current hiv situation in india and national aids control programme an overview

NACO HCP - ORIENTATION
PROGRAMME FOR DOCTORS
Venue : Government Thiruvarur Medical College
and Hospital, Thiruvarur
Date : 26-12-2013 & 27-12-2013
Resource Persons :
Dr. Asika Beham, M.D., H.O.D. - Microbiology, GTMCH, Thiruvarur
Dr. T.S. Santhi, M.D., H.O.D. – Medicine, GTMCH, Thiruvarur
Dr. A. Annamalai Vadivoo, M.B.B.S., F.H.M., ART Medical Officer, Thiruvarur

Current HIV Situation in India
and
National AIDS Control Programme
An Overview

Session Objectives
By the end of the session, we will be able to
Learn current HIV situation in India
Understand NACO’s objectives and approaches to
control HIV India
Know the National guidelines in detecting HIV in adults
and children (including infants)
Discuss NACO’s comprehensive HIV care and initiation
of first line ART in adults & children
Learn the linkages and referral in the National
Programme to retain PLHIV under Care, Support and
Treatment fold
Understand NACO’s efforts to scale up CST services
2

Estimated Range
People living with HIV 34.2million 31.8–35.9million
New HIV infections in 2011 2.5million 2.2–2.8million
Deaths due to AIDS in 2011 1.7million 1.6–1.9million
Global estimates for Adults and Children
2011
3National AIDS Control Programme

Disease Burden of HIV in India
Provisional estimates place the number of people
living with HIV in India in 2011 at 20.9 lakhs with
an estimated adult HIV prevalence of 0.27 percent
Available evidence on HIV epidemic in India shows
a declining trend at national level
The epidemic is concentrated among high risk group
populations and is heterogeneous in its spread
Heterosexual route of transmission accounts for
87% of HIV cases detected
Source: HIV Estimations,2008-09
National AIDS Control Programme 4

Declining Trends of HIV Epidemic in India
Control Programme
Female: 39% of PLHIV; Children: 7% of PLHIV
National AIDS Source: TechnicalReport India HIV Estimates 2012, NACO & NIMS

Category NACP-IIIDefinition
A >1%ANC prevalence in any of the sites in
The last 3 years
B
<1%ANC prevalence in all the sites during
Last 3 years with >5% prevalence in any HRG
site(STD/FSW/MSM/IDU)
C
<1%ANC prevalence in all sites during last 3
Years with <5%in all STD clinic attendees or
Any HRG,with known hots pots
D
<1%ANC prevalence in all sites during last 3
Years with <5% in all STD clinic attendees or
Any HRG or poor HIV data with no
Known hot spots
Category NACP-III
A 156
B 39
C 296
D 118
NewDistricts 30
Total 609
District-wise Scenario of HIV/AIDS

Routes of Transmission of HIV
NACO Annual Report 2009-2010

Goal :
Halt and reverse the epidemic in India
Objectives:
Prevention of new infections: Saturate High Risk Group
coverage and scale up of interventions for General
population
Increased proportion of PLHIV receiving care, support
and treatment
Strengthening capacities at district, state and national
levels

•Targeted Interventions for High Risk Groups (FSW, MSM,
IDU, Truckers & Migrants)
•Link Worker Scheme for rural population
•Prevention & Control of Sexually Transmitted Infections
•IEC, Social Mobilization & Mainstreaming
•Condom promotion
•Blood safety
•Counselling & Testing Services (ICTC, PPTCT, HIV/TB)
• First line & second line
ART
• Care &Support Centres
• HIV-TB Coordination
• Focus on PPTCT
• Treatment of
Opportunistic Infections
Prevention is the mainstay
High risk
populations
Low risk
populations
People living with
HIV/AIDS
Care, Support and Treatment
Institutional StrengtheningStrategic Information Management
NACP Strategies

Prevention Strategies
Targeted Interventions for High Risk Groups
(FSW, MSM, IDU, Truckers & Migrants)
Link Worker Scheme for rural population
Prevention & Control of Sexually Transmitted Infections
IEC, Social Mobilisation & Mainstreaming
Condom promotion
Blood safety
Counselling & Testing Services (ICTC, PPTCT, HIV/TB)

Linkages of ICTC: Gateway to HIV Care
STI
Services
Walk-in
Clients
Prevention
Services
Targeted
Interventions
TB
Services
ART Centres
CD4 testing,
Care, support & treatment
Antenatal
Care
Onsite Services: PPTCT, TB/HIV, Basic OI
Management, TB and STI Care, Reproductive
and Child Health, Routine and Emergency
Medical Care
STI and TB Clients,
Pregnant Women, Key
Populations, and
General Populations
Referred
Integrated Counselling and Testing Centres (ICTC):
HIV Counselling and Testing
PLHIV linked to care, support
and treatment services
through referrals to
Referral to home and community based
care

Integrated Counselling & Testing Centres
Single window service for:
Pre-test counselling before HIV testing
HIV testing and providing results of the test
Post-test counselling to both positive and negative persons
Condom promotion and distribution
Identification for HIV+ pregnant women
Providing prophylaxis for prevention of transmission from mother to
child
Prophylactic (Cotrimoxazole) to HIV exposed children
Education regarding infant feeding
Referral to ART Centre for investigation and treatment
Cross referral between RNTCP and ICTCs

Tests for Diagnosing HIV
Screening Tests: Antibody Tests
Rapid tests
Enzyme linked immunosorbent
assays (ELISA)
Confirmatory/Supplemental Tests
2nd/3 rd Rapid /ELISA tests to
confirm 1st HIV test
Same blood sample is utilised for
performing the tests for identifying
HIV antibodies (Strategy III)

Report
A1+,A2+,A3+ ReactivetoHIVAb
A1-(or)A1+,A2-,A3- NonReactivetoHIVAb
A1+,A2-,A3+(or)A1+,A2+,A3- Indeterminate
HIV Testing Strategy III
First Test A1
A1 Reactive
Second Test A2
A1 Non Reactive
Third Test A3
A2 Reactive A2 Non Reactive A3 Reactive A3 Non Reactive

Birth
6 weeks 14 weeks
10 weeks 6 months
9 months
12 months
18 months
DNA PCR
DNA PCR for all
HIV exposed
infants
HIV Antibody test followed by
DNA PCR if HIV+
Final confirmatory
Antibody Test for all
HIV exposed infants at
18 months, irrespective
of earlier testing results /
treatment status
All HIV infected and / or symptomatic infants / children
are to be referred to ART centre
Early HIV detection in Infants & Children
Schedule of visits at ICTC

Comprehensive HIV Care
The overall goal is to improve the survival and
quality of life of PLHIV with Comprehensive HIV care
To ensure Free Diagnostic services
To provide appropriate pre ART care and Treatment of
Opportunistic Infections
To widen Access to ART:
Standardised combination of ARV therapy
Regular and secured supply of ARV drugs
Emphasis on Treatment adherence
To enhance capacity building and strengthen linkages
and monitoring of care, support & treatment services
Robust Monitoring & Evaluation system

Bacterial Viral Fungal Parasites
Tuberculosis Varicella Zoster Candida Toxoplasma
Respiratory
Pathogens:
Streptococcus
H.influenza
Herpes simplex
Pneumocystis
jiroveci(PCP)
Intestinal:
Cryptosporidium
Isospora
Microspora
Intestinal:
Salmonella,
Shigella
Cytomegalovirus Cryptococcus
Giardia
Entamoeba
Human papiloma PenicilliumM. Leishmania
Ebstein BarrVirus
(OralHairyLeukoplakia;
Lymphoma)
Histoplasma
capsulatum
JC Virus(PML)
Common OIs seen in India

CD4cellcountAssociation between OIs & CD4 Count
PCP; Oesophageal Candidiasis;
Mucocutaneous Herpes
Toxoplasmosis; Cryptococcosis;
Cryptosporidiosis;
PML; CMV; MAC
Herpes Zoster
Tuberculosis
Oral Candidiasis
Time

Eligible for ART
ART preparedness counselling, Address verification,
Identification of care giver (family / community
support), CPT (if eligible), Treatment of active OIs,
ART initiation in TB co-infected
Enrolled in ART Enrolment Register
Enrolment in HIV care (New patients)
Detected HIV Positive at ICTC
• Enrolment in HIV Care at ART Centre / LAC plus Filling up of HIV Care Register,
White card, Green book
• Counselling, Screening for OIs (including TB), STIs and other co-infections
• WHO staging, initial work up (Baseline investigations)
Patient revisits when reports of investigations (including CD4) are available
Not eligible as per ART Guidelines
Continued in Pre-ART Care

Based on WHO Clinical Staging and CD4 Count
WHO
Clinical Staging
CD4 (cells/cu.mm)
I and II Treat if CD4 Count <350
III and IV Treat irrespective of CD4 Count
Initiation of ART
in Adults and Adolescents
National Guidelines, 2011

Type of
Tuberculosis
Eligible
Clinical Staging
And CD4 Counts
Timing of ART
In relation to start of
TB treatment
Pulmonary TB
(StageIII)
Start ART
Irrespective of
Any clinical
stage
or
Irrespective of
CD4 counts
Start ATT first;
Start ART as soon as
TB treatment is
tolerated
(after 2 weeks &
Before 2 months)
Extrapulmonary TB
(StageIV)
Initiation of ART
in PLHIV with TB Co-infection

Co-infection
WHO
Clinical
Staging
CD4(cells/cu.mm)
HIV-HBV or HIV-HCV
co-infection without any
Evidence of chronic active
Hepatitis
I and II
Start ART at CD4 Count
<350
III & IV
Start ART irrespective
Of CD4 Count
HIV-HBVorHIV-HCV
co-infection with documented
Evidence of chronic active
Hepatitis
All Clinical
stages
Start ART Irrespective
Of any CD4 count
Preferred regimen for PLHIV with HBVorHCVco-infection:
Tenofovir+Lamivudine+Efavirenz
Initiation of ART in PLHIV with
Hepatitis B or Hepatitis C Co-infection

NRTIs
NNRTI BoostedProtease
Inhibitors
NRTI NtRTI
Zidovudine
(AZT)
Stavudine(d4T)
Lamivudine
(3TC)
Abacavir(ABC)
Tenofovir
(TDF)
Nevirapine
(NVP)
Efavirenz
(EFV)
Atazanavir(ATV)
/Ritonavir(RTV)
Lopinavir
(LPV)/Ritonavir(RTV)
ARV Drugs available in

Regimen NationalARTRegimen Preference
RegimenI
Zidovudine+
Lamivudine+Nevirapine
First line regimen for patients with
Hb>9gm/dl and not on
Concomitant ATT
RegimenI(a)
Tenofovir+
Lamivudine+Nevirapine
Hb<9gm/dl and not on
Concomitant ATT
RegimenII
Zidovudine+
Lamivudine+Efavirenz
Hb>9gm/dl and on concomitant
ATT
RegimenII(a)
Tenofovir+
Lamivudine+Efavirenz
•First line regimen for patients
With Hb <9gm/dl and on
Concomitant ATT
•First line regimen for all patients
With HepatitisB & HepatitisC
co-infection
•First line regimen for pregnant
women, with no exposure to
sd-NVP in the past
NACO First line ART Regimens for HIV-1 infection

Clinical and Immunological Criteria
for starting ART in Children
All infants and young children under 24 months of age
with confirmed HIV infection should be started on ART,
irrespective of clinical or immunological stage
Children >24 Months-upto 5 years of age:
Initiate ART for all clinical stage 3 and 4, irrespective of CD4
count or percentage
CD4 less than 25 % for CLHIV with Clinical stages 1 & 2
Children >5 years of age:
Follow CD4 count as in Adult ART Guidelines

Paediatric
Regimen
Regimen Remarks
RegimenPI
Zidovudine+Lamivudine+
Nevirapine
Preferred paediatric regimen
For children with Hb >9g/dl
RegimenPI(a)
Stavudine+Lamivudine+
Nevirapine
For children with Hb < 9g/dl
RegimenPII
Zidovudine+Lamivudine+
Efavirenz
Preferred for children on anti-TB
treatment;
Hb>9g/dl and
age>3 yr and weight >10kg
RegimenPII(a)
Stavudine+Lamivudine+
Efavirenz
For children on anti-TB treatment
Tuberculosis treatment;
Hb<9g/dl and
age>3 yr and weight>10kg
1.Efavirenz is the preferred drug over Nevirapine, whenever children are being
Treated with Rifampicin containing drug regimen for TB coinfection
2.In Children aged <3 years and in children weighing <10Kg, Efavirenz is
contraindicated.
Paediatric First line ART Regimens

MonitoringTool WhentoMonitor?
Body weight Every Visit
Treatment Adherence Every Visit
Clinical Monitoring&
T-Staging
Every Visit
Hb*, TLC,DLC,ALT(SGPT)** Every6-months
CD4 Count
Every 6-months,
Or earlier, if required
Routine Monitoring & Follow up of ART
*Hb checked on 15th day after initiation on Zidovudine
** ALT checked on 15th day , when patients on Nevirapine
27

Modifying / Changing Therapy
Due to adverse drug effects / intolerance /
Drug Interaction
Due to occurrence of tuberculosis
Due to treatment failure

Substitution vs. Switch
Substitution:
Single drug replacement of individual ARV (usually
within the same class) refers to SUBSTITUTION of
individual drugs for toxicity, drug-drug interactions,
or intolerance; which does not indicate a second line
regimen being used.
Switch:
Failure refers to the loss of antiviral efficacy and
triggers the SWITCH of the entire regimen from
first to second line. It is identified by clinical and/or
immunological and/or virological monitoring.

Terms of Reference to
State AIDS Control Expert Panel
Review referred cases for alternative first line ART
Review and decide all cases referred by the referring ART
centre for second-line ART provision
for finding the eligibility for viral load testing
for starting second line ART, if found eligible
Mentoring referring ART centres and ensuring high
quality case management of PLHIV
Documentation and follow up of all patients registered for
SACEP review

Public Health
Infrastructure
Selected Medical
colleges
Medical college
and District Level
Hospital
Sub-District level
hospitals &
CHC
Three-Tier Model of HIV Treatment
Service
CoE
& ART
Plus
Centres
(43)
ART Centres
(400)
Link ART Centres and LAC Plus Centres
( 850)
31

LAC LAC
LAC
plus
LAC
plus
Care &
Support
Centres
CoE (10)
pCoE (7)
ART plus (26)
(SACEP)
ART
Centres
(400)
840
Updated
April, 2013
CST Services: Referral and Linkages
Functions
Out Reach working and
Tracing of LFU
Functions
1. ART: Monthly Distribution
2. Monitoring and Drug Adherence
3. Treating Minor OIs
32

ICTC
LAC
LAC plus
ART
Centres
Centres of
Excellence,
pCoE &
ART plus
centres
Network of PLHIV / District level Network of Positive People (DLN+)
CST Services: Referral and Linkages
HIV-TB linkages: RNTCP

Evidence of Programme Impact
57% Reduction in New Infections
(2000-11) with Scale-up of Prevention
Strategies
29% Reduction in AIDS-related Deaths
(2007-11) with Scale-up of Anti-Retroviral
Treatment
Source: Technical Report India HIV Estimates 2012, NACO & NIMS

Issues and Challenges
Low referrals from ICTC to ART centres
Early Infant Diagnosis
Enrollment of children under ART care
Pre-ART care and Follow up
Timely and Early initiation of ART
Ensuring optimal (>95%) adherence to ART
Tracking patients Lost to follow up (LFU)
Second line ART initiation
Linkages with RNTCP and other local networks
Irrational ART Prescriptions outside National Programme

Key Points
The estimated number of people living with HIV in India
in 2011 is placed at 20.9 lakhs
NACP phase III aims to halt and reverse the epidemic
in India, to scale up care and support services and to
strengthen capacity at all levels
ICTC is the entry point for providing comprehensive
care and support to the HIV-infected persons
ART services are being expanded to provide treatment
nearer to patients' residence
Process of decentralisation and appropriate referral
and linkage services ensure PLHIV of comprehensive
care in the existing health delivery system
38

current hiv situation in india and national aids control programme an overview

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