Epidemiology of HIV and update in the NACO programme

1. EPIDEMIOLOGY OF HIV/AIDS WITH
UPDATE IN THE PROGRAMME AND
RECENT ADVANCES
Name of the Presenter
Dr.Rama Shankar
PG Resident
Name of the Moderator
Dr.Nirankar Singh
Professor
Department of Community Medicine
Muzaffarnagar Medical College
9/3/2016
1

2. CONTENTS
• Introduction
• Epidemiology of HIV/AIDS
• Global and National fact sheet
• AIDS control Programme in India
• HIV surveillance
• Counselling and HIV testing services
• Care, support and Treatment
• NACP-IV
• Objectives/Strategies
• Key initiatives
• Guiding Principles
• Services
• Monitoring framework
• Summary
• References 2

3. INTRODUCTION
• AIDS also called slim disease caused by retrovirus known as HIV.
• Destroy specific blood cells, called CD4+T cells, which are crucial
for fighting diseases.
• Once infected a person will be affected for life.
• AIDS can be called as modern pandemic affecting both
industrialised and developing countries.
• First clinically observed in 1981 in USA. The term GRID was
coined which later turned to be "4H disease". This was later in
1982 renamed by CDC and AIDS came into existence.
3

4. EPIDEMIOLOGICAL DETERMINANTS
• Agent:HIV virus is 1/10000th of a mm
in diameter.
• The virus replicates in T4 lymphocytes
and can destroy T4 helper cells, a subset
of T lymphocyte
• It can cross BBB and account for
neurological and psychological
abnormalities
• Reservoir of Infection: Cases and
Carrier
• Source of infection:Blood, semen and
CSF. Lower concentration detected in
tears, saliva breast milk etc.
4
• Host Factors:
• Age: most cases in sexually active person
aged 20-49 yrs.
• Sex:In Africa the sex ratio is equal where
as in NA, Europe and Australia 51% in
homosexual and bisexual men.
• HRG: Male homosexuals and bisexuals,
heterosexuals partners, IDUs, transfusion
recipients of blood and blood products,
haemophiliacs and clients of STD

5. 5
• NRTI!
• ABC- Abacavir 300
mg BD!
• ddl-Didanosine
200mg BD!
• FTC- Emtricitabine
200 mg BD!
• 3TC- Lamivudine 150
mg BD!
• d4T- Stavudine 40 mg
BD!
• AZT- Zidovudine
300mg BD!
• NtRTI!
• TDF- Tenofovir!
• NNRTI!
• EFV-Efavirenz 600 mg
OD!
• ETV- Etavirine 200 mg
BD !
• NVP-Nevirapine 200
mg OD for 14 days
then BD
• PIs!
• ATV/r-Atazanavir+
Ritonavir (300+100 mg)
OD!
• DRV/r- Darunavir+r (600
+ 200 mg BD!
• FPV/r- Fos-amprenavir+r
(1400 +200 mg OD)!
• IDV/r-Indinavir+r
(800+100 mg) BD!
• LPV/r- Lopinavir+r
(400+100 mg) BD!
• SQV/r- Saquinavir+r
(1000 mg+100 mg) BD!
• INSTIs!
• RAL-Raltegravir (400 mg
BD

6. 6

7. EPIDEMIOLOGICAL DETERMINANTS
• Mode of transmission
• Sexual transmission
• Blood Contact
• Maternal to foetal transmission:MTCT
• Incubation Period: Few months to 10 years and even more
7
CLINICAL MANIFESTATIONS
• Initial infections with the virus and
development of antibodies
• Asymptomatic carrier state
• AIDS-related complex ( ARC)
• AIDS
0
1
Absolute CD4 count /Ul
500 200 50
Bacterial infection
TB
Hairy cell Leukoplakia
Herpes simplex
infection
Herpes Zoster
Vaginal Candidiasis
Kaposi Sarcoma
Pneumocystosis
Toxoplamsmosis
Cryptococcosis
coccidioidomycosis
Cryptosporidiosis
Disseminated
MAC infection
Histoplasmosis
CMV retinitis
CNS lymphoma
HIV ELISA
Screening test for HIV infection. Sensitivity>
99.9
Western blot Confirmatory test for HIV
CBC Anaemia, neutropenia and thrombocytopenia
Absolute CD4
lymphocyte
count
Predictor of HIV progression
CD4 lymphocyte
Percentage
can be more reliable than CD4 count
HIV viral load
tests
Measures the amount of actively replicating
HIV virus
B2-
Microglobulin
Cell surface protein indicative of
macrophage-monocyte stimulation
p24 antigen Indicates active HIV replication
LABORATORY DIAGNOSIS RELATION OF CD4 COUNT TO OPPORTUNISTIC
INFECTION

8. WHO CASE DEFINITION OF AIDS SURVEILLANCE
• For adults & adolescent (>12 yrs of age): 2 major signs and one
minor signs
• Major sign
• Weight loss> equal to 10% of body weight
• Chronic diarrhoea for more than 1 month
• Prolonged fever for more than 1 month
• Minor sign
• Persistent cough for more than one month
• Generalised pruritic dermatitis
• History of Herpes Zoster
• Oropharyngeal candidiasis
• Disseminated herpes simplex infection
• Generalised lymphadenopathy
• For children :2 major signs and 2 minor signs
• Major sign
• Weight loss or abnormally slow growth
• Chronic diarrhoea for more than 1 month
• Prolonged fever for more than 1 month
• Minor sign
• Generalised lymph node enlargement
• Oropharyngeal candidiasis
• Recurrent common infections e.g. ear infection
• Persistent cough
• Generalised rash
• EXPANDED CASE DEFINITION OF AIDS SURVEILLANCE
• For adults & adolescent (>12 yrs of age) to be considered to have AIDS if a test for HIV antibody gives a positive
result & one or more of below mentioned conditions are present
• >10% body weight weight loss, with diarrhoea or fever,or both for at a least one month
• Cryptococcal meningitis
• PTB or EPTB
• Kaposi Sarcoma
• Neurological complications sufficient to prevent daily activities
• Candidiasis of the oesophagus
• Clinically diagnosed life threatening episodes of pneumonia
• Invasive cervical cancer 8

9. WHO CLINICAL STAGING OF HIV DISEASE IN ADULTS, ADOLESCENTS AND
CHILDREN
• Clinical stage 1
(Adults)
• Asymptomatic
• PGL
• For children
• Asymptomatic
• PGL
• Clinical stage 2 (Adults)
• Moderate unexplained weight
loss ( under 10% of BW)
• Recurrent RTI
• Herpes zoster/Angular
cheilitis
• Recurrent oral infections
• Papular pruritic eruptions
• Seborrhoeic dermatitis
• Fungal nail infections
• For children
• Unexplained chronic
diarrhoea
• Severe persistent candidiasis
outside the neonatal period
• Weight loss
• Persistent fever
• Severe bacterial infections
• Clinical stage 3 (Adults)
• Moderate unexplained
weight loss (over 10% of
BW)
• Unexplained chronic
diarrhoea for more than 1
month
• Unexplained persistent
fever for more than 1 month
• Oral candidiasis/oral hairy
leukoplakia/PTB
• Bacterial infections
• Stomatitis, gingivitis or
peridontitis
• unexplained anaemia (< 8g/
dl), neutropenia,
thrombocytopenia
• For children
• AIDS-defining opportunistic
infections
• Severe failure to thrive
• Progressive encephalopathy
• Malignancy
• Septicaemia or meningitis
• Clinical stage 4 (Adults)
• HIV wasting syndrome
• Pneumocystis jiroveci
pneumonia
• Several bacterial pneumonia
• Chronic herpes simplex
infections
• Oesophageal candidiasis
• EPTB/Kapsoi Sarcoma
• CMV disease
• CNS toxoplasmosis
• HIV encephalopathy
• Extra pulmonary
cyptococcosis including
meningitis
• Disseminated non-
tuberculous mycobacteria
infection
• Progressive multifocal
leukoencephalopathy
• Chronic cryptosporidiosis
• Chronic isosporiasis
• Disseminated mycosis
• Septicaemia/lymphoma
• Invasive cervical carcinoma/
atypical disseminated
Leishmaniasis9

10. 2013 WHO GUIDELINES ON WHEN TO START
ART
• Treat adults, adolescents & children with CD4 count of 500 cells/mm3 or less, with more priority to
CD4 count less than 350 cells/mm3.
• Start with ART regardless of CD4 count in PLHIV with comorbidity like HBV TB, HIV positive
partners in serodiscordant couples, Pregnancy and breastfeeding women and children under 5 yrs
of age.
• A new preferred first line ART regimen for adults, pregnant and BFW and children under age 3
• Accelerate the phasing out of Stavudine (D4T) in first line ART regimen for adults and adolescents.
• Use of viral load testing as the preferred approach to monitor the success of ART and diagnosing
treatment failure.
• Community based HIV testing and counselling and HIV testing of adolescents to diagnose people
with HIV earlier and link them to care and treatment
10

11. 2015 WHO GUIDELINES ON WHEN TO START ART
Recommendation 1: When to start ART among people living with HIV
Target
Population
Specific Recommendation
Adults (>19 yrs)
ART to be initiated in all adults living with HIV at any CD4 cell count
As a priority, initiation in WHO clinical stage 3 or 4 and individuals with CD4 count less than equal to 350 cells/mm3
Pregnant and
BFW
ART should be initiated in all pregnant and BFW living with HIV at any CD4 cell count and continued lifelong
Adolescents
ART to be initiated in all adolescents living with HIV at any CD4 cell count
As a priority, initiation in WHO clinical stage 3 or 4 and individuals with CD4 count less than equal to 350 cells/mm3
Children ( 1 to
<10 yrs old)
ART to be initiated in all mentioned group living with HIV at any CD4 cell count
As a priority, ART should be initiated among all children <2 yrs old and in WHO clinical stage 3 or 4 and individuals with
CD4% <25% ( if < 5 yrs old )or CD4 count less than equal to 350 cells/mm3 ( if greater than equal to 5 yrs old)
Children (< 1 yrs
old)
ART to be initiated in all mentioned group living with HIV at any CD4 cell count
Recommendation 2: Oral pre-exposure prophylaxis to prevent HIV infection
HIV negative
individuals at
substantial risk
of HIV infection
Oral PrEP ( containing TDF) should be offered as an additional prevention choice for people at substantial risk of HIV
infection as part of combination prevention approaches
11

12. SUMMARY OF FIRST/SECOND/THIRD LINE ART REGIMEN FOR ADULTS,
ADOLESCENTS, PREGNANT AND BREASTFEEDING WOMEN AND CHILDREN
First-line ART
Preferred First line
Regimen
Alternative first line Regimen
New treatment guideline
2015
Adults ( including Pregnant & BFW and
adults with TB and HBV confections
TDF+3TC (or FTC)+ EFV
AZT+3TC+EFV
AZT+3TC+NVP
TDF+FTC +NVP
Preferred Option ( TDF
+XTC{3TC or FTC)+EFV600
Alternative options
AZT+3TC+EFV600
AZT+3TC+NVP
TDF+XTC+NVP
TDP+XTC+DTG (Dolutegravir)
TDF+XTC+EFV400
!
!
Adolescents (10-19 yrs) > equal to 35kg
AZT+3TC+EFV
AZT+3TC+NVP
TDF+3TC (or FTC) +NVP
ABC+3TC+EFV (or NVP)
Children 3 yrs to>10 yrs and adolescents
<35 kg
ABC+3TC+EFV
ABC+3TC+NVP
AZT+3TC+NVP
AZT+3TC (or FTC) +EFV
TDF +3TC (or FTC) +NVP
TDF+3TC (or FTC) + NVP
Children < 3 yrs ABC or AZT+3TC+LPV/r
ABC+3TC+NVP
AZT+3TC+NVP
2nd-line ART Preferred regimen Alternative Regimen Note
Adults and Adolescents (>10 yrs), including
pregnant and BFW
AZT+3TC+LPV/r
AZT+3TC+ATV/r
TDF+3TC( or FTC)+ATV/r
TDF+3TC ( or FTC)+LPV/r
Follow the same regimen if AZT
is used in 1st line. If TDF is
used in 1st line then use AZT
+3TC+ATV/r or LPV/r
HIV and TB
coinfection
If rifabutin available Standard PI containing regimen as recommended for adults and adolescents
If Rifabutin not available
Same NRTI backbones as recommended for adults and adolescents plus double dose LPV/r (800 mg/200
mg BD daily) or( 400 mg/400 mg BD daily
HIV and
HBV
infection
AZT+TDF+3TC (or FTC) + )ATV/r or LPV/r)
Children
If a NNRTI-based first line regimen
was used
ABC+3TC+LPV/r
ABC+3TC+LPV/r
TDF+3TC (or FTC)+LPV/r
If a PI-based first line
regimen was used
< 3yrs
No change from the first-
line regimen in use
AZT ( or ABC)+3TC+NVP
3 yrs to <10
yrs
AZT ( or ABC) +3TC+EFV ABC (or TDF)+ 3TC+NVP12

13. Targeted viral load
monitoring clinical or
immunological failure
Routine viral load
monitoring ( early detection
of virological failure)
Test viral load
Viral load>1000 copies/ml
Evaluate for adherence
concerns
Repeat viral load testings
after 3-6 months
Viral load <1000 copies/ml Viral load>1000 copies/ml
Maintain first line therapy Switch to second line therapy
13

14. POST EXPOSURE PROPHYLAXIS FOR HIV
Preferred regimen
Preferred third drug or
alternative regimen
For adults and
Adolescents
TDF +3TC ( or
FTC)
LPV/r or ATV/r is the
preferred third drug
For Children ≤ 10 yrs
old AZT+3TC
ABC+3TC or TDF
+3TC(or FTC) as
alternative.LPV/r
recommended as third
drug
A 28 day prescription of AR drugs should be provided for HIV post
exposure prophylaxis following initial risk assessment
• Eligibility of post-exposure prophylaxis
• Commencement within 72 hrs of possible
infection
• Based on HIV status of the source whenever
possible
• Parenteral or mucus membrane exposure and
certain body fluids like blood, breast milk, genital
secretions etc. can pose risk
• PEP not required when the exposed individual is
already HIV positive and source is established to
be HIV negative and exposure to bodily fluids that
does not pose a risk like tears, non blood stained
saliva, urine, sweat.
14
USE OF CO-TRIMOXAZOLE FOR HIV RELATED
INFECTIONS WHO (2014)
For adults (
including
PW)
• Recommended for WHO clinical
stage 3 or 4 and for CD4 count ≤350
cells/mm3
!
• Can be initiated and continued
regardless of CD4 count in settings
where malaria and other bacterial
infections are highly prevalent.
!
Infants,
children
and
adolescent
s
• Recommended but priority to
children <5 yrs regardless of CD4
count or clinical stage and to children
with WHO clinical stage 3 or 4 and for
CD4 count ≤350 cells/mm3
!
• Can be continued until adulthood at
places where malaria and other
bacterial infections are highly
prevalent
!
• It can be discontinued in settings
where malaria and other bacterial
infections are low prevalent for
children 5 yrs and older who are
clinically stable, virally suppressed on
ART for 6 months and CD4 count>
350cells/mm
!It should be administered to all HIV-infected people
with active TB disease regardless of CD4 cell.

15. GLOBAL HIV TRENDS
Numberinmillion
0
4
8
12
16
NumberinMillion
32
33.25
34.5
35.75
37
Years
2007 2008 2009 2010 2011 2012 2013 2014/2015
PLHIV New Infection total ARD People Accessing treatment
15.8
13
11.4
9.4
7.5
6.1
1.21.31.41.51.61.71.71.9 22.12.22.32.32.42.42.5
36.9
36.2
35.6
34.9
34.4
33.8
33.3
32.932.9
33.3
33.8
34.4
34.9
35.6
36.2
36.9
15
Regional Statistics
Sub-
Saharan
Africa
Asia and
the Pacific
Latin
America
Western and
central
Europe and
North
America
Eastern
Europe and
Central Asia
The
Caribbe
an
Middle East and
North Africa
Global
PLHIV
25.8
million
5.0 million
1.7
million
2.4 million 1.5 million 280000 240000
36.9
million
New HIV Infections
1.4
million
340000 87,000 85,000 140000 13000 22000 2.0 million
ARD 790000 240000 41000 26000 62000 8800 12000 1.2 million
Estimated %age of PW living with
HIV who received ART to PPTCT
75 38 78 _____ ______ 89 13 73
Estimated %age of adults (15+ yrs)
living with HIV receiving ART
43 36 47 ——- 18 44 14 41
Estimated %age of children (0-14 yrs)
living with HIV receiving ART
30 36 54 ——- ——— 36 15 32
IND, CHN and IND
account for 78% of new
HIV infection

16. Adult HIV Prevalence (%) in India, with uncertainty
bounds
Percentage
0
0.105
0.21
0.315
0.42
Years
2007 2008 2009 2010 2011 2012 2013 2014 2015
0.41
0.39
0.37 0.36 0.35 0.34 0.33 0.32 0.32
0.34
0.32 0.31 0.3 0.29 0.28 0.27 0.27 0.26
0.28 0.27 0.26 0.25 0.24 0.23 0.23 0.22 0.22
Lower bounds Point estimate Upper bounds States
New HIV infection
Annual AIDS-related death
Estimated New HIV Infections in India (1998-2015)
Years
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
New HIV Infection in Lakhs
0 0.75 1.5 2.25 3
0.1
0.12
0.15
0.16
0.17
0.17
0.18
0.2
0.21
0.23
0.24
0.25
0.25
0.26
0.25
0.24
0.23
0.21
0.76
0.77
0.79
0.8
0.82
0.85
0.88
0.96
1.06
1.17
1.29
1.41
1.56
1.78
2
2.27
2.51
2.64
Adult (15+ yrs)
Children (0-14 yrs)
16

17. Annual AIDS-Related Deaths and ART Scale-up
India 2007-14
PLHIV(Alive&OnART
0
2.25
4.5
6.75
9
AnnualARDinlakhs
0
0.375
0.75
1.125
1.5
2007
2008
2009
2010
2011
2012
2013
2014
AIDS related Death PLHIV on ART
1.3
2.2
3.1
4.1
5.2
6.3
7.8
8.5
1.5
1.4
1.3
1.2
1.1
1
0.9
0.8
17
• India has achieved 6th MDG in regards to
HIV/AIDS
• Between 2000 and 2015, new HIV infection
dropped from 2.51 lakhs to 86 thousand, a
reduction of 66% against a global average of
35%.
• ARD declined falling from by 54% from 2007
to 2015 against a global average of 41%
• SDG Target: Reduce the annual number newly infected with HIV by 90% and
annual number of people dying from AIDS related cause by 80% ( compared
with 2010 data)

18. HIV "SENTINEL" SURVEILLANCE
HSS is defined as "a system of monitoring HIV epidemic
among specified population groups by collecting information
on HIV from designated sites ( sentinel sites) over years
through consistent methodology that allow comparison of
findings across place and time to guide programme response".
Sentinel sites is defined as "designated service point/facility
where blood specimen and information are collected from a
fixed number of eligible individuals from a specified
population group over a fixed period of time, periodically, for
the purpose of monitoring the HIV Epidemic"
18

19. OBJECTIVES OF HIV SENTINEL SURVEILLANCE
To understand the trends of the HIV epidemic among
the general population, bridge population and HRG in
different states
To understand the geographical spread of the HIV
infection and to identify emerging pockets
To provide information for prioritisation of programme
resources and evaluation of programme impact
To estimate HIV prevalence and HIV burden in the
country
19

20. HIV SENTINEL SURVEILLANCE IN INDIA
20
One of the world largest and most robust HSS systems.
Since 1998, it has helped GOI to monitor the trends, levels and burden of
HIV among different population group in the country.
The 14th round of HSS was implemented during 14-15 at 776 sites, including
all 776 ANC surveillance sites covering 557 district covering 34 states/UT
For HRGs and Bridge population, nationwide IBBS is being carried out as a
strategic shift to strengthen the surveillance system among these groups
FSW
IDUs
MSM
Male
Male
client
FemaleSpouse/
partners
Children
Source: Dr.Tim Brown's
work on the Asian
Epidemic
Epidemiological Basis of
HIV surveillance

21. EXPANSION OF HSS SITES IN INDIA
21
Site type 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008-09 2010-11 2012-13 2014-15
STD 76 75 98 133 166 163 171 175 251 248 217 184 13 -
ANC 92 93 111 172 200 266 268 267 470 484 498 514 564 776
ANC
( Rural)
- - - - - 210 122 124 158 162 162 182 186
IDU 5 6 10 10 13 18 24 30 51 52 61 79 -
MSM - - 3 3 3 9 15 18 31 40 67 96
Migrant - - - - - - - 1 6 3 8 19 -
TG - - - - - - - 1 1 1 1 3
Truckers - - - - - - - - 15 7 7 20 —
TB 2 2 - - - - 7 4 - - - - -
Fisher-
Folk/
Seamen
- - - - - 1 - - 1 - - - -
Total 176 177 224 320 384 699 649 703 1122 1134 1215 1359 763 776

22. 22
NACO
Technical resource Group on Surveillance & Estimation
( Nodal Agency: Policy, Strategy & Plan)
NIHFW
( Nodal Agency: Co-ordination, Supervision, Analysis
and Documentation)
NIMS
( Nodal Agency: HIV Estimation)
CENTRAL TEAM
Supervision
REGIONAL
INSTITUTIONS
REFERENCE LABORATORIES
Quality Control on Testing Labs
NORTH
ZONE
PGIMER
Chandigarh
( 5 states)
CENTRAL
ZONE
AIIMS
New Delhi
( 5 States)
WEST
ZONE
NARI
Pune( 7
States)
SOUTH
ZONE
NIE
Chennai ( 7
States)
EAST
ZONE
NICED
Kolkata( 6
States)
NORTH
EAST
RIMS
Imphal
(5 States)
Technical Validation of New Sites, Training, Monitoring, Supervision & Data Entry; Technical Support &
Guidance to SACs in Planning, Implementation, trouble-shooting & Analysis
STATE AIDS CONTROL SOCIETY
Primary Implementing Agency in the State
STATE SURVEILLANCE TEAMS
( Training and Supervision)
Testing Laboratories
117 SRL and 13
NRL
Sentinel sites
DAPCU
Coordination

23. WHY SURVEILLANCE AMONG ANC CLINIC ATTENDEES?
Pregnant women represent the sexually segment of the general population
and hence taken as proxy for monitoring HIV among general population.
At ANC clinics, routine blood specimen collection is done for Syphilis and
Hb testing, apart of which can be used for HIV testing.
Pregnant women represent a more homogeneous group than persons
attending any other clinic/OPD
Pregnancy being physiological, does not introduce any bias in HIV
prevalence which other illnesses/diseases may introduce due to underlying
factors common to HIV.
Facilities for antenatal care are available across the country at different
levels of health care system and hence are feasible for implementation
23

24. 24
HIV prevalence (%) among ANC clients (2014-2015) & other
risk groups (2010-11).
HIV prevalence (%) at ANC sites India
and States (2014-2015)
ANC (2014-15)
Migrants ( 2010-11)
Truckers (2010-11)
FSW (2010-11)
MSM (2010-11)
IDU (2010-11)
TG (2010-11)
0 2.25 4.5 6.75 9
8.82
7.14
4.43
2.67
2.59
0.99
0.29
HIV Prevalence
India
UP
Bihar
Kerala
Nagaland
0 0.35 0.7 1.05 1.4
1.29
0.05
0.37
0.21
0.29
HIV Prevalence

25. THREE GROUPS OF STATES/UT
Group 1 ( High Prevalence states)
MHA, TN, KTN, AP, MAN
& NGN
HIV infection crossed 5%
mark in HRG and 1% or
more in antenatal women
25
Group II ( Moderate Prevalence
states)
GJN, GOA, and PUD
HIV infection crossed 5%
mark in HRG but less than
1% in antenatal women
Group III ( Low Prevalence states)
Remaining states
HIV infection less than 5% mark in HRG
and less than 1% in antenatal women
Based on sentinel surveillance data, HIV prevalence in adults
population can be classified into 3 groups of States/UT
CATEGORIES OF DISTRICTS
>1% ANC/PTCT prevalence in district at any time in any of the sites in the last 3 years A
156
Districts
<1% ANC/PTCT prevalence in all the sites during last 3 years associated with >5%
prevalence in any HRG
B
39
Districts
<1% in ANC prevalence in all sites during last 3 years with <5% in all STD clinics
attendees or any HRG with known hot spots
C
296
Districts
<1% in ANC prevalence in all sites during last years with <5% in all STD clinics
attendees or any HRG or poor HIV data with no known hot spots
C
118
Districts

26. 26
INTEGRATED BIOLOGICAL AND BEHAVIOURAL SURVEILLANCE (IBBS)
It is one of the largest bio-
behavioural surveys among
HRGs in the world
Objectives;
To understand HIV
related behaviour and
prevalence among Key risk
groups in different regions
!
!
To measure and estimate
the change in HIV related
risk behaviours and HIV
prevalence among key
groups.
Profile of FSW/MSM/IDU
Sexual Behaviour
Pattern types and condom use
Anal sex and condom use
Alcohol and other substance use
Self-reported STI
Stigma and discrimination
HIV Prevalence {2.2%, [FSW]
4.3% [MSM], 9.9% [IDU]}

27. INTEGRATED COUNSELLING
AND TESTING CENTRES (ICTC)
HIV Counselling:It is a confidential dialogue
between a client and counsellor aimed at
providing information on HIV/AIDS and bring
about behaviour change in the client.
An ICTC is a place where a person is counselled
and test for HIV, on his own free will or as
advised by a medical provider.
Functions of ICTC
Early detection of HIV
Provision of basic information on mode of
transmission and prevention of HIV/AIDS
Link people with other HIV prevention,
care and treatment services.
Types of ICTC
Fixed facility ICTCs
Mobile ICTC
27
• HIV%screening%using%whole%blood%
finger%prick%test/mobile%ICTCs%
reaching%vulnerable/HRGs/unreached%
popula@on%
Community%%
Level%
• Standalone%ICTCs%and%facility%
ICTCs%
Village%level%
PHC%
24%X%7%PHCs%etc.%
Private%
hospitals/labs/
NGOs%etc.%
• Standalone%ICTC%and%
facility%ICTC %%
SubMdistrict%level%
e.g.%Civil%Hospitals%
Community%Health%
Centres%etc.%
• Standalone%ICTCs%
State%and%District%level%
e.g.%Medical%colleges/District%
hospitals%etc.%
LEVEL OF HIV
COUNSELLING AND
TESTING SERVICES

28. DIFFERENT TYPES OF ICTCS
Fixed-facility ICTCs: those located within existing health-care facility/hospital/
centre. It is of two types
Standalone ICTC ( SA-ICTCs): Having a full time counsellor and laboratory
technician who undertake HIV counselling and testing.Exist in medical colleges and
district hospitals.
Facility ICTC (F-ICTCs): Does not have full-time staff and provide HIV
counselling and testing as service along with other services. Existing staff such as
ANM/Staff nurse etc. are expected to take the activity.
Mobile ICTC:It is a van with a room to conduct general examination, counselling and
space for collection and processing blood samples by a team of paramedical healthcare
providers. Useful in H2R with flexible working hours and provide services like
Counselling and testing services for HIV
Syndromic management of STI/RTI
Regular health check ups/ANC/Immunization etc.28

29. OUTCOME
On a site wise analysis, it is noted overall that 70 sentinel sites have shown HIV
prevalence of 1% or more among ANC clinic attendees. 9 sites showed
prevalence of 2% or more [CTG (3/1), GUJ (7/1), KTN (5/1), MAN
(3/1),MIZ (3/1), NGN (7/3),RAJ (4/1)]
The declining number of the HIV epidemic in the country is also corroborated
by declining numb of HSS sites showing prevalence of 1% or more.
No. of surveillance sites among ANC in 2003-476
No. of surveillance sites among ANC in 2014-15 –776
No. of ANC HSS showing prevalence of 1% or more in 2003-140
No. of ANC HSS showing prevalence of 1% or more in 2014-15-70
29

30. PPTCT
In India the PPTCT intervention under NACP started in 2001-02 using SD-NVP
prophylaxis for HIV-positive pregnant women during labour and her newborn child
immediately after birth.
India has transitioned from the SD-NVP to multi-drug ARV prophylaxis from
September 2012.This was initially executed in souther high HIV prevalent states of
AP, KTN and TN.
30
The new guidelines of WHO (June 2013)
recommends following options to be practiced;
Provide life long ART to all PW and BFW
living with HIV regardless of CD4 count or
clinical stage
OR
Providing ART for PW and BFW with HIV
during mother to child transmission risk
period and continuing lifelong ART for
those women eligible for treatment of their
own health.

31. ESSENTIAL PACKAGE OF PPTCT SERVICES
Routine offer of HIV counselling and testing to all pregnant women through ANC
with "opt out option".
Ensure involvement of spouse & family members and move from an "ANC
centric" to family centric approach
Provide ART to all infected pregnant women regardless of CD4 count or staging .
Preferred regimen is TDF+3TC+EFV
Promote Institutional delivery. Provision of care for associated conditions
( STI/RTI & TB)
Nutritional counselling and psychosocial support to infected pregnant
women.
Provide counselling and support for initiation of BF within one hour as the
preferred option and follow protocol henceforth.31

32. Provide antiretroviral prophylaxis to infant from birth up to
minimum period of six weeks.
Integrate follow up of HIV exposed infant (HEIs) into routine
healthcare services including immunisations.
Ensure initiation of CPT and Early Infant Diagnosis (EID) using
HIV DNA PCR at 6 weeks of age onwards
Strengthen follow up in the community through ANM/ASHAs and
district level networks
32
ESSENTIAL PACKAGE OF PPTCT SERVICES

33. 33
Pregnant women visiting HSC
ANC registration by HSC ANM
HSC:Routine ANC & PNC
HSC: Screen Pregnant women for HIV,
Syphilis and TB
Screening test for HIV:
Provide group/individual counselling
session
Offer HIV test
Screening test for Syphilis: Does finger
prick whole blood test for syphilis
screening
Screening for TB
Refer PW to DMC at PHC if there is
persistent cough of any duration
Agree for test collection of blood
sample and does finger prick whole
blood test for HIV
Opt out/refuse test
Repeat counselling
Offer HIV test at each subsequent visit
HIV -ve HIV reactive
Post test counselling , information
Support
Refer to ICTC for
confirmation of HIV
ICTC collect 5 ml blood for HIV rapid
test and RPR test if not done earlier
If HIV +ve
RPR +ve
If HIV -ve
provide post
test
counselling
Start treatment ,
advice condom
use and Partner
test
If syphilis reactive refer to PHC/STI
clinic for symptomatic treatment and
RPR testing for confirmation
Continue treatment , advice condom use
and partner treatment
Refer to PHC with DMC if women
has above symptoms
Start ATT
RPR +ve
Refer to ART for CD4 test, TB
screening and clinical staging

34. AIDS CONTROL PROGRAMME IN INDIA
• HIV infection 1st detected in 1986 when 10 HIV positive samples were found from a group
of 102 female sex workers from Chennai
• In 1986 AIDS Task Force set up under ICMR and established NAC chaired by MOHFW
• In 1990 Medium Term Plan launched for 4 states and 4 metros
• NACP-I launched in 1992/NACP-II launched in 1999/NACP-III implemented during
2007-12/NACP-IV ( 2012-2017)
• NACP and NBP adopted in 2002. ART started in 2004. In 2006 National council on AIDS
constituted under PM chairmanship followed by paediatric ART formulation.
34

35. NACP-I
• OBJECTIVE
• Slow and prevent the spread of HIV through a major effort to prevent HIV transmission.
• KEY STRATEGIES
• Raising awareness, Blood safety, Prevention among high risk populations and Improved
surveillance
• ACHIEVEMENTS
• National AIDS response structure at both national and state levels and provided critical financing
• Strong partnership with WHO followed by establishment of State AIDS control cells
• Improved blood safety and expanded sentinel surveillance followed by National HIV testing policy
• Improved condom promotion activities.
35

36. NACP-II
• OBJECTIVE
• Reduce the spread of HIV infection in India through behaviour change and increase capacity to
respond to HIV on long term basis
• KEY STRATEGIES
• TI for HRG, Preventive intervention for general populations, Involvement of NGOs, Institutional
strengthening.
• ACHIEVEMENTS
• At the operational level 1033 TI set up, 875 Voluntary counselling and testing centres (VCTC) and 679
STI clinics at the district level
• Nation wide and state level BSS surveys were conducted
• PPTCT programme expanded. CMIS created.Support from partner agencies increased substantially.
• HIV prevention, care and support organisations and networks were strengthened
36

37. • Reduce the rate of incidence by 60% in the first year of the programme in high
prevalence states to obtain the reversal of epidemic, and by 40% in the
vulnerable states to stabilise the epidemic
37
OBJECTIVE OF NACP-III

38. NACP-IV PROJECT DESIGN
Key strategies
under NACP-IV
Strengthening
SIMS
Intensify and
consolidate
preventive
services
Increase access
& promote
comprehensive
care, support and
treatment
Capacity
building
Expanding
IEC services
Objective 1: Reduce new infections by 50% ( 2007 Baseline of NACP
III)
Objective 2: Provide Comprehensive care and support to all
PLHIV and treatment services those who require it
38

39. INTENSIFYING AND CONSOLIDATING PREVENTION
39
•Prevention the core strategy as 99% of the people are HIV negative.
!
•It is planned to cover 90% of HRG through TI implemented by NGOs and CBOs.
!
•High risk migrants, their spouses, truckers and other vulnerable population will be assessed by
collaborating with other departments, women groups and youth clubs
!
Activities
•Saturating quality HIV prevention services to all HRG groups,based on emerging behaviour
patterns and evidence
!
•Strengthening needle exchange programme , drug substitution programme and providing
Opioid Substitution Therapy
!
•Reaching out to MSM and Transgender
!
•Addressing the issue related to coverage and management of rural interventions
!
•Providing quality STI/RTI services
!
•Strengthening management structure of blood transfusion services
!
•Expanding the ICTC services and strengthen referral services.

40. COMPREHENSIVE CST
Additional CoEs and upgraded ART plus Centres will be established to provide high quality
treatment
Treatment of HIV/AIDS will include:
• ART including second line
• Management of opportunistic infections including TB in PLHIV.
• Positive interventions
• facilitating social protection and insurance for PLHIV.
Activities
• Scale of ART centres, LACs, and CoEs ART services.
• Strengthening follow up of patients on ART and improving quality of counselling services at
ART service delivery points
• Comprehensive care and support services for PLHIV through linkages
• Provide guidelines and training for integration in health care settings to NRHM
40
CoE$&$
$ART$plus$
Selected$Medical$
$college$
ART$Centres$
Medical$college$and$District$hospital$
Link$ART$centre$and$LAC$plus$centre$
Sub$district$hospital$and$CHC$

41. EXPANDING IEC SERVICES FOR (A) GENERAL POPULATION AND
(B) HIGH RISK GROUPS WITH A FOCUS ON BEHAVIOUR CHANGE
• Increasing awareness among general population in
particular women and youth.
• BCC strategies for HRG and vulnerable groups
• Continued focus on demand generation of services
• Reach out to vulnerable populations in rural settings ( Link
Worker Scheme)
• Extending services to tribal groups and hard to reach
populations
41

42. STRENGTHENING INSTITUTIONAL CAPACITIES
• The programme management structures established under NACP will be
strengthened
• Programme planning and management responsibilities will be enhanced at national
state districts and facility levels
• Phased integration of the HIV services with the routine public sector health
delivery systems, streamlining the supply chain mechanism and building
capacities of governmental and non-governmental institutions
42
GUIDING PRINCIPLES FOR NACP-IV
• 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 right of the PLHIV
• Civil society representation and participation, improved PPP. Evidence based and result oriented
programme implementation

43. KEY PRIORITIES UNDER NACP-IV
• Prevention new infections by sustaining the reach of current interventions
• PPTCT. Focusing on IEC strategies for behaviour change in HRG, awareness among general
population and demand generation for HIV services
• Providing CST to eligible PLHIV, reduce stigma and discrimination through Greater
involvement of PLHA ( GIPA)
• Ensure effective use of strategic information at all levels of programme
• Integrating HIV services with health systems in a phased manner. Building capacity of
NGOs and civil society partners
• Maintaining of HIV/AIDs activities with all key central/state level ministries/departments
will be given a high priority.
43

44. KEYS INITIATIVES UNDER
SIMS
44
• IBBS among HRG and Bridge
groups
• National Data Analysis Plan
• National Research Plan
• Advanced analytic and GIS
MONITORING FRAMEWORK
• Impact Indicators
• Reduction of HIV Incidence
• Estimated number of annual ARD
• %age of adults and children with HIV known to be on
treatment at 24 months after initiation of ART at
selected ART centres.
• Outcome Indicators
• %age of FSW who report using condom with their last client ( Target 80-85%
by 2017; 5% increase over the baseline 2012-13)
• MSM who report using condoms during sex ( Target 45% to 65% increase by
2017. 20% increase over the baseline of IBBS 2012-13)
• %age of IDU who do not share injecting equipment during last injecting act
( Target 45% to 65% increase by 2017; 2-% increase over the baseline of IBBS
2012-13)

45. TI FOR HRG
• Objective: Improve health seeking behaviour and reducing risk of getting STD and HIV infection
• Services offered include;
• Detection and treatment of STD
• Condom Distribution and promotion through social marketing. Based on HIV prevalence and
family planning districts classified into 4 categories
• HPHF (42), HPLF (45), LPHF (135 ) and LPLF .
• BCC with community involvement and participation
• Linkage with ICTC and CST
• For IDUs
• Distribution of clean needles and syringes, Abscess prevention and management, Opioid
substitution therapy and Linkage with detoxification and rehabilitation services
• For MSM/TGs
• Provision of project based STI clinics
45

46. 46

47. BLOOD TRANSFUSION SERVICES
The division of blood safety has been renamed to Blood transfusion services to
expand the horizon of blood safety to include;
TTI/Immunopathology/Quality Management systems
Logistic and other process involved to improve confidence in safety of blood.
Blood transfusion council have been set at national and state level.
Licensed blood bank operate in the country and voluntary blood donation is
encouraged.
The strategy is to ensure safe collection, processing, storage and distribution of blood
and blood products.
Every unit of blood need to be tested to rule out HIV/HBV/HCV/Malaria and
Syphilis.
Access to safe blood is the responsibility of NACO. Role of FRUS at Sub district
level.
47

48. TB and HIV
• TB is the most important opportunistic infection among PLHIV.
– TB infection: 10% life time risk of getting TB
– HIV infection: 30% life time risk of getting TB
– Dual infection of TB and HIV:50% life time of getting TB.
• HIV- infected TB patients should be referred to ART. The visit should be at least 2
weeks after initiation of TB treatment to ensure reduction in TB transmission from
these patients to large HIV- infected persons.
• NACO recommends that ART be given to
• All patients with EPTB and
• All those with PTB ( stage 3) with CD4 count<350 cells/mm
3
48

49. Activities to reduce HIV-TB
Mortality
49
TB/HIV co-ordination to reduce mortality
Prevention
Isoniazid preventive treatment
Airborne infection control
Awareness generation
Early Detection of TB/HIV
100% coverage of PITC in TB patients
Rapid diagnostic for detection of TB and DR-TB in PLHIV
ICF activities at all HIV settings-ICTC, ART, LAC, and TI
setting
Prompt T/T of TB/HIV
Early initiation of ART
Prompt treatment of TB treatment
Management of Special/TB/HIV cases
TB/HIV patients on PI based ARV
TB/HIV in children
TB/HIV pregnant women
Drug resistant TB/HIV

50. 50
UNIVERSAL PRECAUTIONS
Universal Precautions are control guidelines designed to protect workers from exposure to
diseases spread by blood and other body fluids.
By now we have the name called standard precautions which is designed to reduce the risk of
transmission of blood borne and other pathogens from both recognised and unrecognised
sources to a susceptible host.
Universal precautions include the following interventions;
Hand washing after any direct contacts with patients. Prevent recapping of needles
Safe collection and disposal of needles.
Wearing gloves for contact with body fluids, non- intact skin and mucus membrane.
Wearing a mask eye protection,and a gown if blood or other body fluids might splash.
Covering all cuts and abrasions. Carefully cleaning up spills of blood and other body fluids
Using safe system for health care waste management and disposals

51. 51
MonitoringandEvaluation:DraftGlobalHealthSector
Strategy2016-2021
Vision:Zero new HIV Infections. Zero HIV related deaths and Zero HIV related discriminations in world
where PLHIV are able to live long and healthy lives
Goal:End AIDS Epidemic as public health threat by 2030
2020 Targets:Reduce new HIV infections to less than 5,00,000. Zero new infection among infants. Reduce HIV
related deaths to below 5,00,000.90% of PLHIV to be tested.90% treated .90% virally suppressed.
Framework of action : Universal Health coverage , the continuum of services and a public health approach
Strategic Direction
1
Information and
focused action
The "who" and
"where"
Strategic Direction 2
Intervention for
impact
The "what"
Strategic Direction 3
Delivering for equity
The "how
Strategic Direction 4
Delivering for equity
Financing for
sustainability
The "financing"
Strategic Direction
5
Innovation for
acceleration
The future
Strategy Implementation
Leadership,Partnership,Accountability,Monitoring & Evaluation
Country action Country Partner action
WHO action HQ, Regions and
Countries
Global Partner action

52. 52
• Major Challenges towards the development of an effective HIV/AIDS vaccine
• Genetic diversity: HIV multiplies at very rapid pace and is different from the parent virus.
• Failure in formation of virus neutralising antibodies
• Lack of proper animal model since infection can occur with SIV
• World largest trail phase III was done in Thailand from 2003-2009. Trial is known as RV 144
"prime (ALVACHIV)—boost (AIDS VAX B/E)" combination
• 6 dose given in 6 months ( 4 with ALVAC and last two with AIDS VAX B/E)
• Result announced in 2009 in which it is estimated of 31.2% effective in preventing HIV
infections.

53. 53
• HIV continue to be major public
health issue globally claiming
more than 34 million lives so far.
• Can be transmitted via exchange of
variety of body fluids from infected
individuals
• Risk Factors
• unprotected vaginal or anal
sex and having STI
• Sharing contaminated
needles, syringe, receiving
unsafe injections and Needle
stick injury
• All HIV testing services must
include 5 C's recommended by
WHO;
consent,confidentiality,Counselling
,Correct test result and connection
( linkage to CST)
• Prevention
• Male and female
condom use
• Testing and counselling
for HIV and STI
• ART for prevention
• Harm reduction fo IDU
• EMTCT
SUMMARY

54. REFERENCES:
1. Park's Textbook of PSM 23rd Edition/Epidemiology of communicable disease/Health Programme in
India/HIV/AIDS
2. Community Medicine with recent advances/Epidemiology of communicable disease/Health
Programme in India/HIV/AIDS
3. India HIV estimation 2015 Technical report by NACO, MIMS, ICMR, MOHFW GOI
4. HIV Sentinel Surveillance Technical Brief by NACO 2014-15
5. Operational Guidelines on ICTC by NACO
6. NACP-IV (2012-2017) strategy document by NACO GOI.
7. National Integrated Biological and Behavioural Surveillance (IBBS) 2014-2015
8. Health 2015 from MDGs to SDGs by WHO
9. UNAIDS fact sheet 2015
10.Draft HIV strategy 2016-2021 by WHO
11.Guideline on when to start ART and on pre-exposure prophylaxis for HIV sept 2015
54

55. Thank you and its open for
discussion!!!
55

56. 56
HRG ( IDU/FSW/MSM/TG)
Bridge Population ( STD
Patients/SMM/LDT)
General Population: Pregnant
Women attending ANC clinics
Sentinel site Target intervention (TI)
projects)
STD clinic, TI Projects ANC
Sample size 250 250 400
Duration 3 months 3 months 3 months
Frequency Once in 2 years Once in 2 years Once in 2 years
Sampling
methods
Consecutive/random Consecutive Consecutive
Age group 15-49 yrs 15-49 yrs 15-49 yrs
Testing Strategy
Unlinked anonymous with
informed consent
unlinked anonymous at STD,
with informed consent at TI sites
Unlinked anonymous
Blood specimen Dried blood spot Serum at STD, DBS at TI sites Serum
Testing Protocol Two tested protocol Two tested protocol Two tested protocol