A detailed overview of National AIDS Control Program - IV

1. NATIONALAIDS CONTROL
PROGRAMME(NACP)-IV
Dr. Bharat Paul

2. CONTENTS
• Introduction
• Epidemiology of HIV/AIDS
• AIDS Control Programme in India
• NACP I,II & III
• NACP-IV
– Objectives
– Strategies
– Key initiatives
– Guiding Principles
– Services
– Monitoring framework
– Challenges
• References

3. INTRODUCTION
HIV is the Human Immunodeficiency Virus- lentivirus
-retrovirus
 Leads to Acquired Immune Deficiency Syndrome, or
AIDS.
Destroy specific blood cells, called CD4+ T cells,
which are crucial for fighting diseases.
 No cure for HIV infection.
Currently, people can live much longer - even decades -
with HIV before they develop AIDS.
“Highly active” combinations of medications that were
introduced in the mid 1990s.

4. Modes of transmission
Heterosexual 87.4
Parent to Child
5.4
others
3.3
Injecting Drug Use
1.6
Homosexual/
Bisexual
1.3
Blood and Blood
Products
1

5. Risk of transmission
ROUTE EFFICIENCY (%)
Sexual 0.01 to 1
Transfusion of blood products >90
Sharing needles/syringes 3-5
Percutaneous exposure 0.4
Mucocutaneous exposure 0.05
Mother to child transmission 25-30

6. ADULTS --Positive test for HIV
antibody by 2 separate test
using 2 different antigens +
Any one of the following
 Weight loss >10% of bw
 Chronic diarrhoea >1 month
 Chronic cough >1 month
 Disseminated ,miliary or
extrapulmonary TB
 Neurological impairment
 Esophageal candidiasis
 Kaposi sarcoma
 Major –Weight loss,Failure to
thrive,Candidiasis,Tuberculosis,
Herpes zoster
 Minor—Generalised
lymphadynopathy,Oropharynge
al candidiasis,Persistant cough
for >I month , Generalised
dermatitis, Confirmed maternal
HIV infection
CHILDREN—At least 2 major
signs + 2 minor signs
Case definition of AIDS

7. Epidemiology of HIV/AIDS in India
• The HIV epidemic in India is concentrated among
High Risk Groups and is heterogeneous in its
distribution.
• Overall trends of HIV portray a declining
epidemic at national level, though regional
variations exist.
• The total number of people living with HIV/
AIDS in India was estimated at around 20.9 lakh
in 2011, 86% of whom were in 15-49 years age-
group.

8. Epidemiology of HIV/AIDS in India
• According to HSS 2012-2013, the overall HIV
prevalence among ANC attendees continued to
be low at 0.35% in the country, with an overall
declining trend at the national level.
• According to HIV Estimations 2012, the adult
(15-49 years) HIV prevalence at national level
continued its steady decline from the estimated
level of 0.41% in 2001 to 0.27% in 2011

9. Epidemiology of HIV/AIDS in India
• India has demonstrated an overall reduction of
57% in estimated annual new HIV infections
(among adult population) during the past
decade from 2.74 lakh in 2000 to 1.16 lakh in
2011.

12. Classification of states
• High prevalence
– >5% in HRG & >1% in ANC
– Maharashtra, TN, Andhra, Manipur, Karnataka,
Nagaland
• Moderate prevalence
– >5% in HRG & <1% in ANC
– Gujarat, Puducherry, Goa
• Low prevalence
– <5% in HRG & <1% in ANC
– All other states/UTs

13. Classification of districts
• Districts are classified into four categories A to D
• Category A:
– More than 1% ANC prevalence in district in any of the sites in the last 3
years.
• Category B:
– Less than 1% ANC prevalence in all the sites during last 3 years
with more than 5% prevalence in any HRG site (STD/FSW/MSM/IDU)
• Category C:
– Less than 1% ANC prevalence in all sites during last 3 years with less
than 5% in all HRG sites, with known hot spots (Migrants, truckers, large
aggregation of factory workers, tourist etc.,)
• Category D:
– Less than 1% ANC prevalence in all sites during last 3 years with less
than 5% in all HRG sites with no known hot spots OR no or poor HIV
data

14. Haryana
• Category A – Bhiwani
• Category B – None
• Category C –
Ambala,Faridabad,Fatehabad,Gurgaon,Hisar,
Jhajjar, Jind, Kaithal, Karnal, Kurukshetra,
Mewat, Panchkula,Panipat, Rewari, Rohtak,
Sirsa, Sonipat, Yamunanagar
• Category D - Mahendergarh

15. AIDS Control Programme in India
• HIV infection first detected in India in 1986, when 10 HIV
positive samples were found from a group of 102 female sex
workers from Chennai.
• In 1986 Government set up an AIDS Task Force under ICMR
and established a National AIDS Committee (NAC) chaired
by Secretary, Department of Health and Family Welfare.
• In 1987, National AIDS Control Programme was initiated,
with help from the World Bank.
• In 1989, a Medium Term Plan for AIDS Control was
developed with the support of the WHO.

16. AIDS Control Programme in India
• First National AIDS Control Programme (NACP-
I) was launched in 1992.
• NACP-II launched in 1999: decentralization of
programme implementation to State level and
greater involvement of NGOs.
• NACP- III implemented during 2007-2012:
scaling up HIV prevention interventions for HRG
and general population, and integrate them with
Care, Support & Treatment services.
• NACP-IV has been developed for the period
2012-2017

17. NACP-I
OBJECTIVE
 Slow and prevent the spread of HIV through a major effort to prevent HIV
transmission.
KEY STRATEGIES
 Focus on raising awareness, Blood safety, Prevention among high-risk
populations,
 Improving surveillance
ACHIEVEMENTS
 National AIDS response structures at both the national and state levels and provided
critical financing.
 Strong partnership with the World Health Organisation(WHO) and later helped
mobilize additional donor resources.
 Established the State AIDS Control Cells
 Improved blood safety.
 Expanded sentinel surveillance and improved coverage and reliability of data.
 Improved condom promotion activities.
 National HIV testing policy.

18. NACP-II
OBJECTIVE
 Reduce the spread of HIV infection in India
through behavior change and increase capacity
to respond to HIV on a long-term basis.
KEY STRATEGIES
 Targeted Interventions for high-risk groups
 Preventive interventions for general
populations
 Involvement of NGOs
 Institutional strengthening

19. NACP-II
ACHIEVEMENT
 At the operational level 1,033 targeted interventions set up,
875 Voluntary counseling and testing centers (VCTC) and
679 STI clinics at the district level.
 Nation-wide and state level Behaviour Sentinel
Surveillance (BSS) surveys were conducted
 Prevention of parent-to-child transmission (PPTCT)
programme was expanded.
 A computerized management information system (CMIS)
created.
 HIV prevention and care and support organizations and
networks were strengthened.
 Support from partner agencies increased substantially

20. NACP-III
OBJECTIVE
 Reduce the rate of incidence by 60 per cent in the first year of the programme in
high prevalence states to obtain the reversal of the epidemic, and by 40 percent in
the vulnerable states to stabilise the epidemic.
STRATEGIES
 Prevention – Targeted intervention (TI), ICTC, blood safety, communication,
advocacy and mobilisation, condom promotion.
 Care, support and treatment – ART, Pediatric ART, Center for
excellence, Community Care Centers.
 Capacity building – establishment, support and capacity
strengthening, training, managing programme implementation and
contracts, mainstreaming/private sector partnerships.
 Strategic information management – monitoring and evaluation.

21. NACP-III
ACHIEVEMENTS
 There were 306 fully functional ART Centres against the target of 250 by
March 2012
 Nearly 12.5 lakh PLHIV were registered and 420000 patients were on
ART.
 612 Link ART centre (LAC) had been established wherein, 26023 PLHIV
were taking Services
 There were 10 Centres of Excellence,
 7 Regional Pediatric centres also functional.
 259 Community Care Centres across the Country
 6000 condoms & 6000 village information centres established
 3000 Red ribbon clubs established
 Link Workers training module updated

22. NACP-IV
• Launched on 12 February 2014
• Total budget outlay Rs 14295 crores.
• Goal: Accelerate Reversal and Integrate
Response

23. NACP-IV
• Objective 1:
• Reduce new infections by 50% (2007 Baseline
of NACP III)
• Objective 2:
• Provide comprehensive care and support to all
persons living with HIV/AIDS and treatment
services for all those who require it.

24. STRATEGIES UNDER NACP-IV

25. Key
Strategies
under
NACP-IV
Intensify
&consolidate
preventive
services
Increase access
&promote
comprehensive
care, support &
treatment
Expanding
IEC services
Capacity
building
Strengthening
Strategic
Information
Management
system

26. Strategy 1: Intensifying and
Consolidating Prevention Services
• Prevention will continue to be the core strategy of
NACP-IV as more than 99% of the people are
HIV negative
• It is planned to cover 90% of HRGs through
Targeted Interventions (TI) implemented by NGO
and CBOs
• High risk migrants, their spouses, truckers and
other vulnerable population will be accessed by
collaborating with other departments, voluntary
groups, civil society networks, women groups and
youth clubs.

27. Activities
• Saturating quality HIV prevention services to
all HRG groups, based on emerging behavior
patterns and evidence.
• Strengthening needle exchange Programme,
drug substitution programme and providing
Opioid Substitution Therapy (OST).
• Reaching out to MSM and Transgender
communities.

28. Activities
• Addressing the issue related to coverage and
management of rural interventions.
• Providing quality STI/RTI services.
• Strengthening management structure of blood
transfusion services.
• Expand the ICTC services and strengthen
referral linkages.

29. Strategy 2:
Comprehensive Care,Support and
Treatment
• Additional Centres of Excellence (CoEs) and
upgraded ART Plus Centres will be established
to provide high quality treatment
• Treatment of HIV/AIDS will include: (i) anti-
retroviral treatment (ART), including second
line (ii) management of opportunistic
infections including TB in PLHIV, (iii)
positive preventions and (iv) facilitating social
protection and insurance for PLHIV.

30. Activities
1. Scale up ART Centres, LACs, and COEs ART
services.
2. Strengthening follow up of patients on ART
and improving quality of counseling services
at ART service delivery points.
3. Comprehensive care and support services for
PLHIV through linkages.
4. Provide guidelines and training for integration
in health care settings to NRHM.

31. Strategy 3: Expanding IEC services for (a)
general population and (b) high risk groups with a focus on
behavior change and demand generation
1. Increasing awareness among general population
,in particular women and youth.
2. Behavior change communication strategies for
HRG and vulnerable groups.
3. Continued focus on demand generation of
services.
4. Reach out to vulnerable populations in rural
settings.
5. Extending services to tribal groups and hard-to-
reach populations.

32. Strategy 4:
Strengthening institutional capacities
• The programme management structures
established under NACP will be strengthened.
• Programme planning and management
responsibilities will be enhanced at national, state,
district and facility levels.
• Phased integration of the HIV services with the
routine public sector health delivery systems,
streamlining the supply chain mechanisms and
quality control mechanisms and building
capacities of governmental and non-governmental
institutions.

33. Strategy 5: Strategic
Information Management System
• This will ensure
– high quality of data generation systems such as
Surveillance, Programme Monitoring and
Research.
– strengthening systematic analysis, synthesis,
development and dissemination of Knowledge
products in various forms.
– emphasis on Knowledge Translation as an
important element of policy making and
programme management at all levels.

34. Key initiatives under SIMS
• National Integrated Biological & Behavioural
Surveillance(IBBS) among HRG & Bridge
Groups
• National Data Analysis Plan
• National Research Plan
• Advanced analytic and Geographic
Information System(GIS)

35. Guiding Principles of NACP-IV
1.Continued emphasis on three ones - one Agreed Action
Framework, one National HIV/AIDS Coordinating
Authority and one Agreed National M&E System.
2. Equity
3. Gender
4. Respect for the rights of the PLHIV
5. Civil society representation and participation.
6. Improved public private partnerships.
7. Evidence based and result oriented programme
implementation.

36. CROSS CUTTING AREAS OF
FOCUS
1. Quality
2. Innovation
3. Integration
4. Leveraging Partnerships
5. Stigma and Discrimination

37. KEY PRIORITIES UNDER NACP-IV
1. Preventing new infections by sustaining the
reach of current interventions and effectively
addressing emerging epidemics.
2. Prevention of Parent to Child transmission
3. Focusing on IEC strategies for behavior
change in HRG, awareness among general
population and demand generation for HIV
services.

38. KEY PRIORITIES UNDER NACP-IV
4. Providing comprehensive care, support and
treatment to eligible PLHIV
5. Reducing stigma and discrimination through
Greater involvement of PLHA (GIPA)
6. De-centralizing rollout of services including
technical support
7. Ensuring effective use of strategic information
at all levels of programme

39. KEY PRIORITIES UNDER NACP-IV
8. Building capacities of NGO and civil society
partners especially in states with emerging
epidemics
9. Integrating HIV services with health systems
in a phased manner
10. Mainstreaming of HIV/ AIDS activities with
all key central/state level Ministries/
departments will be given a high priority.

40. PACKAGE OF SERVICES

41. PREVENTION SERVICES
• Targeted Interventions for High Risk Groups
and Bridge Population.
• Needle-Syringe Exchange Programme (NSEP)
and Opioid Substitution Therapy (OST) for
IDUs
• Prevention Interventions for Migrant
population at source, transit and destination
• Link Worker Scheme (LWS) for HRGs and
vulnerable population in rural areas

42. PREVENTION SERVICES
• Prevention & Control of Sexually Transmitted
Infections/Reproductive Tract Infections
(STI/RTI)
• Blood Safety
• HIV Counseling & Testing Services
• Prevention of Parent to Child Transmission
• Condom promotion
• Information, Education & Communication (IEC)
& Behavior Change Communication (BCC).

43. Care, Support & Treatment
Services
• Laboratory services for CD4 Testing and other
investigations.
• Free First line & second line Anti-Retroviral
Treatment (ART) through ART centres and Link
ART Centres (LACs), Centres of Excellence
(COE) & ART Plus Centres
• Pediatric ART for children.
• Early Infant Diagnosis for HIV exposed infants
and children below 18 months.

44. Care, Support & Treatment
Services
• HIV-TB Coordination (Cross referral,
detection and treatment of co-infections)
• Treatment of Opportunistic Infections
• Drop-in Centres for PLHIV networks

45. New Initiatives under NACP-IV
• Differential strategies for districts based on
data triangulation with due weightage to
vulnerabilities.
• Scale up of programmes to target key
vulnerabilities
– Scale up of Opioid Substitution Therapy(OST) for
IDUs
– strengthening of Migrant Interventions at
Source,Transit & Destinations

46. New Initiatives under NACP-IV
• Scale up of Multi-Drug Regimen for
Prevention of Parent to Child
Transmission(PPTCT).
• Social protection for marginalized populations
through mainstreaming and earmarking
budgets for HIV among concerned government
departments.
• Establishment of Metro Blood Banks and
Plasma Fractionation Centre.

47. New Initiatives under NACP-IV
• Launch of Third Line ART and scale up of first
and second Line ART.
• Demand promotion strategies specially using
media, e.g., National Folk Media Campaign &
Red Ribbon Express and buses.

48. MONITORING FRAMEWORK

49. IMPACT INDICATORS
• Reduction of new HIV infections (HIV
Incidence): Estimated number of Annual New
HIV Infections (HIV incidence)
• Reduction in mortality among people living
with HIV/AIDS: Estimated number of annual
AIDS-related deaths
• Survival of AIDS patients on ART

50. OUTCOME INDICATORS
• Behavioural Change among Female Sex Workers:
Percentage of female sex workers who report
using a condom with their last client(Target: 80%
to 85% increase by 2017; 5% increase over the
baseline of IBBS 2012-13).
• Behavioural Change among Men who have Sex
with Men: Percentage of men who have sex with
men who report using a condom during sex with
their last male partner (Target: 45% to 65%
increase by 2017; 20% increase over the baseline
of IBBS 2012-13).

51. OUTCOME INDICATORS
• Behavioural Change among Injecting Drug
Users :Percentage of injecting drug users who
do not share injecting equipment during the
last injecting act (Target: 45% to 65% increase
2017; 20% increase over the baseline of IBBS
2012-13

52. PROGRAMME TARGETS
• By 2017, NACP- IV will cover 9 lakh FSWs, 4.40
lakh MSMs including TG/Hijras and 1.62 lakh
IDUs through Targeted Interventions.
• Over 16 lakh long distance truckers and 56 lakh
high-risk migrants will be separately targeted as
part of bridge population.
• 140 lakh pregnant women will be targeted, in
close collaboration with NRHM, to prevent
mother to- child transmission in the community

53. PROGRAMME TARGETS
• Supply of 90 lakh units of safe-blood and
enhanced use of blood products will be
ensured.
• It is estimated that there will be 10,05,000
people on ART (including 50,000 children who
require 1st line ART and nearly 50,000 PLHIV
who require 2nd line drugs) by 2017.

54. NACP-IV BUDGET

55. NACP-IV Challenges
• Need to consolidate successes gained, by
sustaining prevention focus besides effectively
addressing the challenges.
• Given the experience of previous phases where
the programme focused on saturating the
coverage, NACP- IV needs to advance towards
focusing on ensuring higher quality of services
under interventions while sustaining the
coverage.

56. NACP-IV Challenges
• Emerging Epidemics in certain low prevalence
states and districts due to Migration to high
prevalence areas.
• Major challenge for the programme will be to
ensure that the treatment requirements are fully
met without sacrificing the needs of prevention
• Regions with different maturity levels of the
epidemic will require different resources and
services

57. NACP-IV Challenges
• International finances for HIV/AIDS
programme are shrinking.
• Stigma and Discrimination that is still
prevailing against the vulnerable population,
persons and families infected and affected with
HIV.

58. REFERENCES
• NACP – IV strategy document – National
AIDS Control Organisation
• Annual report of NACO,2013-14
• National AIDS Control Program –Health
Programs in India – Dr. D.K Taneja
• National AIDS Control program- National
Health Programs of India – Dr.J.Kishore