National AIDS control program- NACP

1. Presenter: Kartikey, Parnava, Migom
Moderator: Dr. Madhu Upadhyay

2. History
• 1981, cases of Pneumocystis carinii pneumonia (PCP) in 5 gay men in Los Angeles
• New York and California reported with Kaposi’s Sarcoma
• 1981, December- PCP were reported in people who inject drugs.
• 270 reported cases of severe immune deficiency among gay men - 121 of them had died
• 1982- initially called gay-related immune deficiency (GRID)
• In Uganda, doctors reported cases of a new, fatal wasting disease locally known as ‘slim’

5. Suniti Solomon
Diagnosed the first indian cases in Chennai in
1985.
In 2009, she was awarded , “National Women
Bio-scientist Award” by the Indian ministry of
Science and Technology.
On 25th January 2017, Govt. of India announced
“Padma shri” award for her contribution
towards Medicine
“what is killing people with AIDS more is the
stigma and discrimination”

6. INDIAN SCENARIO

7. Estimated Adult HIV Prevalence (%) in India

8. Estimated New HIV infections in India

9. State Wise Estimated New HIV Infections among Adults, 2015

10. Annual AIDS-Related Deaths and ART Scale-up, India

11. Routes of HIV Transmission among individuals in 2015-16, SIMS Data 2015-16

12. 1986
• AIDS taskforce
• National AIDS committee
1987
• National AIDS Control Programme
1992
• NACP I launched
• NACO setup
1999
• NACP II begins
• SACS established
2004 • ART initiated
2007
• NACP III launched
2012
• NACP IV launched
MILESTONES

13. • 1992, IDA Credit of USD 84 million, commitment to combat the disease
• Objective - slowing down the spread of HIV infections so as to reduce morbidity,
mortality and impact of AIDS in the country
• NACB was constituted and an autonomous NACO was set up to implement the project
• Focus:
• awareness generation
• setting up surveillance system
• access to safe blood and preventive services for high risk group populations
NACP-I

14. NACP II
• 1999 November, World Bank credit support of USD 191 million
• Objective:
• To reduce the spread of HIV infection in India
• To increase India’s capacity to respond to HIV/AIDS on a long-term basis
• Key policy initiatives:
• National AIDS Prevention and Control Policy (2002);
• Scale up of Targeted Interventions for High risk groups in high prevalence states
• National Blood Policy
• Greater Involvement of People with HIV/AIDS (GIPA)
• National Adolescent Education Programme (NAEP)
• Introduction of counselling, testing and PPTCT
• National Anti-Retroviral Treatment (ART) programme
• Inter-ministerial group for mainstreaming
• National Council on AIDS
• Setting up of State AIDS Control Societies in all states

15. NACP-III
• 2007, July
• Goal - Halting and Reversing the Epidemic by the end of project period
• Key pillars:
• Prevention among HRG and general population
• Care, support and treatment
• Key activities:
• The capacities of SACS and DAPCUs have been strengthened
• Technical Support Units (TSUs) established
• Dedicated North-East regional Office established
• State Training Resource Centres (STRC) set up
• Strategic Information Management System (SIMS) established

16. • OBJECTIVES:
– Objective 1: Reduce new infections by 50% (2007 Baseline of NACP III)
– Objective 2: Comprehensive care, support and treatment to all persons living with
HIV/AIDS
NACP-IV

17. Key strategies
Strategy 1: Intensifying and consolidating prevention services
Strategy 2: Comprehensive care, support and treatment
Strategy 3: Expanding IEC services
Strategy 4: Strengthening institutional capacity
Strategy 5: Strategic Information Management System

18. Guiding principles
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.

19. Areas of focus
1. Quality
2. Innovation
3. Integration
4. Leveraging Partnerships
5. Stigma and Discrimination

20. Key priorities
• Preventing new infections
• PPTCT
• Focus on IEC
• CST
• GIPA
• Decentralising rollout of services including technical support
• Effective use of strategic information
• Building capacities
• Integrating HIV services
• Mainstreaming of HIV/AIDS activities

21. PRIORITISATION OF DISTRICTS FOR PROGRAMME
IMPLEMENTATION
• 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

22. Classification of states
• High prevalence:
• >5% in HRG & >1% in ANC
• Moderate prevalence
• >5% in HRG & <1% in ANC
• Low prevalence
• <5% in HRG & <1% in ANC

23. Implementation structure
•The NACP is implemented through 35 States AIDS Control Societies(SACS) in
the states and UTs
•3 additional municipal AIDS control societies in Mumbai, Chennai,
Ahmedabad
•District AIDS Prevention and Control Units(DAPCUs) with a team of field
funtionaries in A and B category districts for decentralised programme
implementation

24. Organogram

25. State AIDS control society (SACS)
• Autonomous & decentralized
• A governing body headed by the minister in charge of health/ the chief secretary
• Representatives from key government departments, the civil society, trade and industry, private
health sector and PLHA networks, who meet twice a year
• It approves new policy initiatives, annual plan and budget, appoints statutory auditors and accepts
the annual audit report
• For better financial and operational efficiency, administrative and financial powers are vested in the
executive committee and the programme director
Functions:
• Medical and public health services;
• Communication and social sector services; and
• Administration, planning, coordination, monitoring and evaluation, finance and procurement.

26. District AIDS Prevention and Control Units
• 188 District AIDS Prevention and Control Units (DAPCUs) in A and B category districts
spread across 22 states
Key Activities:
• Capacity Building of DAPCU
• DAPCU led single window approach for PLHIV/HRG linkage with Social incentive/benefit
schemes

27. • Prevention services
• Targeted Interventions
• NSEP, OST for IDUs
• Migrant population
• Link Worker Scheme
• Prevention & Control of STI/RTI
• Blood Transfusion Services
• HIV Counselling & Testing
• PPTCT
• Condom promotion
• IEC and BCC
• Social Mobilization, YIs and AEP
• Mainstreaming HIV/AIDS
• Work Place Interventions
Care, Support & Treatment
• Lab services- CD4 Testing, Viral load testing,
EID, diagnosis of HIV-2
• Free first line & second line ART - ART Centres,
link ART Centres, Centres of Excellence & ART
plus centres
• Pediatric ART
• Nutritional and psycho-social support:-
community and support centres
• HIV-TB coordination
• Treatment of Opportunistic Infections

28. TARGETED INTERVENTIONS (TI)
Core High Risk Groups( FSW, MSM, Transgenders, IDU)
Bridge Populations ( Migrants and long distance Truckers)
• Linkages with care and support services
• Community mobilization and ownership
building
• Distribution of clean needles and syringes
• Abscess prevention and management
• Opioid substitution therapy
• Linkages with detoxification/ rehabilitation
services.
Package of services:-
• Prevention, support and linkage
services
• Screening& treatment of STI
• Free condom and lubricant
distribution
• Social Marketing of condoms
• BCC, enabling environment
• Linkages to ICTC for HIV testing

30. TI

32. New Initiatives under Targeted Interventions
1.“Sustaining the HIV Prevention Impact among Key Populations”
2. Workshop with Law Enforcement Agencies
3. Project Sunrise
4. Project NIRANTAR
5. Migrant Interventions

33. LINK WORKER SCHEME (LWS)
• To intensify and consolidate prevention services in the
rural areas in 163 districts across 18 States
• Village level workforce - Zonal Supervisors, Cluster Link
Workers
• 20 Cluster Link Workers in each district for clusters of
villages (5 villages each)
• Supervised by 2 zonal supervisors in each district

34. SEXUALLY TRANSMITTED INFECTIONS (STI) AND REPRODUCTIVE TRACT
INFECTION (RTI) CONTROL & PREVENTION PROGRAMME
• Pre-packed STI/RTI colour-coded kits

36. CONDOM PROMOTION PROGRAMME
• Targeted Condom Social Marketing programme
• Condom Demand Generation
• Optimization of Free Supply of Condoms
Ganpati mandals join hands

37. BLOOD TRANSFUSION SERVICES
• Current Scenario - 2760 licensed blood banks
• National Blood Transfusion Council (NBTC)
• Promotion of Voluntary Blood Donation
• New initiatives under BTS
• Model Blood Banks
• Blood Component Separation Units
• Major Blood Banks and District Level Blood Banks
• Blood Transportation Vans
• Monitoring and supervision of Blood
• Transfusion Services
• Metro Blood Banks
• Plasma Fractionation Centre

38. HIV counselling and testing services
I. Integrated Counselling and Testing Centre
II. Prevention of Parent-to-Child Transmission of HIV
III. HIV/Tuberculosis collaborative activities

39. 1. All HCTS facilities have been divided into two groups:
· Screening Facility (F-ICTC, PPP-ICTC, TI-ICTC, OPD, IPD, Emergency wards etc.), and
· Confirmatory Facility (SA-ICTC)
2. Community-based HIV screening approaches
3. Public Private Partnership models
4. Standardize pre-test and post-test counselling
5. All individuals accessing ICTCs will now be verbally screened for TB, STI/RTI and other co-infections by the
counsellor.
6. Standard operating procedures for all counsellors
7. New sections on (a) HIV-TB collaborative activities, (b) linkages, (c) supply chain management,
(d) IEC activities, (e) information management system and (f) testing for syphilis at the HCTS testing
facility, have also been added.
Key changes

40. ICTC
• Fixed facility ICTCs
• Stand alone ICTCs (SA-ICTC)
• Facility ICTCs (F-ICTC)
• Mobile ICTC

41. Unique PID code
Digits Meaning
First 2 digits Type of individual (PW/GI)
Second 6 digits Reporting unit
Third 2 digits State code
Fourth 3 digits District code
Fifth 3 digits ICTC Centre number
Sixth 2 digits Year
Last 5 digits Individual serial number
E.g. PW SAICTC DL SED 001 17 12345

42. PPTCT

43. • TWO OPTIONS:
1. Providing lifelong ART to all the pregnant and breastfeeding women
living with HIV regardless of CD4 count or clinical stage
OR
2. Providing ART (ARV drugs) for pregnant and breastfeeding women with
HIV during the mother-to-child transmission risk period and then
continuing life long ART for those eligible for treatment for their own
health

44. GOALS
1. Primary prevention of HIV, especially among women in child-bearing age.
2. Integration of PPTCT interventions with general health services such as basic Ante-natal
Care (ANC), Natal and Post –Natal Services, Sexual Reproductive Health and Family
Planning, EID, Paediatric ART and Adolescent Reproductive and Sexual Health (ARSH), TB
and STI/RTI services.
3. Strengthening post-natal care of the HIV-infected mother and her exposed infant
4. Provide the essential package of PPTCT services

45. Essential package of PPTCT services
• Routine offer to all pregnant women, ‘opt out’ option
• ‘ANC Centric’ to ‘Family Centric’ approach
• Life long ART (TDF+3TC+EFV)
• Promotion of institutional delivery
• Provision of nutrition, counselling and psychosocial support
• Provision of care for associated conditions
• Provision of ARV prophylaxis with syrup Nevirapine to infants
• Early infant diagnosis using HIV-DNA PCR at 6 weeks of age, repeat testing at 6 months, 12
months, and 6 months after cessation of BF
• Integrate follow up of HIV exposed infants into routine healthcare services
• All babies detected positive <2 years of age to be given Pediatric ARV irrespective of CD4 count
• Exclusive BF, MIXED FEEDING SHOULD NOT BE DONE

47. HIV TB co-infection
• Out of 2.1 million PLHIV in India, 95000 co-infected with TB
• 15-18% of all deaths among HIV infected individuals
• Active TB is the commonest opportunistic infection
• All HIV TB co-infected patients regardless of the CD4 count should be ART
• First priority is to start TB treatment
• National framework for joint HIV/TB collaborative activities-November 2013

48. Management of special TB/HIV cases
• TB/HIV patients on Protease inhibitor
based ARV
• TB/HIV in children
• TB/HIV in pregnant women
• Drug resistant TB/HIV
Prevention
• Isoniazid preventive therapy
• Air borne infection control
• Awareness generation
Early detection of TB/HIV
• 100% coverage of provider initiated
testing and counselling
• PITC in presumptive TB cases
• Rapid diagnostics for detection of TB
and DR-TB in PLHIV
• Intensified case finding activities at all
HIV settings
Prompt treatment of TB/HIV
• Early initiation of ART
• Prompt initiation of TB treatment

49. HIV TESTING GUIDELINES
Diagnosis
<18 months
DNA PCR
>18 months
and adult
Detection of
antibody
Rapid test
ELISA
Western Blot
Detection of
virus
p24 antigen
DNA PCR

50. Strategy 1
For transfusion and
transplant safety
A1
A1 +
Consider Positive
A1 –
Consider Negative
Strategy 2 A
For Sentinel Surveillance
2 tests required
A1 +
Second test done A2
A1+ A2+ Report Positive
A1+A2- Report Negative
A1 –
Negative

51. Strategy 2B for
Diagnosis in
symptomatic
patients
A1 + A2
A1+ A2 + Report
positive with post
test counselling
A1+ A2 – DO test A3
A1+ A2- A3+
Indeterminate
A1+ A2- A3- Report
Negative
A1 – Report
Negative
Strategy 3
Diagnosis of
asymptomatic
A1 + A2
A1+ A2 + Do
A3
A1+ A2+ A3+
Report positive
A1 + A2+ A3 –
inderminate
A1+ A2 – DO
test A3
A1+ A2- A3+
Indeterminate
A1+ A2- A3-
If high risk-
inderminate
If low risk-
negative
A1 – Report
Negative

52. Initiation of ART based on CD4 count and WHO clinical staging
WHO Clinical Stage Recommendations
HIV infected Adults & Adolescents (Including pregnant women)
Clinical Stage I and II Start ART if CD4 < 350 cells/mm3
Clinical Stage III and IV Start ART irrespective of CD4 count
For HIV and TB co-infected patients
Patients with HIV and TB co-infection (Pulmonary/
Extra-Pulmonary)
Start ART irrespective of CD4 count and type of
tuberculosis (Start ATT first, initiate ART as early as
possible between 2 weeks to 2 months when TB
treatment is tolerated)
For HIV and Hepatitis B and C co-infected patients
HIV and HBV / HCV co-infection – without any
evidence of chronic active Hepatitis
Start ART if CD4 < 350 cells/mm3
HIV and HBV / HCV co-infection – With documented
evidence of chronic active Hepatitis
Start ART irrespective of CD4 count

53. 0 hr 0 min
As soon as
possible
Ideally within 2 hrs, but
certainly within 72 hrs 6 months
Step 1: Manage
exposure site
Step 2: Establish
eligibility for PEP
Step 3: Counsel for
PEP
Assess source
patient’s ARV status
Step 5: Laboratory
evaluation
Step 6: Follow up
and monitor
adherence
Wash wound and
surrounding skin
with water and
soap
OR
Irrigate exposed eye
immediately with
water or normal
saline
OR
Rinse the mouth
thoroughly , using
water or saline and
spit again
Refer to physician
Exposure within 72
hours
Assess exposed
individual
Assess exposure
source
Assess type of
exposure
Determine risk of
transmission
Determine eligibility
for PEP
Provide information
on HIV and PEP
Obtain consent for
PEP
Offer special leave
from work
Step 4: Prescribe
PEP
Check for pregnancy
if exposed female
HCP
Explain side-effects
of ARVs
Explain post-
exposure measures
against HBV and
HBC
Provide HIV pre-test
counselling
Check immunisation
status for hepatitis B
Offer HIV, HBV, HBC
test
Draw blood to
include CBC, Liver
function tests,
pregnancy test, if
applicable
Provide HIV post-
test counselling
Record- keeping
Follow up visits for
clinical assessment
at 2 weeks and
hepatitis B
vaccination if
needed
HIV test at 3 and 6
months
Steps for Occupational Exposure

54. Assessing the nature of exposure and risk of transmission
Categories of exposure
Category Definition and example
Mild exposure Mucous membrane/non-intact skin with small volumes e.g. superficial
wound (erosion of the epidermis) with a plain or low calibre needle,
subcutaneous injection following small- bore needle.
Moderate exposure Mucous membrane/non-intact skin with large volumes OR percutaneous
superficial exposure with solid needle e.g. a cut or needle stick injury
penetrating glove
Severe exposure Percutaneous with large volume, e.g. an accident with high calibre needle
(>18 G) visibly contaminated with blood; a deep wound ;
Transmission of a significant volume of blood ; an accident with material
that has previously been used intravenously or intraarterially.

55. Assessing the HIV status of the source of exposure
Categories of situations depending on results of the source
Source HIV status Definition of risk in source
HIV negative Source is not HIV infected but consider HBV AND HCV
Low risk
High risk
Unknown
HIV positive and clinically asymptomatic
HIV positive and clinically symptomatic ( see WHO clinical staging)
Status of the patient is unknown, and neither the patient nor his/her blood is
available for testing ( e.g. injury during medical waste management the source patient
might be unknown). The risk assessment will be based only upon the exposure ( HIV
prevalence in the locality can be considered)

56. HIV post-exposure evaluation for prophylaxis
Exposure Status of source
HIV+
and
Asymptomatic
HIV+
and
Clinically symptomatic
HIV status unknown HIV status negative
Mild
Moderate
Severe
Consider 2-drug
PEP
Start 2-drug PEP
Start 3-drug PEP
Start 2-drug PEP
Start 3-drug PEP
Start 3-drug PEP
Consider 2-drug PEP
Consider 2-drug PEP
Consider 2-drug PEP
No PEP is required if the
source blood is confirmed
HIV negative

57. PEP Drug Regimens to be Prescribed by Health Centres
Preferred Alternative
2-drug regimen (basic PEP regimen) 1st choice:
Zidovudine (AZT) + Lamivudine ( 3TC)
2nd choice:
Stavudine (d4T) + Lamivudine (3TC)
3-drug regimen (expanded PEP regimen) – consult expert opinion for starting 3rd drug e.g. Lopinavir/ Ritonavir,
Nelfinavir or Indinavir
Not recommended Didanosine (ddl) + Stavudine ( d4T)
Non nucleoside Reverse Transcriptase Inhibitor (NNRTI) such as Nevirapine
should not be used in PEP
HIV chemoprophylaxis

58. SURVEILLANCE OF HIV AIDS
1. AIDS case surveillance
2. HIV sentinel surveillance
3. STD surveillance
4. Behavioural surveillance

59. Element Summary
Sentinel site ANC clinic
Sample size 400
Duration 3 months
Frequency Once in two years since 2008-09
Sampling method Consecutive
Eligibility criteria Pregnant women. 15-49 years, attending the ANC for the first time
Exclusion criteria Already visited once at the ANC site
Blood specimen Serum
Testing strategy Unlinked anonymous
Testing protocol Two test protocol
HSS methodology

60. National integrated biological and behavioural surveillance
• To strengthen HIV surveillance among high risk groups and bridge population
• Objective:
– To analyse and understand HIV related behaviours and HIV prevalence among key risk groups
by linking behaviours with biological findings
– To measure and estimate the change in HIV related risk behaviours and HIV prevalence among
key risk groups, between baseline and end line for NACP-IV
• 276 Domains – independent/composite
• FSW, MSM, TG, IDU, MIG, CMW

61. Care, support and treatment
Service Delivery Mechanism:-
• ART Centers,
• Centers of Excellence
• Pediatric Centers of Excellence
• Facility Integrated ART Centers
• Link ART Centers
• Link ART Plus Center
• Care & Support Centers
Model of HIV
treatment
service
Public Health
Infrastructure
& HIV-Relevant Staff
HIV-Related
Services
Medical
College
ART Centre/ Link ART
Centre
Link ART
Centres
Community-
Based HIV
Screening
CCC / NGOs
Referral
District
Hospital
Community Health
Centre
Primary Health Centre (PHC)
Sub-Centres & Anganwadi
Centres
ICTC
District with low Sero -
positivity may have LAC
only.
ART Centres
+
tertiary level care
Centres of
Excellence -
alternate First line
& Second line ART

62. a. CST package: free universal access to ART,CD4 testing services, EID, counseling services,
Management of Opportunistic Infections
b. CST Services Referral and Linkage Mechanism
c. Capacity building for CST
d. Endeavors to enhance and ensure the provision of high quality services:- State grievance
redressal committee
e. Other initiatives: PG diploma in HIV medicine, - capacity building
f. Computerized online inventory mechanism, airborne infection control, HIV-Visceral
Leishmaniasis co infection programme coordination

63. INFORMATION, EDUCATION & COMMUNICATION (IEC)
• To increase knowledge in general population
• To sustain behaviour change-at risk populations
• To generate demand for care, support & treatment services
• To strengthen the enabling environment
Key activities undertaken by IEC
• Mass Media Campaigns
• Long Format Programmes
• Outdoor activities
• Folk Media and IEC Vans

64. STRATEGIC INFORMATION MANAGEMENT
UNIT
Four divisions:
• Monitoring & Evaluation Division
• Research Division
• Surveillance & Epidemiology Division
• Data Analysis & Dissemination Unit
Functions:
• generates and manages crucial information on the entire spectrum of the HIV epidemic
and its control
• promote data use for policymaking, programme planning, implementation and review at
national, state, district and reporting unit levels

65. Monitoring framework
• Impact indicators:
– Reduction of HIV incidence
– Reduction in mortality among PLHIV
– Survival of AIDS patients on ART
• Outcome indicators:
– Behaviour change among FSW
– Behaviour change among MSM
– Behaviour change among IDU
• 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.
– Supply of 90 lakh units of safe-blood and enhanced use of blood products
– The programme will provide 1st and 2nd line ART to all who require it.

66. Key concerns and challenges for NACP-IV
• Need to consolidate successes gained
• Need to advance towards focusing on ensuring high quality services
• Emerging epidemics in certain low prevalence states and districts
• Treatment coverage are fully met
• Regions with different maturity levels of epidemic will require different resources and
services
• Budgetary support
• Integration with larger health systems
• Ensuring social protection schemes for people infected and affected with HIV
• Stigma and discrimination that is still prevailing
• Need for innovation

67. Key issues in targeted intervention
Strategy related:
1. Adaptation of design of Tis to the changing context
2. Budgeting and contracting flexibilities
Operational issues:
1. Budget cuts, fund flow and financial uncertainties
2. Community mobilisation and enabling environment
3. Key population size estimates
4. Recent decline in coverage of population
5. Focus, mechanisms and investments for capacity building
6. Context specific BCC and IEC material
7. TSU/NTSU
8. Partnerships with communities and civil society

68. Key issues in HCTS
1. Coverage gaps in testing of target population
2. Gaps in detection and linkage loss of HIV positive cases between ICTC and ART
3. Increasing sero-discordance among spouses

71. Thank you!