NATIONAL AIDS CONTROL PROGRAMME Dr Lipilekha Patnaik Professor, Community Medicine Institute of Medical Sciences & SUM Hospital Siksha ‘O’ Anusandhan deemed to be University Bhubaneswar, Odisha, India Email: drlipilekhag@yahoo.co.inINTRODUCTION *AIDS(acquired immunodeficiency syndrome) «Caused by- HIV (Human immunodeficiency virus) +Family- Retroviridae *Disease characterized by profound immunosupression that leads to opportunistic infections, secondary neoplasms, neurological manifestations transcriptase ANAProblem statement *World * According to WHO, HIV continues to be a major global public health issue * Globally Total Cases - 36.9million + Death -9,40,000 * Newly infected -1.8 million * Adult receiving ART -59% * Children on ART -52% « Pregnant womenonART -80% * According to report between 2000-17, new HIV infection fell by 36%, HIV related deaths fell by 38% with 11,4 million lives saved due to ART.INDIAN SCENARIO ‘The total number of people National adult (15 to 49 yrs) living with HIV (PLHIV) in india | HIV prevalence in 2015 21,17L people who inject drugs «PwiD) National Average MR 714%. Manipur 12.9% Mizoram 1296 MeghalayaMilestones of the programme * 1986- First case of HIV detected. AIDS task force set up by ICMR. National AIDS Committee by M + 1990 — Medium term plan for states and 4 metros. + 1992—NACP I launched National AIDS control board constituted. NACO set up. + 1999 — NACP II began, SACS established + 2002 - National AIDS control policy National blood policy + 2004 — Antiretroviral treatment initiated * 2006 - National council on AIDS under chairmanship of Prime Minister . ry of Health. National policy on Pediatric ART + 2007 — NACP III launched for 5 years (2007 — 2012) + 2012- NACP IV launched for next 5 yearsNACP I OBJECTIVE: Slow & prevent spread of HIV through a major effort to prevent its transmission STRATEGIES: * Focus on raising awareness, blood safety , prevention among high risk populations «Improving surveillance ACHIEVEMENTS: * Strong partnership with WHO * Establishment of the state AIDS control cells + Improved blood safety + Expanded sentinel surveillance & improved coverage and collection of data * Improved condom promotion activities * Development of national HIV testing policyNACP II OBJECTIVES: Reduce the spread of HIV infection in India through behavioral changes & Increase capacity to respond to HIV on a long term basis STRATEGY: * Target interventions for high risk groups. * Preventive interventions for general populations * Involvements of NGOs + Institutional strengthening ACHIEVEMENTS; 1,1033 TIs, 875 VCTC, 679 STI clinics started at district level 2.Nation wide behavioral sentinel surveillance were conducted 3.PPTCT program was expanded 4.Computerized management information system was created 5.HIV prevention & care and support networks were strengthened 6.Supports from partner agencies increasedNACP II OBJECTIVES: Reduce the rate of incidence by 60% in 1* year of program in high prevalence states and by 40% in vulnerable states STRATEGY: * Prevention by TI, ICTC, Blood safety, Communication, and condom promotion + Care support & treatment- ART, CoEs, Community center * Capacity building * Strategic information management by monitoring & evaluation ACHIEVEMENTS: 1. 306 fully functional ART center & 612 LINK ART center, 10 CoE, 259 Community cares were established 2. 12.5 lakh PLHIV were registered & 4.2 lakh patients were on ART 3. 3000 Red ribbon clubs were established 4. Link workers training module updated & condom promotion program was strengthenedNACP-IV GOAL: TO HALT AND REVERSE the epidemic in India over next 5 years by integrating programmes for preventions & care, support & treatment. OBJECTIVE: 1 Reduce new infection by 50% (ac. To NACP II] base line) 2.Provide care, support & treatment to all living with HIV/AIDS. and treatment service for all who needs it.Strategy 1: Intensifying and consolidating prevention services Strategy 2: Comprehensive care, support and treatment Siler eecli alae a ary Strategy 4: Strengthening institutional capacity Strategy 5: Strategic Information Management SystemPACKAGE OF SERVICES PREVENTION SERVICES. “Targeted Interventions For High Risk Groupsand lbridge population “Neciile Syringe Exchange Program and apoid substitution therapy for IDUs “Prevention interventions for Migrant population at ‘source, transit and destonation “Link worker seheme for HGS and vulnerable popoulation in rural areas “Prevention & Control OF STURT “Blood Safety IV counselling and testing services “Provention OF Parent To Child Transmission Condom Promotion HEC & BCC “Social Mobilization, Youth Interventions and. adolescent education programme *Mainstreaming HIV/AIDS “Workplace interventions CARE, SUPPORT & TREATMENT SERVICES +Lab services for CD4 testing and other investigations +Free first lineand second line ART Pediatric ART for children *Early infant diagnosis for HIV exposed infimts and children below 18:months *Nutritional and psychosocia! supports through care ‘ans support centres SHIVITB coordination (cross referral, detection and treatment of ea-infeetions) “Treatment of oppurtunistic inféetion *Drop-in centres for PLHIV networksCountry scenario: Classification of states *High prevalence >5% in HRG & >1% inANC Maharashtra, TN, Andhra, Manipur, Karnataka, Nagaland * Moderate prevalence >5% in HRG & <1% inANC Gujarat, Puducherry, Goa * Low prevalence <5% in HRG & <1% in ANC All other states/UTsClassification of districts Districts are classified into four categories A to D * Category A: More than 1% ANC/PTCT prevalence in district in any of the sites in the last 3 years, * Category B: Less than 1% ANC/PTCT 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 than1% 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 cte.,) * Category D: Less than 1% ANC prevalence in all sites during last 3 years with less than 5% in all HRG sites with no known hot spots OR no or poor HIV dataHIV SURVEILLANCE *Surveillances are being carried out to detect spread of the disease & to make appropriate strategy for prevention and controli.e by area specific Targeted Interventions & Best Practice Approach. «Types of surveillances HIV sentinel surveillance HIV sero surveillance AIDS case surveillance STD surveillance Behavioural surveillance Integration with surveillance of other diseases like TB etc. * Out of the above most effective one is HIVsentinel surveillance The main aim of the surveillance is confined to monitor the trend of HIV infection.Objectives of the surveillance 2. To determine the level of HIV infection among general population as well as HRGs in different states To understand the trend of HIV epidemic among general population as well as HRGs in different states . To understand the geographical spread of infection and to identify emerging pockets To provide information for prioritization of the programme resources & evaluation of program impact To estimate prevalence & HIV burden in the country. It is done in the same place over a few years by anonymous serological tests. ie HIV testing is done without identification of name of samples collected for other purposes eg. VDRL, STD clinics+ The demerit of the test is that +ve person is not identified fe it was started with 55 sentinel sites and became 180 in 1 * The number of HRG of people increased with increase in HIV sentinel sites . *THE KEY FEATURES OF THIS SURVEILLANCE ARE 1. Inclusion of data from high risk population through targeted intervention sites 2. Adding rural samples through antenatal clinics *THE STRATEGY ADOPTED WAS Whatever be the sentinel site and amount of sample collected-the duration , frequency and age group of people in the surveillance should be same in all HRG , bridge population and general population.sentinel wurellenee round 2010-2011 HighencpropeiUyssMyeSwTG paar S/T Geren er semen inng XC Penusel wie Targried exserveauions (TD projects ‘STD clinic, Th projects Antenatal ci fasple ae co co] oJ powe Sina mene sevens pesca ne 22 once yn oe sya fucpinynenos —contetneinaten conaecne connect od sepa 14 yan yeu feseene “memes aan amt feet spemen rnd ae pt seroma $0,088 1 eee sen fronted wee jt Totes ent reCOUNSELLING and HIV TESTING SERVICES These services started in India since 1997 * Components: 1.I[CTC, 2. Prevention of parent-to-child transmission of HIV (PPTCT) 3. HIV/TB collaberative activities Integrated Counselling and Testing Centres + This is available to increase access to HIV diagnosis ‘It includes testing services & community approaches at various level of health system in India like state, district, sub district, & village/community level. FUNCTIONS 1. Early detection of HIV, 2. Provision of basic information on modes of transmission, prevention of HIV for promoting behavioral change and reducing vulnerability and linking the PLHIV to care, support & treatment. A person is counselled and tested for HIV at ICTC, either of his own free will (client initiated) or as advised by a medical provider (provider initiated).Two Types of ICTC 1.Fixed facility ICTC 2. Mobile ICTC 1, Fixed facility ICTC: are located within an existing healthcare facility/hospital/health centre *areofof2types 1. Standalone [CTC (SA-ICTC) 2. Facility-integrated ICTC (F-ICTC) SA-ICTC: The client load is high in the center with full time counsellorand lab technician who provide HIV counselling & testing services F-ICTC: + These are set below the block level in 24x7 PHCs * Staffs are trained in counselling and testing services of HIV * Similar to this Public Private Partnership ICTCs are also established in private facilities * The above center are supported by SACS & DACS2. MOBILE ICTC: *Itis a van with a room to conduct general examination, counselling and collection and processing of blood and blood products * These are set in hard to reach areas as temporary clinics * They also provide counselling and services about regular health check up, antenatal check up & immunization. *Community based HIV screening is done by ANM at sub centre level to provide HIV testing to all pregnant women . *|t is done to prevent transmission of HIV from parents to child.PREVENTION OF PARENT-TO-CHILD TRANSMISSION OF HIV * The prevention of parent-to-child transmission of HIV/ AIDS (PPTCT) programme was started in 2002. * Currently there are more than 15,000 ICTCs in the country which offer PPTCT services to pregnant women. * The aim of the PPTCT programme is to offer HIV testing to every pregnant woman (universal coverage} in the country, so as to cover all estimated HIV positive pregnant women and eliminate transmission of HIV from mother-to-child. * In india, PPTCT interventions under NACP was started in 2002, using SD-NVP prophylaxis for HIV positive pregnant women during labour and also for her new born child immediately after birth.* With the department of AIDS control adopting “Option B” of the World Health Organization recommendations (2010), India has also transitioned from the single dose Nevirapine strategy to that of multi- drug ARV prophylaxis fram September 2012. * The national strategic plan for PPTCT services using multi-drug ARVs in India was developed in May-June 2013 for nationwide implementation in a phased manner. * Based on the new WHO guidelines (June 2013) and on the suggestions from the technical resource groups during December 2013, department of AIDS control has decided to initiate lifelong ART (using the triple drug regimen) for all pregnant and breast-feeding women living with HIV, regardless of CD4 count or WHO clinical stage, both for their own health and to prevent vertical HIV transmission, and for additional HIV prevention benefits. * The PPTCT services provide access to all pregnant women for HIV diagnostic, prevention, care and treatment services.HIV/TB COLLABERATIVE ACTIVITIES *NACP IV covers the HIV testing of TB patients *It is combined work of NACP & RNTCP *State with high HIV prevalence covers about 90% of TB patients for HIV testing. “There is expected detection of HIV within 2-4 weeks of TB Positivity. “This service was started in October 2012 in Karnataka followed by Maharastra , Andhra Pradesh & Tamil Nadu.Prevention 1. Isonianid preventive treatment 2. Air borne infection controt ‘3. Awareness generation ‘TB/HIV co-ordination to reduce mortality Early detection of TB/HIV 300% caverage of PITC in Ti patieats . PITC in presumptive TS casea Rapid diagnostics for detection of TB and DR-TB in PLE JOP activities at als HIV settings - ICTC, ART, LAC ana] Th settings Prompt treatment of TB/HIV 1. Barly tnitiaion of ART 2. Prompt initiation of TB treatment Ye ‘Management of special TB/HIV cases ‘TH/HIV patients on PI based ARV TBY/HIV in children Taye Drugresi ant women THY HIV rs = Aclivities to feduee HIV-TB mortality PITC - provider inttunted HIV testing and counseling: IC - link ART centres; 11+ Targeted imerventions intensified case finding: LAC =CARE, SUPPORT & TREATMENT The care, support and treatment (CST) component of NACP aims to provide comprehensive services to people living with HIV (PLHIV) with respect to *free Anti-Retroviral Therapy (ART) «psychosocial support *prevention and treatment of opportunistic infections (OT) including tuberculosis sand facilitating home-based care and impact mitigation+ These services are provided through ART center across the country * Someare linked to Centre of Excellence (CoE) & ART Plus center at selected institutions. * Some are linked through Link ART center like linking to ICTC, STI clinics, PPTCT services & with RNTCP. ART CENTERS-519 LINK ART CENTERS-1073 Centre of Excellence -10 PEDIATRIC CoE -7 ART PLUS CENTERS-52 CST CENTERS - 350 ‘acre FIG. 6 Model of HIV treatment servicesServices provided 1) ANTIRETROVIRAL THERAPY: A) 1 line ART- Provided free of cost to PLHIV through ART centers. * Patients are provided counselling on treatment and nutrition, * Follow up is done by assessing drug adherence, regularity of visit, periodic examination & CD4 count testing in every 6 months * — Till 2017 — 7.68 lakh PLHIV were on I*' line ART + After launching of Pediatric HIV/AIDS initiative ,till march 2017 -1,06,824 cases were registered and out of that 42,015 are on I line ARTB, Alternative first-line ART: *It has been observed that a small number of patients initiated on first-line ART, experience acute/chronic toxicity/intolerance to first-line. + ARV drugs, thus necessitating change of ARV drugs to alternative first-line drugs. Presently, the provision of alternative first-line ART is done through the Centres of Excellence and ART- Plus centres across the country.C. Second line ART: *The second-line ART began in January 2008 at two sites - GHTM, Tambaram, Chennai and JJ Hospital Mumbai on a pilot basis, and was then further expanded to the other CoEs in January *Some ART centers were upgraded to plus centers *Till march 2017 — 8,897 patients were on 2 line ART *All ART centres are linked to CoE/ART-Plus centres. *For the evaluation of patients for initiation on second-line and alternate first- line ART, a State AIDS Clinical Expert Panel (SACEP) has been constituted by DAC at all CoEs and ART-Plus centres. *This panel meets once in a week for taking decisions on patients referred to them with treatment failure/major side effects.National paediatric HIV/AIDS initiative: * The national paediatric HIV/AIDS initiative was launched on 30 November 2006, + Till March 2014, nearly 1,06,824 children living with HIV/AIDS (CLHIV) were registered in HIV care at ART centres, of whom 42,015 were receiving free ART. * Paediatric formulations of ARV drugs are available at all ART centres. Paediatric second-line ART: * While the first-line therapy is efficacious, certain proportion of children do show evidence of failure. + There is not much data available on the failure rate of Nevirapine- based ART in children. * Currently, second- line ART for children has been made available at all CoE and ART-Plus centres.Early infant diagnosis: + In order to promote confirmatory diagnosis for HIV exposed children, a programme on Early Infant Diagnosis (EID) was launched by DAC. All children with HIV infection confirmed through EID have been linked to ART services. TARGETED INTERVENTIONS FOR HIGH RISK GROUPS: The main objective of targeted interventions (T1) is * To improve health-seeking behaviour of high risk groups (HRG) and * To reduce their risk of acquiring sexually transmitted infections (STI) and HIV infections.The services offered through targeted interventions include: * Detection and treatment for sexually transmitted infections * Condom distribution (except in TIs for bridge population) «Condom promotion through social marketing (for HRG and bridge population) * Behaviour change communication * Creating an enabling environment with community * involvement and participation + Linkages to integrated counselling and testing centres * Linkages with care and support services for HIV positive * HRGs «Community organization and ownership buildingSpecific interventions for IDUs Distribution of clean needles and syringes *Abscess prevention and management *Opioid substitution therapy *Linkage with detoxification/rehabilitation services Specific interventions for MSM/TGs Provision of lubricants Specific interventions for TG/hijra populations Provision of project-based STI clinicsLink worker scheme: * The Link worker scheme is a community-based outreach strategy to address HIV prevention and care needs of HRG and vulnerable population in rural areas. * The specific objectives of the scheme include reaching out to these groups with information and knowledge on prevention and risk reduction of HIV and STI, condom promotion and distribution, providing referral and follow-up linkages for various services. + It includes counselling, testing and treatment of STI and opportunistic infections through link workers, creating an enabling environment for PLHIV and their families, and reducing stigma and discrimination against them. + In partnership with various development partners, the link worker scheme has been expanded and is being implemented in 17 states covering 163 highly vulnerable districts.Blood transfusion services: * Only licensed blood banks are permitted to operate in country and voluntary blood donation is encouraged since |“ Jan 1998. + The strategy is to ensure safe collection, processing, storage and distribution of blood and blood products. + Zonal blood testing centres have been established to provide linkage with other blood banks. + As per national blood safety policy, testing of every unit of blood is mandatory for detecting infections like HIV, hepatitis B, hepatitis C, malaria and syphilis. *NACO is supporting 1167 blood banks, including 304 Blood Component Separation Units (BCSU) and 34 Model Blood Banks, 260 major blood banks and 613 district level blood banks, * Blood storage centres were established at First Referral Units (FRUs), at sub-district levels, for wider availability of safe blood, particularly for emergency obstetric care and trauma care services.Condom promotion: + Condom promotion strategies will be strengthened through free distribution and social marketing channels, non-traditional outlets, female condoms, etc. aided by an effective communication strategy. * On the basis of HIV prevalence and family planning needs, the districts have been mapped and classified into four categories: (a) High prevalence of HIV and high fertility (HPHF); (b) High prevalence of HIV and low fertility (HPLF); (c) Low prevalence of HIV and low fertility (LPLF); and (d) Low prevalence of HIV and high fertility (LPHF). + During 2014 the coverage of condom social marketing programme implementation was spread across 395 districts, i.e. 141 HPHF, 84 HPLF and 170 LPHF districts in 11 states.OBJECTIVES: 1. Increase demand for condoms among high risk, bridge & general population Maximize access of free condoms with minimize wastage Increase sells in rural areas To make it available within 15 minutes of walking distance from any location This prevents HIV infection as well as decreases STD. Free condoms NIRODH are procured by Ministry of Health & Family Welfare and distributed by NACO/SACS to HRGs through TI/NGOs/ICTC/ART centers for HIV preventionSTD CONTROL PROGRAMME * STD control is linked to HIV/AIDS control as behaviour resulting in the transmission of STD and HIV are same. *HIV is transmitted more easily in the presence of another STD. *Hence, carly diagnosis and treatment of STD is now recognized as one of the major strategies to control spread of HIV infection. Following measures are taken for STD control A) Management of STDs through syndromic approaches by colour coded kits B) Integration of services for treatment of reproductive tract infections & STDs at all levels of health care STDs Clinics at district / block/ First Referral Unit (FRU) level would function as referral centres for treatment of STDs referred from peripheries. All STDs clinics would also provide counselling services and good quality condoms to the STD patients.* NACO has branded the STI/RTI services as “Suraksha Clinic”, and has developed a communication strategy for generating demand for these services. * PRE-PACKED STURTI COLOUR CODED KITS: Pre- packed colour coded STI/RTI kits have been provided for free supply to all designated STI/RTI clinics. These kits are being procured and supplied to all State AIDS Control Societies. * The colour code is as follows: + Kit | - grey, for urethral discharge, ano-rectal discharge and cervicitis. * Kit 2 - green, for vaginitis. * Kit 3 - white, for genital ulcers. * Kit 4 - blue, for genital ulcers. + Kit 5 - red, for genital ulcers. * Kit 6 - yellow, for lower abdominal pain. * Kit 7 - black, for inguinal buboUrethral or Anorectal ‘oF Cervical discharge ‘Vaginal Discharge vaginitis) Genital Ulcer Disease (Non Herpitic) Genital uicer disease (monherpetic) in Penieittin Genital uicer disease Lower abdominal pain (Pelvic inflammatory Disease) Inguinal Bubo KIT 1: Gray KIT 2: Green KIT: White KIT 4: Blue KIT 6: Yellow KITS: Black Tab Secnidazole 2.9 Tab Fluconazote 150 mg (1 tab) Inj. Benzathine Penicillin 24 MU (1 val} + Tab Aaithromycin 1 g (Kit also contains 10 ml disposable syringes 21 gauge needle + 1 vial Of 10 mi sterile water Tab Doxycycline 100 mg (1 tab. BD for 14 days) Tab Azithromycin 1g x 1 tab Tab Acyclovir 400 mg x 1 tab TDS x 7 days Tab Geficime 400 mg x 1 tab Tab Metronidazole 400 mg x (1 BD 14 days) Tab Doxycycline 1g (1 8D 14 days) Tab Doxycycline 100 mg (1 BD x 21 days) Tab Azithromycin 1g x 1 tabInformation, education and communication Communication is the key to generating awareness on prevention as well as motivating access to testing, treatment, care and support. Communication in NACP-IV is directed at: a.To increase knowledgeamong general population (especially youth and women) on safe sexual behaviour b.To sustain behaviour change in high risk groups and bridge populations c.To generate demand for care, support and treatment services and d.To make appropriate changes in societal norms that reinforce positive attitude, beliefs and practices to reduce stigma and discrimination.Adolescence Education Programme: * This programme runs in secondary and senior secondary schools to built up life skills of adolescents to cope with the physical and psychological changes associated with growing up. * Under the programme, 16 hour sessions are scheduled during the academic terms of class [X and XI. «State AIDS control society have further adapted the modules after state level consultations with NGOs, academicians, psychologists and parent-teacher bodies. * This programme is being implemented in 23 states and by March 2014, 49,000 schools have been covered.Red Ribbon Clubs: * The purpose of Red Ribbon Club formation in colleges is to encourage peer-to-peer messaging on HIV prevention and to provide a safe space for young people to seek clarifications of their doubts and myths surrounding HIV/AIDS. * The RRCs also promote voluntary blood donation among youth. Red Ribbon ClubACHIEVEMENTS Capacities of State AIDS control societies & District AIDS prevention and control units have been strengthened. Technical support units were established at National & State level to assist in program monitoring. State training resource centers were set up. Strategic information management system (SIMS) has been established with 15,000 reporting units across country ART centers, ART link centers , CoEs , ICTCs were established & Support agencies were increased.+ The 2016-21 strategy by UNAIDS is a bold call to reach all those people who were left. *It is a call to reach 90-90-90 treatment targets to protect the health of people living with HIV. * 90% of people should be aware of there infection > 90% of that population should start on ART 90% out of those taking ART should have undetectable HIV in their body till 2020. Target- 1.75 % reduction in incidence of infection from 2010-20. 2.Reduce in annual death rates to less than 5,00,000 till 2020._panern