NATIONAL AIDS CONTROL PROGRAMME PHASE-IV

CURRENT STATUS AND CRITICAL APPRAISAL

 Tracking the journey in
India
 1986 – 1 case of HIV detected
st

National AIDS Committee established

 1990 – medium term plan launched
 1992 – NACP I launched
 1999 – NACP II launched
 2002 – National AIDS prevention & control policy adopted
National blood policy adopted
 2004 – Anti-retroviral treatment initiated
 2006 – National Council on AIDS constituted
national policy on paediatric ART formulated
 2007 – NACP III launched
 2014 –NACP IV launched
 Epidemiolog
ytotal number of people living
The
with HIV (PLHIV) in India is
estimated at 21.17 lakhs (17.11
lakhs–26.49 lakhs) in 2015
Children (less than 15 years)
account for 6.54%, while two fifth
(40.5%) of total HIV infections
are among females
National adult (15–49 years) HIV
prevalence is estimated at
0.26% (0.22%–0.32%) in 2015

Source: NACO annual report 2015-16

 Annual New HIV
Infections
 India is estimated to have around 86
thousand new HIV infections in
2015,showing 66% decline in new
infections from 2000 and 32%
decline from 2007, the year is set as
baseline in the NACP-IV

 Children (<15 years) accounted for

12% (10.4 thousand) of total new
infections while the remaining (75.9
thousand) new infections were
among adults (15+years).
 AIDS-Related
Deaths
Since 2007 the annual number of
AIDS related deaths has
declined by 54%.

In 2015 an estimated 67.6 [46.4–

106.0] thousand people died of
AIDS-related cause nationally.

Source: NACO annual report 2015-16

 India continues to portray a
concentrated epidemic

 HIV prevalence among FSW is 2.2%

 Among TRANSGENDERS 7.5%

 Among IDU 9.9%

KEY
TERMS
Bridge population
High risk groups
 Migrants
 Female sex workers
 Truckers
 MSM
 Clients to sex
 Transgender
 workers
Injecting drug users

Vulnerable population
 Women having
sex with casual
partners
 Spouses of high risk
groups
 Classification of
states
GROUP I:HIGH PREVALENCE STATES
Prevalence more than 5% in HRG and 1% or
more in ANC.
Maharashtra, Tamilnadu, Karnataka, Andhra
Pradesh, Manipur and Nagaland
 GROUP II:MODERATE PREVALENCE
Prevalence 5% or more among HRG but
below 1% in ANC
Gujarat, Goa, Puducherry
 GROUP III:LOW PREVALENCE STATES
Prevalence less than 5% in any HRG and less
than 1% in ANC
 Classification of districts
 CATEGORY A:
 More than 1% ANC/PPTCT prevalence in district in any of the sites in the last 3 years.
 156 distracts
 CATEGORY B:
 Less than 1% ANC/PPTCT prevalence in all the sites during last 3 years with more than 5%
prevalence in any HRG site (STD/FSW/MSM/IDU)
 39districts
 CATEGORY C:
 Less than 1% ANC/PPTCT 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.,)
 296 districts
 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
 118 districts
Routes of
transmission
 NACP I(1992 to
1999)
• OBJECTIVES: To slow down and prevent the spread of HIV transmission through a major effect to
prevent HIV transmission
• KEY STRATEGIES:
 Focus on raising awareness, Blood safety, Prevention among high risk populations,
Improving surveillance
• ACHIEVEMENTS:
 National aids response structure at national and state level and provided critical
financing
 Strong partnership with WHO and later helped mobilize additional donor resources
 Established the state AIDS control cell
 Improved blood safety
 Expanded sentinel surveillance and improved coverage and reliability of data
 Improved condom promotion activities
 National HIV testing policy
 NACP II(1999 –
OBJECTIVE
2007)
 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
 NACP
ACHIEVEMENT II
 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 Behavior Sentinel Surveillance (BSS) surveys were
conducted
 Prevention of parent-to-child transmission (PPTCT) programme was
expanded.
 A computerized management information system (CMIS) created.
 Anti Retroviral Therapy was started in eight centers in six high prevalence
districts
NACP-III(2007 –
2014)
OBJECTIVE
 Reduce the rate of incidence by 60 per cent in the first year of the program in
high prevalence states to obtain the reversal of the epidemic, and by 40 percent in
the vulnerable states to stabilize the epidemic.
STRATEGIES
 Prevention – Targeted intervention (TI), ICTC, blood safety, communication,
advocacy and mobilization, condom promotion.
 Care, support and treatment – ART, Pediatric ART, Center for

excellence, Community Care Centers.

 Capacity building – establishment, support and capacity strengthening,

training, managing program implementation and contracts,

mainstreaming/private sector partnerships.
 Strategic information management – monitoring and evaluation
NACP-
ACHIEVEMENTS
III
 There were 306 fully functional ART Centers against the target of 250 by March 2012
 Nearly 12.5 lakh PLHIV were registered and 4,20,000 patients were on ART.
 612 Link ART center (LAC) had been established wherein, 26,023 PLHIV were
taking Services
 There were 10 Centers of Excellence(CoE)
 7 Regional Pediatric centers.
 259 Community Care Centers across the Country
 6000 condoms distribution & 6000 village information centers established
 3000 Red ribbon clubs established
 Link Workers training module updated
 NACP
 From 2014 to 2019 IV
GOAL

Halt and reverse the epidemic by integrating programmes for prevention, care,
support and treatment

OBJECTIVES

 Reduce the infection by 50%(2007 baseline of NACP III)

Provide comprehensive care and support to all persons living with HIV/AIDS and
treatment services for all those who require it
 Intensify and
consolidate
prevention
services Promoting
comprehensiv
Strengthenin e care,support
g SIMS treatment
Key
strategie
s under
NACP IV

Capacity Expanding
IEC services
building
A. INTENSIFYING AND CONSOLIDATING PREVENTION SERVICES,
WITH A FOCUS ON HIGH RISK GROUPS AND VULNERABLE
POPULATION

 Saturating quality HIV prevention services to all HRG groups

Strengthening needle syringe exchange Programme, drug substitution programme

and providing Opioid Substitution Therapy

 Reaching out to MSM and Transgender communities

 Providing quality STI/RTI services

 Expand the ICTC services and strengthen referral linkages

 Strengthening management structure of blood transfusion services

B. INCREASING ACCESS AND PROMOTING COMPREHENSIVE CARE,
SUPPORT AND TREATMENT

Activities

 Scale up ART centres, Linked ART centres, Centres of Excellence ART services

Strengthening follow up of patients on ART and improving quality of counselling

services at ART delivery points

 Comprehensive care and support services for PLHIV through proper linkages

Provide guidelines and training for integration in health care settings to NRHM
staffs
C. EXPANDING IEC SERVICES FOR (A) GENERAL POPULATION AND (B) HIGH RISK
GROUPS WITH A FOCUS ON BEHAVIOUR CHANGE AND DEMAND GENERATION

 Increasing awareness among general population in particular women and youth

 Behaviour change communication strategies for HRG and vulnerable groups

 Continued focus on demand generation of services

 Reach out to vulnerable population in rural settings

 Extending services to tribal groups and hard-to-reach populations

D. BUILDING CAPACITIES AT NATIONAL, STATE, DISTRICT AND
FACILITY LEVELS

 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 to ensure high quality, timely and effective implementation and supervision of
field level activities to achieve desired outcomes

 The planning processes and systems will be further strengthened to ensure that the annual
action plans are based on evidence, local priorities and in alignment with NACP IV objectives.

 Phased integration of the HIV services with the routine public sector health delivery systems,
streamlining the supply chain mechanisms and quality control mechanisms.
E. STRENGTHENING STRATEGIC INFORMATION MANAGEMENT
SYSTEMS
National Integrated Biological & Behavioural Surveillance(IBBS) among HRG & Bridge
Groups.

 National data analysis plan

 National research plan

 Transforming SIMS into an integrated decision support system with advanced analytic
and Geographic Information System capabilities

 Institutionalising data quality monitoring system for routine programme data

collection

 Institutionalising data use for decision making

GUIDING PRINCIPLES
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 rights of the PLHIV

 Civil society representation and participation

 Improved public private partnerships

 Evidence based and result oriented programme implementation.

KEY PRIORITIES

 Preventing new infections by sustaining the reach of current interventions and

effectively addressing emerging epidemics

 Prevention of parent to child transmission

Focussing on IEC strategies for behaviour change in HRG groups, awareness

among general population and demand generations for HIV services

 Providing comprehensive care ,support and treatment to eligible PLHIV

 Reducing stigma and discrimination

Key priorities cont…..

 Ensuring effective utilization of strategic information at all level of programmes

Building capacity of NGO and civil society partners especially in states with
emerging epidemics

 Integrating HIV services with health system in a phased manner

Mainstreaming of HIV/ AIDS activities with all key central/state level

Ministries/departments will be given a high priority.
New
initiatives
 Differential strategies for districts based on data triangulation with due weightage on
vulnerabilities

 Scale up of programme to target key vulnerabilities

i. Scale up of opioid substitution therapy for IDUs

ii. Scale up and strengthening of migrant interventions at source, transit and destination
including roll out of migrant tracking system

iii. Establishment and scale up of interventions for transgenders by bringing in community

participation and focussed strategies

iv. Employer-led model for addressing vulnerabilities among migrant labourers

v. Female condom programme

New
initiatives
 Scale up of multi drug regimen for prevention of parent to child transmission in
keeping with international protocol

 Community based testing

 Test and treat policy

 Establishment of Metro Blood Banks and Plasma Fractionation Centre

 Launch of third line ART and scale up of first and second line ART

Promotion strategies specially using mid-media, e.g., National Folk Media

Campaign & Red Ribbon Express and buses
 Monitoring
Framework
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: Percentage of adults and children with HIV known to
be
on treatment at 24 months after initiation of antiretroviral therapy at select ART Centres
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).

 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 by 2017; 20% increase over the baseline of IBBS
2012-13)
Programme Targets
 By 2017,NACP will cover 9 lakh FSWs,4.40 lakh MSMs including transgender, hijras and
1.62 lakh Injectable drug users through targeted interventions.

Over 16 lakh truckers and 56 lakh high risk migrant workers will be targeted separately
as bridge population

140 lakh women will be targeted in collaboration with NRHM to prevent mother to
child transmission

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
Service
packages
 Targeted
Intervention
Needle syringe
IEC & BCC exchange and
OST

Link
PPTCT PREVENTION
SERVICES
Worker
Scheme

HIV
counselling Treatment
of
& testing Blood STI/RTIs
safety
Targeted intervention(TI)

Objective:

 To reduce risk of acquiring STI and HIV/AIDS

 To improve health seeking behaviour of HRG, bridge population

 Also focuses on improving sexual and reproductive health and general health of HRG
and bridge population
Services provided by
TIs
BCC
COMMUNITY
ORGANIZATIO CONDOM
N & PROMOTION
OWNERSHIP
BUILDING

HRG
DIAGNOSIS
ENABLING AND
ENVIRONMENT TREATMENT OF
STI

LINKING WITH
OTHER
SERVICES
Coverage of Core HRGs (FSW, MSM,IDU) during 2015-16 (Up to Sept
2015)

Source: NACO annual report 2015-16

Specific interventions for MSM/TGs
 Provision of lubricants
 Provision of project based STI clinics

Specific intervention for IDUs

 Distribution of clean needle and syringes
 Abscess prevention and management
 Opioid substitution therapy
 Linkage with rehabilitation services
 Condom
promotion
Strategies will be strengthened through
 free distribution of condoms

 Social marketing channels

 Non-traditional outlets

 Female condoms

The figure shows the typology-wise number of

condoms (free and social marketing) distributed to
the HRGs during 2015-16 (Up to Sept 2015)

Source: NACO annual report 2015-16

Link worker
scheme
Community based outreach strategy to address HIV prevention and care needs of
HRG and vulnerable population in rural areas

Objectives
 Providing information and knowledge on prevention and risk reduction of HIV &
STI

 Condom promotion and distribution

 Providing follow up and referral linkages to various services

Management of
STI/RTI
 There are 1160 Designated STI/RTI Clinics in the country

 NACO has branded the STI/RTI services as SURAKSHA CLINIC

 The Package of services for HRG includes

(a) Symptomatic Treatment using standardized STI colour coded treatment kits

(b) Presumptive treatment

(c) Regular Medical Check-up

(d) Bi-annual Syphilis screening

Pre Packed STI/RTI Colour Coded
Kits
Counselling and HIV testing
services
Components:
I. Integrated counselling and testing centres
II. Prevention of parent to child transmission
III. HIV-TB collaborative activity
 Integrated counselling and testing
An centres
ICTC is a facility where a person is
counselled and tested for HIV on his
own free will or as advised by medical
providers
 Fixed facility ICTC: located within existing
hospital/health centre/health care
facility.
 Stand alone ICTC
 Facility integrated ICTC

Mobile ICTC: a van with room to conduct

counselling, examination and collection
and processing of blood samples by a
group of paramedical staff. useful in hard
to reach areas with flexible working hours
 Integrated Counselling And Testing
Centres
 Functions
 Early detection of HIV
Provision of basic information about the mode of transmission and
prevention of HIV/AIDS
 Link people with other HIV prevention, treatment care facilities
 Expansion of counselling & testing
services
 There is an 88% increase in number of
HIV testing centres from 2011-12
(10,515 centres) to 2015-16 (19,800
centres).
 There is a 58% increase in HIV testing
from 2012-13 (104 lakh tests
conducted) to 2015-16 (164 lakh tests)
 During 2015-16, 99% of the ICTC
attendees were tested for HIV and 98%
have received the test reports after
post-test counselling.
Prevention of parent to child
transmission(PPTCT)
 Started in 2002

 Aim is to offer HIV testing to every pregnant women

 Started with single dose Nevirapine to HIV positive mother in labour and for the new born
immediately after birth

 From 2013, life long ART using triple drug regimen

for all pregnant and breast feeding women living

with HIV irrespective of CD4 count was started

Packages of
PPTCT
Routine offer of HIV testing and counselling to all pregnant women enrolled into
antenatal care, with opt out option

 Provision of life long ART to all pregnant and breast feeding HIV positive women
regardless of CD4 count and clinical stages of HIV

 Promotion of institutional delivery of all HIV infected women

 Provision of care for associated conditions(STI/RTI, TB, opportunistic infections)

 Provision of nutrition , counselling and psychosocial support

Packages of PPTCT
cont…..
 Provision of counselling and support for initiation of exclusive breast feeding
within an hour of delivery and continue for 6 months

 Provision of ARV prophylaxis to infants from birth up to 6 months

Integrating follow up of HIV infected children into routine health care services
and immunization

Ensuring co-trimoxazole prophylaxis therapy and Early Infant Diagnosis (EID)

using HIV DNA PCR at 6 weeks

 Strengthening community follow up and out reach through local community

network to support HIV infected mother and family
 Prevention of Parent to Child Transmission
The (PPTCT)
program has reached 42% of the total estimated pregnant women in the country, in the year 2015-
16 (n=280 lakhs), with 31% of tests performed at F-ICTCs.
29% of the estimated HIV positive pregnant women were identified in 2015-16 (n=35,255) and among
those 94.7% of them were put on ART
In the year 2014-15, of the 11,186 infants born to HIV positive mothers, 83% of the children were
initiated on ARV, and 80% (n=8,981) of them were tested for EID within 6 months
HIV positivity was 3.8%.
 HIV/TB collaborative
 TBactivity
is the commonest opportunistic infection in PLHIV

 Nationally about 3% people registered under RNTCP is HIV positive

Case fatality among HIV infected TB patients are 13-14%,as compared to HIV negative TB
cases, where it is less than 4%

NACP & RNTCP has jointly decided to offer HIV testing during evaluation on TB patients,
when they present with TB symptoms

 The national HIV/TB responses include 3I’s

i. Intensified TB case finding at HIV care setting

ii. Isoniazid preventive therapy
iii. Infection control at HIV care setting
i. Intensified TB Case Finding
 All ICTC clients are screened by ICTC counsellor for presence of TB symptoms at every
encounter
 Clients who have symptoms and signs irrespective of their HIV status are referred to the
RNTCP centre of the institution
 Cartridge Based Nucleic Acid Amplification Test (CBNAAT) is used for early diagnosis in PLHIV
in ART centres

ii. Isoniazid preventive therapy

Globally recommended strategy for prevention of TB among HIV infected individuals

iii. Infection control

To prevent the transmission of HIV at health care settings , air borne infection control measures
are implemented
The trend of known HIV status is increasing, in 2014-15, out of the total 15,17,728 registered
cases, 10,83,527 of TB patients i.e. 71% knew their HIV status. During 2015-16 (till June 2015) it
has increased up to 77% (i.e. out of 3,92,242 registered TB cases 3,02,026 TB patients know their
HIV status
Care, support and treatment initiatives:

 Laboratory services for CD4 testing and other services

 Free 1st line and 2nd line ART

 Paediatric ART for children

 Early infant diagnosis for HIV exposed infants and children below 18 months

 Treatment of opportunistic infections

 Drop-in centres for PLHIV networks

 Care support and
treatment
Services are provided by ART centres.

These are linked to Centre Of Excellence (CoE)

and ART plus centres

Some of the services are decentralized

through
Link ART centre

The ART centres are also linked with ICTC,PPTCT

clinics, STI clinics and other departments and
also with RNTCP to provide comprehensive
management
The facilities providing HIV treatment services are mentioned in the table
below.
1.FREE UNIVERSAL ACCESS TO ART

First line ART:

 Provided free of cost to all PLHIV through ART centres.

 Follow up is done by assessing drug adherence, regularity of visits, periodic examinations and CD4
count 6 monthly

 Treatment of opportunistic infections are also provided

Second line art

 Over the years some percentage of PLHIV on first line ART develop resistance to these drugs due to
mutations in virus

 Till August 2015, 12,823 PLHIV are receiving second line drugs at CoEs and ART Plus Centres.
Scaling up of service provisioning under CST component since march 2015.
National Paediatric HIV/AIDS Initiative
The national paediatric HIV/AIDS initiative was launched on 30th November 2016.

Till September 2015, nearly 77,729 Children Living with HIV/AIDS (CLHIV) are active
in HIV care at ART centres and of whom, 49,909 are receiving free ART.

Paediatric Second line ART

While the first line therapy is efficacious, certain proportion of children do show
evidence of failure.

Currently, provision of second line ART for children has been made available at
all
CoEs and ART plus Centers.
ART Scale up for Children Living with HIV/AIDS in India, 2005 – 2015
Revised guidelines on initiation of Anti Retroviral treatment
As per the revised guideline it has been decided to treat all PLHIV with ART
regardless of CD4 count, clinical stage, age or population.

Patients who are in pre ART care should undergo a fresh CD4 count if it is more
than 3 months old, and baseline investigations before ART initiation.

Adequate counselling and preparedness is required before ART initiation,

particularly in those with high CD4 count, as they are more likely to be
asymptomatic hence more likely to default.
Outcome of PLHIV ever initiated on ART till September 2015
2. CD4 TESTING SERVICES
The programme provides facility for baseline and follow up CD4 cell count testing
free of cost to all PLHIV attending ART Centres.
There are 278 CD4 machines installed at present serving 528 ART centres.

3. EARLY INFANT DIAGNOSIS (EID):

In order to promote confirmatory diagnosis for HIV exposed children, a programme
on EID was launched by NACO. All children with HIV infection confirmed through
EID are linked to ART services.

4. COUNSELLING SERVICES:
Counselling services are provided by both ART Centres and Care and Support
Centres.
5. MANAGEMENT OF OPPORTUNISTIC INFECTIONS:
ART centres provide clinical care to both Pre-ART and On-ART clients. The clinical
care includes diagnosis, management as well as primary and secondary
prophylaxis of opportunistic infections.

6 .CARE AND SUPPORT SERVICES PROVIDED THROUGH CARE AND SUPPORT

CENTRES (CSC):
CSCs serve as a comprehensive unit for treatment support for retention,
adherence, positive living, referral, linkages to need based services and
strengthening enabling environment for PLHIV.
CSCs are run by civil society partners including District Level Networks
(DLN) and
non-government organizations (NGOs).
Blood Transfusion
Services
The key strategies envisaged in NACP IV include
1. Strengthening management structure of Blood Transfusion Services

2. Increasing regular voluntary non-remunerated blood donation

3. Promotion of component preparation, rational use of blood

4. Establishing quality management system including the roll out of EQAS

5. Streamlining implementation and referral linkages.

 Current
•scenario
A network of 1,161 blood banks is currently being supported by NACO;

• However, around 45 districts still do not have blood banks.

• There has been a substantial improvement in Voluntary blood donation at the

national level from 54.4% to 78%.

• Number of Blood Component Separation Units (BCSU) increased from 175

(2012) to 304 (2015).
IEC and
youth
Objectives:

To raise awareness, improve knowledge and understanding among the general
population about HIV and AIDS

To promote desirable practices such as avoiding multiple partner sex, use of
condom, sterilization of needles and syringes and voluntary blood donation

To mobilize all sector and society to integrate massages and programs on AIDS
into their activity

To create a supportive environment for the care and rehabilitation of persons
with HIV and AIDS
Launch of National AIDS Helpline (1097) in eight
languages
While a helpline in some form existed earlier,
this was strengthened and revamped with the
launch of the National AIDS Help line (1097) on
1st December 2014.

Red Ribbon Express

 The Red Ribbon Express was launched in India
on World AIDS Day, December 1, 2007
Main purpose is to increase awareness and
providing services to the remote areas
It has 5 coaches for- staff and dancers,
Auditorium, Testing and counselling, Exhibition,
Care and support
90-90-90 Treatment Targets: By 2020
• 90% of all people living with HIV will know their HIV status;

•90% of all people with diagnosed HIV infection will receive sustained
antiretroviral therapy;
•90% of all people receiving antiretroviral therapy will have durable viral
suppression
 There is a gap of 33% in the progress towards the first 90 of the treatment targets. Out of
the estimated 21.2 lakh PLHIV, around 14.2 lakhs are aware of their status

India will be able to reach the fast track target of 90% of PLHIV being aware of their HIV
status by 2020

India reached 66% level in terms of ensuring those who are aware of their status
currently receiving ART. Out of the estimated 14.2 lakh PLHIV who are aware of their
status, 9.4 lakh (66%) PLHIV are currently alive on ART.

 With implementation of ‘Test and Treat’ policy, this gap will be largely filled

 India currently does not have reliable data on the number of PLHIV on ART who are
virally suppressed.
REFERENCE
S
1. DK Taneja’s Health Policies And Programmes In India
2. J.Kishore’s National Health Programs Of India
3. Park’s Textbook Of Preventive And Social Medicines
4. NACO annual report 2015-16
5. NACP-IV strategy document
6. Official website of NACO: http://naco.gov.in/