
SIMS
44
• IBBS among HRG and Bridge
groups
• National Data Analysis Plan
• National Research Plan
•...
TI FOR HRG
• Objective: Improve health seeking behaviour and reducing risk of getting STD and HIV infection
• Services off...
46
BLOOD TRANSFUSION SERVICES
The division of blood safety has been renamed to Blood transfusion services to
expand the horiz...
TB and HIV
• TB is the most important opportunistic infection among PLHIV.
– TB infection: 10% life time risk of getting T...
Activities to reduce HIV-TB
Mortality
49
TB/HIV co-ordination to reduce mortality
Prevention
Isoniazid preventive treatmen...
50
UNIVERSAL PRECAUTIONS
Universal Precautions are control guidelines designed to protect workers from exposure to
disease...
51
MonitoringandEvaluation:DraftGlobalHealthSector
Strategy2016-2021
Vision:Zero new HIV Infections. Zero HIV related deat...
52
• Major Challenges towards the development of an effective HIV/AIDS vaccine
• Genetic diversity: HIV multiplies at very...
53
• HIV continue to be major public
health issue globally claiming
more than 34 million lives so far.
• Can be transmitte...
REFERENCES:
1. Park's Textbook of PSM 23rd Edition/Epidemiology of communicable disease/Health Programme in
India/HIV/AIDS...
Thank you and its open for
discussion!!!
55
56
HRG ( IDU/FSW/MSM/TG)
Bridge Population ( STD
Patients/SMM/LDT)
General Population: Pregnant
Women attending ANC clinic...
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Epidemiology of HIV and update in the NACO programme

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Hiv presentation pdf copy

  1. 1. EPIDEMIOLOGY OF HIV/AIDS WITH UPDATE IN THE PROGRAMME AND RECENT ADVANCES Name of the Presenter Dr.Rama Shankar PG Resident Name of the Moderator Dr.Nirankar Singh Professor Department of Community Medicine Muzaffarnagar Medical College 9/3/2016 1
  2. 2. CONTENTS • Introduction • Epidemiology of HIV/AIDS • Global and National fact sheet • AIDS control Programme in India • HIV surveillance • Counselling and HIV testing services • Care, support and Treatment • NACP-IV • Objectives/Strategies • Key initiatives • Guiding Principles • Services • Monitoring framework • Summary • References 2
  3. 3. INTRODUCTION • AIDS also called slim disease caused by retrovirus known as HIV. • Destroy specific blood cells, called CD4+T cells, which are crucial for fighting diseases. • Once infected a person will be affected for life. • AIDS can be called as modern pandemic affecting both industrialised and developing countries. • First clinically observed in 1981 in USA. The term GRID was coined which later turned to be "4H disease". This was later in 1982 renamed by CDC and AIDS came into existence. 3
  4. 4. EPIDEMIOLOGICAL DETERMINANTS • Agent:HIV virus is 1/10000th of a mm in diameter. • The virus replicates in T4 lymphocytes and can destroy T4 helper cells, a subset of T lymphocyte • It can cross BBB and account for neurological and psychological abnormalities • Reservoir of Infection: Cases and Carrier • Source of infection:Blood, semen and CSF. Lower concentration detected in tears, saliva breast milk etc. 4 • Host Factors: • Age: most cases in sexually active person aged 20-49 yrs. • Sex:In Africa the sex ratio is equal where as in NA, Europe and Australia 51% in homosexual and bisexual men. • HRG: Male homosexuals and bisexuals, heterosexuals partners, IDUs, transfusion recipients of blood and blood products, haemophiliacs and clients of STD
  5. 5. 5 • NRTI! • ABC- Abacavir 300 mg BD! • ddl-Didanosine 200mg BD! • FTC- Emtricitabine 200 mg BD! • 3TC- Lamivudine 150 mg BD! • d4T- Stavudine 40 mg BD! • AZT- Zidovudine 300mg BD! • NtRTI! • TDF- Tenofovir! • NNRTI! • EFV-Efavirenz 600 mg OD! • ETV- Etavirine 200 mg BD ! • NVP-Nevirapine 200 mg OD for 14 days then BD • PIs! • ATV/r-Atazanavir+ Ritonavir (300+100 mg) OD! • DRV/r- Darunavir+r (600 + 200 mg BD! • FPV/r- Fos-amprenavir+r (1400 +200 mg OD)! • IDV/r-Indinavir+r (800+100 mg) BD! • LPV/r- Lopinavir+r (400+100 mg) BD! • SQV/r- Saquinavir+r (1000 mg+100 mg) BD! • INSTIs! • RAL-Raltegravir (400 mg BD
  6. 6. 6
  7. 7. EPIDEMIOLOGICAL DETERMINANTS • Mode of transmission • Sexual transmission • Blood Contact • Maternal to foetal transmission:MTCT • Incubation Period: Few months to 10 years and even more 7 CLINICAL MANIFESTATIONS • Initial infections with the virus and development of antibodies • Asymptomatic carrier state • AIDS-related complex ( ARC) • AIDS 0 1 Absolute CD4 count /Ul 500 200 50 Bacterial infection TB Hairy cell Leukoplakia Herpes simplex infection Herpes Zoster Vaginal Candidiasis Kaposi Sarcoma Pneumocystosis Toxoplamsmosis Cryptococcosis coccidioidomycosis Cryptosporidiosis Disseminated MAC infection Histoplasmosis CMV retinitis CNS lymphoma HIV ELISA Screening test for HIV infection. Sensitivity> 99.9 Western blot Confirmatory test for HIV CBC Anaemia, neutropenia and thrombocytopenia Absolute CD4 lymphocyte count Predictor of HIV progression CD4 lymphocyte Percentage can be more reliable than CD4 count HIV viral load tests Measures the amount of actively replicating HIV virus B2- Microglobulin Cell surface protein indicative of macrophage-monocyte stimulation p24 antigen Indicates active HIV replication LABORATORY DIAGNOSIS RELATION OF CD4 COUNT TO OPPORTUNISTIC INFECTION
  8. 8. WHO CASE DEFINITION OF AIDS SURVEILLANCE • For adults & adolescent (>12 yrs of age): 2 major signs and one minor signs • Major sign • Weight loss> equal to 10% of body weight • Chronic diarrhoea for more than 1 month • Prolonged fever for more than 1 month • Minor sign • Persistent cough for more than one month • Generalised pruritic dermatitis • History of Herpes Zoster • Oropharyngeal candidiasis • Disseminated herpes simplex infection • Generalised lymphadenopathy • For children :2 major signs and 2 minor signs • Major sign • Weight loss or abnormally slow growth • Chronic diarrhoea for more than 1 month • Prolonged fever for more than 1 month • Minor sign • Generalised lymph node enlargement • Oropharyngeal candidiasis • Recurrent common infections e.g. ear infection • Persistent cough • Generalised rash • EXPANDED CASE DEFINITION OF AIDS SURVEILLANCE • For adults & adolescent (>12 yrs of age) to be considered to have AIDS if a test for HIV antibody gives a positive result & one or more of below mentioned conditions are present • >10% body weight weight loss, with diarrhoea or fever,or both for at a least one month • Cryptococcal meningitis • PTB or EPTB • Kaposi Sarcoma • Neurological complications sufficient to prevent daily activities • Candidiasis of the oesophagus • Clinically diagnosed life threatening episodes of pneumonia • Invasive cervical cancer 8
  9. 9. WHO CLINICAL STAGING OF HIV DISEASE IN ADULTS, ADOLESCENTS AND CHILDREN • Clinical stage 1 (Adults) • Asymptomatic • PGL • For children • Asymptomatic • PGL • Clinical stage 2 (Adults) • Moderate unexplained weight loss ( under 10% of BW) • Recurrent RTI • Herpes zoster/Angular cheilitis • Recurrent oral infections • Papular pruritic eruptions • Seborrhoeic dermatitis • Fungal nail infections • For children • Unexplained chronic diarrhoea • Severe persistent candidiasis outside the neonatal period • Weight loss • Persistent fever • Severe bacterial infections • Clinical stage 3 (Adults) • Moderate unexplained weight loss (over 10% of BW) • Unexplained chronic diarrhoea for more than 1 month • Unexplained persistent fever for more than 1 month • Oral candidiasis/oral hairy leukoplakia/PTB • Bacterial infections • Stomatitis, gingivitis or peridontitis • unexplained anaemia (< 8g/ dl), neutropenia, thrombocytopenia • For children • AIDS-defining opportunistic infections • Severe failure to thrive • Progressive encephalopathy • Malignancy • Septicaemia or meningitis • Clinical stage 4 (Adults) • HIV wasting syndrome • Pneumocystis jiroveci pneumonia • Several bacterial pneumonia • Chronic herpes simplex infections • Oesophageal candidiasis • EPTB/Kapsoi Sarcoma • CMV disease • CNS toxoplasmosis • HIV encephalopathy • Extra pulmonary cyptococcosis including meningitis • Disseminated non- tuberculous mycobacteria infection • Progressive multifocal leukoencephalopathy • Chronic cryptosporidiosis • Chronic isosporiasis • Disseminated mycosis • Septicaemia/lymphoma • Invasive cervical carcinoma/ atypical disseminated Leishmaniasis9
  10. 10. 2013 WHO GUIDELINES ON WHEN TO START ART • Treat adults, adolescents & children with CD4 count of 500 cells/mm3 or less, with more priority to CD4 count less than 350 cells/mm3. • Start with ART regardless of CD4 count in PLHIV with comorbidity like HBV TB, HIV positive partners in serodiscordant couples, Pregnancy and breastfeeding women and children under 5 yrs of age. • A new preferred first line ART regimen for adults, pregnant and BFW and children under age 3 • Accelerate the phasing out of Stavudine (D4T) in first line ART regimen for adults and adolescents. • Use of viral load testing as the preferred approach to monitor the success of ART and diagnosing treatment failure. • Community based HIV testing and counselling and HIV testing of adolescents to diagnose people with HIV earlier and link them to care and treatment 10
  11. 11. 2015 WHO GUIDELINES ON WHEN TO START ART Recommendation 1: When to start ART among people living with HIV Target Population Specific Recommendation Adults (>19 yrs) ART to be initiated in all adults living with HIV at any CD4 cell count As a priority, initiation in WHO clinical stage 3 or 4 and individuals with CD4 count less than equal to 350 cells/mm3 Pregnant and BFW ART should be initiated in all pregnant and BFW living with HIV at any CD4 cell count and continued lifelong Adolescents ART to be initiated in all adolescents living with HIV at any CD4 cell count As a priority, initiation in WHO clinical stage 3 or 4 and individuals with CD4 count less than equal to 350 cells/mm3 Children ( 1 to <10 yrs old) ART to be initiated in all mentioned group living with HIV at any CD4 cell count As a priority, ART should be initiated among all children <2 yrs old and in WHO clinical stage 3 or 4 and individuals with CD4% <25% ( if < 5 yrs old )or CD4 count less than equal to 350 cells/mm3 ( if greater than equal to 5 yrs old) Children (< 1 yrs old) ART to be initiated in all mentioned group living with HIV at any CD4 cell count Recommendation 2: Oral pre-exposure prophylaxis to prevent HIV infection HIV negative individuals at substantial risk of HIV infection Oral PrEP ( containing TDF) should be offered as an additional prevention choice for people at substantial risk of HIV infection as part of combination prevention approaches 11
  12. 12. SUMMARY OF FIRST/SECOND/THIRD LINE ART REGIMEN FOR ADULTS, ADOLESCENTS, PREGNANT AND BREASTFEEDING WOMEN AND CHILDREN First-line ART Preferred First line Regimen Alternative first line Regimen New treatment guideline 2015 Adults ( including Pregnant & BFW and adults with TB and HBV confections TDF+3TC (or FTC)+ EFV AZT+3TC+EFV AZT+3TC+NVP TDF+FTC +NVP Preferred Option ( TDF +XTC{3TC or FTC)+EFV600 Alternative options AZT+3TC+EFV600 AZT+3TC+NVP TDF+XTC+NVP TDP+XTC+DTG (Dolutegravir) TDF+XTC+EFV400 ! ! Adolescents (10-19 yrs) > equal to 35kg AZT+3TC+EFV AZT+3TC+NVP TDF+3TC (or FTC) +NVP ABC+3TC+EFV (or NVP) Children 3 yrs to>10 yrs and adolescents <35 kg ABC+3TC+EFV ABC+3TC+NVP AZT+3TC+NVP AZT+3TC (or FTC) +EFV TDF +3TC (or FTC) +NVP TDF+3TC (or FTC) + NVP Children < 3 yrs ABC or AZT+3TC+LPV/r ABC+3TC+NVP AZT+3TC+NVP 2nd-line ART Preferred regimen Alternative Regimen Note Adults and Adolescents (>10 yrs), including pregnant and BFW AZT+3TC+LPV/r AZT+3TC+ATV/r TDF+3TC( or FTC)+ATV/r TDF+3TC ( or FTC)+LPV/r Follow the same regimen if AZT is used in 1st line. If TDF is used in 1st line then use AZT +3TC+ATV/r or LPV/r HIV and TB coinfection If rifabutin available Standard PI containing regimen as recommended for adults and adolescents If Rifabutin not available Same NRTI backbones as recommended for adults and adolescents plus double dose LPV/r (800 mg/200 mg BD daily) or( 400 mg/400 mg BD daily HIV and HBV infection AZT+TDF+3TC (or FTC) + )ATV/r or LPV/r) Children If a NNRTI-based first line regimen was used ABC+3TC+LPV/r ABC+3TC+LPV/r TDF+3TC (or FTC)+LPV/r If a PI-based first line regimen was used < 3yrs No change from the first- line regimen in use AZT ( or ABC)+3TC+NVP 3 yrs to <10 yrs AZT ( or ABC) +3TC+EFV ABC (or TDF)+ 3TC+NVP12
  13. 13. Targeted viral load monitoring clinical or immunological failure Routine viral load monitoring ( early detection of virological failure) Test viral load Viral load>1000 copies/ml Evaluate for adherence concerns Repeat viral load testings after 3-6 months Viral load <1000 copies/ml Viral load>1000 copies/ml Maintain first line therapy Switch to second line therapy 13
  14. 14. POST EXPOSURE PROPHYLAXIS FOR HIV Preferred regimen Preferred third drug or alternative regimen For adults and Adolescents TDF +3TC ( or FTC) LPV/r or ATV/r is the preferred third drug For Children ≤ 10 yrs old AZT+3TC ABC+3TC or TDF +3TC(or FTC) as alternative.LPV/r recommended as third drug A 28 day prescription of AR drugs should be provided for HIV post exposure prophylaxis following initial risk assessment • Eligibility of post-exposure prophylaxis • Commencement within 72 hrs of possible infection • Based on HIV status of the source whenever possible • Parenteral or mucus membrane exposure and certain body fluids like blood, breast milk, genital secretions etc. can pose risk • PEP not required when the exposed individual is already HIV positive and source is established to be HIV negative and exposure to bodily fluids that does not pose a risk like tears, non blood stained saliva, urine, sweat. 14 USE OF CO-TRIMOXAZOLE FOR HIV RELATED INFECTIONS WHO (2014) For adults ( including PW) • Recommended for WHO clinical stage 3 or 4 and for CD4 count ≤350 cells/mm3 ! • Can be initiated and continued regardless of CD4 count in settings where malaria and other bacterial infections are highly prevalent. ! Infants, children and adolescent s • Recommended but priority to children <5 yrs regardless of CD4 count or clinical stage and to children with WHO clinical stage 3 or 4 and for CD4 count ≤350 cells/mm3 ! • Can be continued until adulthood at places where malaria and other bacterial infections are highly prevalent ! • It can be discontinued in settings where malaria and other bacterial infections are low prevalent for children 5 yrs and older who are clinically stable, virally suppressed on ART for 6 months and CD4 count> 350cells/mm !It should be administered to all HIV-infected people with active TB disease regardless of CD4 cell.
  15. 15. GLOBAL HIV TRENDS Numberinmillion 0 4 8 12 16 NumberinMillion 32 33.25 34.5 35.75 37 Years 2007 2008 2009 2010 2011 2012 2013 2014/2015 PLHIV New Infection total ARD People Accessing treatment 15.8 13 11.4 9.4 7.5 6.1 1.21.31.41.51.61.71.71.9 22.12.22.32.32.42.42.5 36.9 36.2 35.6 34.9 34.4 33.8 33.3 32.932.9 33.3 33.8 34.4 34.9 35.6 36.2 36.9 15 Regional Statistics Sub- Saharan Africa Asia and the Pacific Latin America Western and central Europe and North America Eastern Europe and Central Asia The Caribbe an Middle East and North Africa Global PLHIV 25.8 million 5.0 million 1.7 million 2.4 million 1.5 million 280000 240000 36.9 million New HIV Infections 1.4 million 340000 87,000 85,000 140000 13000 22000 2.0 million ARD 790000 240000 41000 26000 62000 8800 12000 1.2 million Estimated %age of PW living with HIV who received ART to PPTCT 75 38 78 _____ ______ 89 13 73 Estimated %age of adults (15+ yrs) living with HIV receiving ART 43 36 47 ——- 18 44 14 41 Estimated %age of children (0-14 yrs) living with HIV receiving ART 30 36 54 ——- ——— 36 15 32 IND, CHN and IND account for 78% of new HIV infection
  16. 16. Adult HIV Prevalence (%) in India, with uncertainty bounds Percentage 0 0.105 0.21 0.315 0.42 Years 2007 2008 2009 2010 2011 2012 2013 2014 2015 0.41 0.39 0.37 0.36 0.35 0.34 0.33 0.32 0.32 0.34 0.32 0.31 0.3 0.29 0.28 0.27 0.27 0.26 0.28 0.27 0.26 0.25 0.24 0.23 0.23 0.22 0.22 Lower bounds Point estimate Upper bounds States New HIV infection Annual AIDS-related death Estimated New HIV Infections in India (1998-2015) Years 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 New HIV Infection in Lakhs 0 0.75 1.5 2.25 3 0.1 0.12 0.15 0.16 0.17 0.17 0.18 0.2 0.21 0.23 0.24 0.25 0.25 0.26 0.25 0.24 0.23 0.21 0.76 0.77 0.79 0.8 0.82 0.85 0.88 0.96 1.06 1.17 1.29 1.41 1.56 1.78 2 2.27 2.51 2.64 Adult (15+ yrs) Children (0-14 yrs) 16
  17. 17. Annual AIDS-Related Deaths and ART Scale-up India 2007-14 PLHIV(Alive&OnART 0 2.25 4.5 6.75 9 AnnualARDinlakhs 0 0.375 0.75 1.125 1.5 2007 2008 2009 2010 2011 2012 2013 2014 AIDS related Death PLHIV on ART 1.3 2.2 3.1 4.1 5.2 6.3 7.8 8.5 1.5 1.4 1.3 1.2 1.1 1 0.9 0.8 17 • India has achieved 6th MDG in regards to HIV/AIDS • Between 2000 and 2015, new HIV infection dropped from 2.51 lakhs to 86 thousand, a reduction of 66% against a global average of 35%. • ARD declined falling from by 54% from 2007 to 2015 against a global average of 41% • SDG Target: Reduce the annual number newly infected with HIV by 90% and annual number of people dying from AIDS related cause by 80% ( compared with 2010 data)
  18. 18. HIV "SENTINEL" SURVEILLANCE HSS is defined as "a system of monitoring HIV epidemic among specified population groups by collecting information on HIV from designated sites ( sentinel sites) over years through consistent methodology that allow comparison of findings across place and time to guide programme response". Sentinel sites is defined as "designated service point/facility where blood specimen and information are collected from a fixed number of eligible individuals from a specified population group over a fixed period of time, periodically, for the purpose of monitoring the HIV Epidemic" 18
  19. 19. OBJECTIVES OF HIV SENTINEL SURVEILLANCE To understand the trends of the HIV epidemic among the general population, bridge population and HRG in different states To understand the geographical spread of the HIV infection and to identify emerging pockets To provide information for prioritisation of programme resources and evaluation of programme impact To estimate HIV prevalence and HIV burden in the country 19
  20. 20. HIV SENTINEL SURVEILLANCE IN INDIA 20 One of the world largest and most robust HSS systems. Since 1998, it has helped GOI to monitor the trends, levels and burden of HIV among different population group in the country. The 14th round of HSS was implemented during 14-15 at 776 sites, including all 776 ANC surveillance sites covering 557 district covering 34 states/UT For HRGs and Bridge population, nationwide IBBS is being carried out as a strategic shift to strengthen the surveillance system among these groups FSW IDUs MSM Male Male client FemaleSpouse/ partners Children Source: Dr.Tim Brown's work on the Asian Epidemic Epidemiological Basis of HIV surveillance
  21. 21. EXPANSION OF HSS SITES IN INDIA 21 Site type 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008-09 2010-11 2012-13 2014-15 STD 76 75 98 133 166 163 171 175 251 248 217 184 13 - ANC 92 93 111 172 200 266 268 267 470 484 498 514 564 776 ANC ( Rural) - - - - - 210 122 124 158 162 162 182 186 IDU 5 6 10 10 13 18 24 30 51 52 61 79 - MSM - - 3 3 3 9 15 18 31 40 67 96 Migrant - - - - - - - 1 6 3 8 19 - TG - - - - - - - 1 1 1 1 3 Truckers - - - - - - - - 15 7 7 20 — TB 2 2 - - - - 7 4 - - - - - Fisher- Folk/ Seamen - - - - - 1 - - 1 - - - - Total 176 177 224 320 384 699 649 703 1122 1134 1215 1359 763 776
  22. 22. 22 NACO Technical resource Group on Surveillance & Estimation ( Nodal Agency: Policy, Strategy & Plan) NIHFW ( Nodal Agency: Co-ordination, Supervision, Analysis and Documentation) NIMS ( Nodal Agency: HIV Estimation) CENTRAL TEAM Supervision REGIONAL INSTITUTIONS REFERENCE LABORATORIES Quality Control on Testing Labs NORTH ZONE PGIMER Chandigarh ( 5 states) CENTRAL ZONE AIIMS New Delhi ( 5 States) WEST ZONE NARI Pune( 7 States) SOUTH ZONE NIE Chennai ( 7 States) EAST ZONE NICED Kolkata( 6 States) NORTH EAST RIMS Imphal (5 States) Technical Validation of New Sites, Training, Monitoring, Supervision & Data Entry; Technical Support & Guidance to SACs in Planning, Implementation, trouble-shooting & Analysis STATE AIDS CONTROL SOCIETY Primary Implementing Agency in the State STATE SURVEILLANCE TEAMS ( Training and Supervision) Testing Laboratories 117 SRL and 13 NRL Sentinel sites DAPCU Coordination
  23. 23. WHY SURVEILLANCE AMONG ANC CLINIC ATTENDEES? Pregnant women represent the sexually segment of the general population and hence taken as proxy for monitoring HIV among general population. At ANC clinics, routine blood specimen collection is done for Syphilis and Hb testing, apart of which can be used for HIV testing. Pregnant women represent a more homogeneous group than persons attending any other clinic/OPD Pregnancy being physiological, does not introduce any bias in HIV prevalence which other illnesses/diseases may introduce due to underlying factors common to HIV. Facilities for antenatal care are available across the country at different levels of health care system and hence are feasible for implementation 23
  24. 24. 24 HIV prevalence (%) among ANC clients (2014-2015) & other risk groups (2010-11). HIV prevalence (%) at ANC sites India and States (2014-2015) ANC (2014-15) Migrants ( 2010-11) Truckers (2010-11) FSW (2010-11) MSM (2010-11) IDU (2010-11) TG (2010-11) 0 2.25 4.5 6.75 9 8.82 7.14 4.43 2.67 2.59 0.99 0.29 HIV Prevalence India UP Bihar Kerala Nagaland 0 0.35 0.7 1.05 1.4 1.29 0.05 0.37 0.21 0.29 HIV Prevalence
  25. 25. THREE GROUPS OF STATES/UT Group 1 ( High Prevalence states) MHA, TN, KTN, AP, MAN & NGN HIV infection crossed 5% mark in HRG and 1% or more in antenatal women 25 Group II ( Moderate Prevalence states) GJN, GOA, and PUD HIV infection crossed 5% mark in HRG but less than 1% in antenatal women Group III ( Low Prevalence states) Remaining states HIV infection less than 5% mark in HRG and less than 1% in antenatal women Based on sentinel surveillance data, HIV prevalence in adults population can be classified into 3 groups of States/UT CATEGORIES OF DISTRICTS >1% ANC/PTCT prevalence in district at any time in any of the sites in the last 3 years A 156 Districts <1% ANC/PTCT prevalence in all the sites during last 3 years associated with >5% prevalence in any HRG B 39 Districts <1% in ANC prevalence in all sites during last 3 years with <5% in all STD clinics attendees or any HRG with known hot spots C 296 Districts <1% in ANC prevalence in all sites during last years with <5% in all STD clinics attendees or any HRG or poor HIV data with no known hot spots C 118 Districts
  26. 26. 26 INTEGRATED BIOLOGICAL AND BEHAVIOURAL SURVEILLANCE (IBBS) It is one of the largest bio- behavioural surveys among HRGs in the world Objectives; To understand HIV related behaviour and prevalence among Key risk groups in different regions ! ! To measure and estimate the change in HIV related risk behaviours and HIV prevalence among key groups. Profile of FSW/MSM/IDU Sexual Behaviour Pattern types and condom use Anal sex and condom use Alcohol and other substance use Self-reported STI Stigma and discrimination HIV Prevalence {2.2%, [FSW] 4.3% [MSM], 9.9% [IDU]}
  27. 27. INTEGRATED COUNSELLING AND TESTING CENTRES (ICTC) HIV Counselling:It is a confidential dialogue between a client and counsellor aimed at providing information on HIV/AIDS and bring about behaviour change in the client. An ICTC is a place where a person is counselled and test for HIV, on his own free will or as advised by a medical provider. Functions of ICTC Early detection of HIV Provision of basic information on mode of transmission and prevention of HIV/AIDS Link people with other HIV prevention, care and treatment services. Types of ICTC Fixed facility ICTCs Mobile ICTC 27 • HIV%screening%using%whole%blood% finger%prick%test/mobile%ICTCs% reaching%vulnerable/HRGs/unreached% popula@on% Community%% Level% • Standalone%ICTCs%and%facility% ICTCs% Village%level% PHC% 24%X%7%PHCs%etc.% Private% hospitals/labs/ NGOs%etc.% • Standalone%ICTC%and% facility%ICTC %% SubMdistrict%level% e.g.%Civil%Hospitals% Community%Health% Centres%etc.% • Standalone%ICTCs% State%and%District%level% e.g.%Medical%colleges/District% hospitals%etc.% LEVEL OF HIV COUNSELLING AND TESTING SERVICES
  28. 28. DIFFERENT TYPES OF ICTCS Fixed-facility ICTCs: those located within existing health-care facility/hospital/ centre. It is of two types Standalone ICTC ( SA-ICTCs): Having a full time counsellor and laboratory technician who undertake HIV counselling and testing.Exist in medical colleges and district hospitals. Facility ICTC (F-ICTCs): Does not have full-time staff and provide HIV counselling and testing as service along with other services. Existing staff such as ANM/Staff nurse etc. are expected to take the activity. Mobile ICTC:It is a van with a room to conduct general examination, counselling and space for collection and processing blood samples by a team of paramedical healthcare providers. Useful in H2R with flexible working hours and provide services like Counselling and testing services for HIV Syndromic management of STI/RTI Regular health check ups/ANC/Immunization etc.28
  29. 29. OUTCOME On a site wise analysis, it is noted overall that 70 sentinel sites have shown HIV prevalence of 1% or more among ANC clinic attendees. 9 sites showed prevalence of 2% or more [CTG (3/1), GUJ (7/1), KTN (5/1), MAN (3/1),MIZ (3/1), NGN (7/3),RAJ (4/1)] The declining number of the HIV epidemic in the country is also corroborated by declining numb of HSS sites showing prevalence of 1% or more. No. of surveillance sites among ANC in 2003-476 No. of surveillance sites among ANC in 2014-15 –776 No. of ANC HSS showing prevalence of 1% or more in 2003-140 No. of ANC HSS showing prevalence of 1% or more in 2014-15-70 29
  30. 30. PPTCT In India the PPTCT intervention under NACP started in 2001-02 using SD-NVP prophylaxis for HIV-positive pregnant women during labour and her newborn child immediately after birth. India has transitioned from the SD-NVP to multi-drug ARV prophylaxis from September 2012.This was initially executed in souther high HIV prevalent states of AP, KTN and TN. 30 The new guidelines of WHO (June 2013) recommends following options to be practiced; Provide life long ART to all PW and BFW living with HIV regardless of CD4 count or clinical stage OR Providing ART for PW and BFW with HIV during mother to child transmission risk period and continuing lifelong ART for those women eligible for treatment of their own health.
  31. 31. ESSENTIAL PACKAGE OF PPTCT SERVICES Routine offer of HIV counselling and testing to all pregnant women through ANC with "opt out option". Ensure involvement of spouse & family members and move from an "ANC centric" to family centric approach Provide ART to all infected pregnant women regardless of CD4 count or staging . Preferred regimen is TDF+3TC+EFV Promote Institutional delivery. Provision of care for associated conditions ( STI/RTI & TB) Nutritional counselling and psychosocial support to infected pregnant women. Provide counselling and support for initiation of BF within one hour as the preferred option and follow protocol henceforth.31
  32. 32. Provide antiretroviral prophylaxis to infant from birth up to minimum period of six weeks. Integrate follow up of HIV exposed infant (HEIs) into routine healthcare services including immunisations. Ensure initiation of CPT and Early Infant Diagnosis (EID) using HIV DNA PCR at 6 weeks of age onwards Strengthen follow up in the community through ANM/ASHAs and district level networks 32 ESSENTIAL PACKAGE OF PPTCT SERVICES
  33. 33. 33 Pregnant women visiting HSC ANC registration by HSC ANM HSC:Routine ANC & PNC HSC: Screen Pregnant women for HIV, Syphilis and TB Screening test for HIV: Provide group/individual counselling session Offer HIV test Screening test for Syphilis: Does finger prick whole blood test for syphilis screening Screening for TB Refer PW to DMC at PHC if there is persistent cough of any duration Agree for test collection of blood sample and does finger prick whole blood test for HIV Opt out/refuse test Repeat counselling Offer HIV test at each subsequent visit HIV -ve HIV reactive Post test counselling , information Support Refer to ICTC for confirmation of HIV ICTC collect 5 ml blood for HIV rapid test and RPR test if not done earlier If HIV +ve RPR +ve If HIV -ve provide post test counselling Start treatment , advice condom use and Partner test If syphilis reactive refer to PHC/STI clinic for symptomatic treatment and RPR testing for confirmation Continue treatment , advice condom use and partner treatment Refer to PHC with DMC if women has above symptoms Start ATT RPR +ve Refer to ART for CD4 test, TB screening and clinical staging
  34. 34. AIDS CONTROL PROGRAMME IN INDIA • HIV infection 1st detected in 1986 when 10 HIV positive samples were found from a group of 102 female sex workers from Chennai • In 1986 AIDS Task Force set up under ICMR and established NAC chaired by MOHFW • In 1990 Medium Term Plan launched for 4 states and 4 metros • NACP-I launched in 1992/NACP-II launched in 1999/NACP-III implemented during 2007-12/NACP-IV ( 2012-2017) • NACP and NBP adopted in 2002. ART started in 2004. In 2006 National council on AIDS constituted under PM chairmanship followed by paediatric ART formulation. 34
  35. 35. NACP-I • OBJECTIVE • Slow and prevent the spread of HIV through a major effort to prevent HIV transmission. • KEY STRATEGIES • Raising awareness, Blood safety, Prevention among high risk populations and Improved surveillance • ACHIEVEMENTS • National AIDS response structure at both national and state levels and provided critical financing • Strong partnership with WHO followed by establishment of State AIDS control cells • Improved blood safety and expanded sentinel surveillance followed by National HIV testing policy • Improved condom promotion activities. 35
  36. 36. NACP-II • OBJECTIVE • Reduce the spread of HIV infection in India through behaviour change and increase capacity to respond to HIV on long term basis • KEY STRATEGIES • TI for HRG, Preventive intervention for general populations, Involvement of NGOs, Institutional strengthening. • ACHIEVEMENTS • At the operational level 1033 TI set up, 875 Voluntary counselling and testing centres (VCTC) and 679 STI clinics at the district level • Nation wide and state level BSS surveys were conducted • PPTCT programme expanded. CMIS created.Support from partner agencies increased substantially. • HIV prevention, care and support organisations and networks were strengthened 36
  37. 37. • Reduce the rate of incidence by 60% in the first year of the programme in high prevalence states to obtain the reversal of epidemic, and by 40% in the vulnerable states to stabilise the epidemic 37 OBJECTIVE OF NACP-III
  38. 38. NACP-IV PROJECT DESIGN Key strategies under NACP-IV Strengthening SIMS Intensify and consolidate preventive services Increase access & promote comprehensive care, support and treatment Capacity building Expanding IEC services Objective 1: Reduce new infections by 50% ( 2007 Baseline of NACP III) Objective 2: Provide Comprehensive care and support to all PLHIV and treatment services those who require it 38
  39. 39. INTENSIFYING AND CONSOLIDATING PREVENTION 39 •Prevention the core strategy as 99% of the people are HIV negative. ! •It is planned to cover 90% of HRG through TI implemented by NGOs and CBOs. ! •High risk migrants, their spouses, truckers and other vulnerable population will be assessed by collaborating with other departments, women groups and youth clubs ! Activities •Saturating quality HIV prevention services to all HRG groups,based on emerging behaviour patterns and evidence ! •Strengthening needle exchange programme , drug substitution programme and providing Opioid Substitution Therapy ! •Reaching out to MSM and Transgender ! •Addressing the issue related to coverage and management of rural interventions ! •Providing quality STI/RTI services ! •Strengthening management structure of blood transfusion services ! •Expanding the ICTC services and strengthen referral services.
  40. 40. COMPREHENSIVE CST Additional CoEs and upgraded ART plus Centres will be established to provide high quality treatment Treatment of HIV/AIDS will include: • ART including second line • Management of opportunistic infections including TB in PLHIV. • Positive interventions • facilitating social protection and insurance for PLHIV. Activities • Scale of ART centres, LACs, and CoEs ART services. • Strengthening follow up of patients on ART and improving quality of counselling services at ART service delivery points • Comprehensive care and support services for PLHIV through linkages • Provide guidelines and training for integration in health care settings to NRHM 40 CoE$&$ $ART$plus$ Selected$Medical$ $college$ ART$Centres$ Medical$college$and$District$hospital$ Link$ART$centre$and$LAC$plus$centre$ Sub$district$hospital$and$CHC$
  41. 41. EXPANDING IEC SERVICES FOR (A) GENERAL POPULATION AND (B) HIGH RISK GROUPS WITH A FOCUS ON BEHAVIOUR CHANGE • Increasing awareness among general population in particular women and youth. • BCC strategies for HRG and vulnerable groups • Continued focus on demand generation of services • Reach out to vulnerable populations in rural settings ( Link Worker Scheme) • Extending services to tribal groups and hard to reach populations 41
  42. 42. STRENGTHENING INSTITUTIONAL CAPACITIES • The programme management structures established under NACP will be strengthened • Programme planning and management responsibilities will be enhanced at national state districts and facility levels • Phased integration of the HIV services with the routine public sector health delivery systems, streamlining the supply chain mechanism and building capacities of governmental and non-governmental institutions 42 GUIDING PRINCIPLES FOR NACP-IV • Continued emphasis on three ones- one Agreed Action Framework, one National HIV/AIDS Coordinating Authority and one Agreed National M&E System • Equity/Gender/Respect for the right of the PLHIV • Civil society representation and participation, improved PPP. Evidence based and result oriented programme implementation
  43. 43. KEY PRIORITIES UNDER NACP-IV • Prevention new infections by sustaining the reach of current interventions • PPTCT. Focusing on IEC strategies for behaviour change in HRG, awareness among general population and demand generation for HIV services • Providing CST to eligible PLHIV, reduce stigma and discrimination through Greater involvement of PLHA ( GIPA) • Ensure effective use of strategic information at all levels of programme • Integrating HIV services with health systems in a phased manner. Building capacity of NGOs and civil society partners • Maintaining of HIV/AIDs activities with all key central/state level ministries/departments will be given a high priority. 43
  44. 44. KEYS INITIATIVES UNDER SIMS 44 • IBBS among HRG and Bridge groups • National Data Analysis Plan • National Research Plan • Advanced analytic and GIS MONITORING FRAMEWORK • Impact Indicators • Reduction of HIV Incidence • Estimated number of annual ARD • %age of adults and children with HIV known to be on treatment at 24 months after initiation of ART at selected ART centres. • Outcome Indicators • %age of FSW who report using condom with their last client ( Target 80-85% by 2017; 5% increase over the baseline 2012-13) • MSM who report using condoms during sex ( Target 45% to 65% increase by 2017. 20% increase over the baseline of IBBS 2012-13) • %age of IDU who do not share injecting equipment during last injecting act ( Target 45% to 65% increase by 2017; 2-% increase over the baseline of IBBS 2012-13)
  45. 45. TI FOR HRG • Objective: Improve health seeking behaviour and reducing risk of getting STD and HIV infection • Services offered include; • Detection and treatment of STD • Condom Distribution and promotion through social marketing. Based on HIV prevalence and family planning districts classified into 4 categories • HPHF (42), HPLF (45), LPHF (135 ) and LPLF . • BCC with community involvement and participation • Linkage with ICTC and CST • For IDUs • Distribution of clean needles and syringes, Abscess prevention and management, Opioid substitution therapy and Linkage with detoxification and rehabilitation services • For MSM/TGs • Provision of project based STI clinics 45
  46. 46. 46
  47. 47. BLOOD TRANSFUSION SERVICES The division of blood safety has been renamed to Blood transfusion services to expand the horizon of blood safety to include; TTI/Immunopathology/Quality Management systems Logistic and other process involved to improve confidence in safety of blood. Blood transfusion council have been set at national and state level. Licensed blood bank operate in the country and voluntary blood donation is encouraged. The strategy is to ensure safe collection, processing, storage and distribution of blood and blood products. Every unit of blood need to be tested to rule out HIV/HBV/HCV/Malaria and Syphilis. Access to safe blood is the responsibility of NACO. Role of FRUS at Sub district level. 47
  48. 48. TB and HIV • TB is the most important opportunistic infection among PLHIV. – TB infection: 10% life time risk of getting TB – HIV infection: 30% life time risk of getting TB – Dual infection of TB and HIV:50% life time of getting TB. • HIV- infected TB patients should be referred to ART. The visit should be at least 2 weeks after initiation of TB treatment to ensure reduction in TB transmission from these patients to large HIV- infected persons. • NACO recommends that ART be given to • All patients with EPTB and • All those with PTB ( stage 3) with CD4 count<350 cells/mm 3 48
  49. 49. Activities to reduce HIV-TB Mortality 49 TB/HIV co-ordination to reduce mortality Prevention Isoniazid preventive treatment Airborne infection control Awareness generation Early Detection of TB/HIV 100% coverage of PITC in TB patients Rapid diagnostic for detection of TB and DR-TB in PLHIV ICF activities at all HIV settings-ICTC, ART, LAC, and TI setting Prompt T/T of TB/HIV Early initiation of ART Prompt treatment of TB treatment Management of Special/TB/HIV cases TB/HIV patients on PI based ARV TB/HIV in children TB/HIV pregnant women Drug resistant TB/HIV
  50. 50. 50 UNIVERSAL PRECAUTIONS Universal Precautions are control guidelines designed to protect workers from exposure to diseases spread by blood and other body fluids. By now we have the name called standard precautions which is designed to reduce the risk of transmission of blood borne and other pathogens from both recognised and unrecognised sources to a susceptible host. Universal precautions include the following interventions; Hand washing after any direct contacts with patients. Prevent recapping of needles Safe collection and disposal of needles. Wearing gloves for contact with body fluids, non- intact skin and mucus membrane. Wearing a mask eye protection,and a gown if blood or other body fluids might splash. Covering all cuts and abrasions. Carefully cleaning up spills of blood and other body fluids Using safe system for health care waste management and disposals
  51. 51. 51 MonitoringandEvaluation:DraftGlobalHealthSector Strategy2016-2021 Vision:Zero new HIV Infections. Zero HIV related deaths and Zero HIV related discriminations in world where PLHIV are able to live long and healthy lives Goal:End AIDS Epidemic as public health threat by 2030 2020 Targets:Reduce new HIV infections to less than 5,00,000. Zero new infection among infants. Reduce HIV related deaths to below 5,00,000.90% of PLHIV to be tested.90% treated .90% virally suppressed. Framework of action : Universal Health coverage , the continuum of services and a public health approach Strategic Direction 1 Information and focused action The "who" and "where" Strategic Direction 2 Intervention for impact The "what" Strategic Direction 3 Delivering for equity The "how Strategic Direction 4 Delivering for equity Financing for sustainability The "financing" Strategic Direction 5 Innovation for acceleration The future Strategy Implementation Leadership,Partnership,Accountability,Monitoring & Evaluation Country action Country Partner action WHO action HQ, Regions and Countries Global Partner action
  52. 52. 52 • Major Challenges towards the development of an effective HIV/AIDS vaccine • Genetic diversity: HIV multiplies at very rapid pace and is different from the parent virus. • Failure in formation of virus neutralising antibodies • Lack of proper animal model since infection can occur with SIV • World largest trail phase III was done in Thailand from 2003-2009. Trial is known as RV 144 "prime (ALVACHIV)—boost (AIDS VAX B/E)" combination • 6 dose given in 6 months ( 4 with ALVAC and last two with AIDS VAX B/E) • Result announced in 2009 in which it is estimated of 31.2% effective in preventing HIV infections.
  53. 53. 53 • HIV continue to be major public health issue globally claiming more than 34 million lives so far. • Can be transmitted via exchange of variety of body fluids from infected individuals • Risk Factors • unprotected vaginal or anal sex and having STI • Sharing contaminated needles, syringe, receiving unsafe injections and Needle stick injury • All HIV testing services must include 5 C's recommended by WHO; consent,confidentiality,Counselling ,Correct test result and connection ( linkage to CST) • Prevention • Male and female condom use • Testing and counselling for HIV and STI • ART for prevention • Harm reduction fo IDU • EMTCT SUMMARY
  54. 54. REFERENCES: 1. Park's Textbook of PSM 23rd Edition/Epidemiology of communicable disease/Health Programme in India/HIV/AIDS 2. Community Medicine with recent advances/Epidemiology of communicable disease/Health Programme in India/HIV/AIDS 3. India HIV estimation 2015 Technical report by NACO, MIMS, ICMR, MOHFW GOI 4. HIV Sentinel Surveillance Technical Brief by NACO 2014-15 5. Operational Guidelines on ICTC by NACO 6. NACP-IV (2012-2017) strategy document by NACO GOI. 7. National Integrated Biological and Behavioural Surveillance (IBBS) 2014-2015 8. Health 2015 from MDGs to SDGs by WHO 9. UNAIDS fact sheet 2015 10.Draft HIV strategy 2016-2021 by WHO 11.Guideline on when to start ART and on pre-exposure prophylaxis for HIV sept 2015 54
  55. 55. Thank you and its open for discussion!!! 55
  56. 56. 56 HRG ( IDU/FSW/MSM/TG) Bridge Population ( STD Patients/SMM/LDT) General Population: Pregnant Women attending ANC clinics Sentinel site Target intervention (TI) projects) STD clinic, TI Projects ANC Sample size 250 250 400 Duration 3 months 3 months 3 months Frequency Once in 2 years Once in 2 years Once in 2 years Sampling methods Consecutive/random Consecutive Consecutive Age group 15-49 yrs 15-49 yrs 15-49 yrs Testing Strategy Unlinked anonymous with informed consent unlinked anonymous at STD, with informed consent at TI sites Unlinked anonymous Blood specimen Dried blood spot Serum at STD, DBS at TI sites Serum Testing Protocol Two tested protocol Two tested protocol Two tested protocol

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