Epidemiology of hiv

 “HIV” stands for Human Immunodeficiency
Virus.
 H - Human: This particular virus can only infect
human beings.
 I - Immunodeficiency: HIV weakens immune
system by destroying important cells that fight
disease and infection.
 V - Virus: A virus can only reproduce itself by
taking over a cell in the body of its host.

 AIDS: The acquired immuno deficiency
syndrome(sometimes called “slim disease” is a fatal
illness caused by a retro virus known as the Human
Immunodeficiency Virus (HIV) which breaks
down the body’s immune system,leaving the victim
vulnerable to a host of life-threatening oppurtinistic
infection,neurological disorder, unusaul
malignancies.
 AIDS refer only to the last stageof the HIV
infection

 HIV is a lenti virus, and like all viruses of this
type, it attacks the immune system. Lenti
viruses are in turn part of a larger group of
viruses known as retroviruses. They are
found in a number of different animals,
including cats, sheep, horses and cattle.
However, the most interesting lenti virus in
terms of the investigation into the origins of
HIV is the Simian Immunodeficiency Virus
(SIV) that affects monkeys, which is believed
to be at least 32,000 years old.

 How could HIV have crossed species?
 It has been known for a long time that certain
viruses can pass between species. Indeed, the
very fact that chimpanzees obtained SIV from
two other species of primate shows just how
easily this crossover can occur. As animals
ourselves, we are just as susceptible. When a
viral transfer between animals and humans
takes place, it is known as zoonosis.

 Below are some of the most common theories
about how this 'zoonosis' took place, and how
SIV became HIV in humans:
 The 'hunter' theory
 The oral polio vaccine (OPV) theory
 The contaminated needle theory
 The colonialism theory
 The conspiracy theory

An HIV particle is around:0.1 microns
HIV particles can be seen with an electron microscope.The
viral core (or capsid) is usually bullet-shaped and is made
from the protein p24. Inside the core are three enzymes
required for HIV replication called reverse transcriptase,
integrase and protease. Within the core is HIV's genetic
material, which consists of two identical strands of RNA.

HIV Strains: Types, Groups and Subtypes
 HIV is a highly variable virus which mutates
very readily. This means there are many
different strains of HIV, even within the body
of a single infected person.
 Based on genetic similarities, the numerous
virus strains may be classified into types,
groups and subtype

 types of HIV:
 HIV-1 and HIV-2. Both types are transmitted
by sexual contact, through blood, and from
mother to child, and they appear to cause
clinically indistinguishable AIDS. However
HIV-2 is less easily transmitted, and the
period between initial infection and illness is
longer .
 Worldwide, the predominant virus is HIV-1,
The relatively uncommon HIV-2 type is
concentrated in West Africa and is rarely
found elsewhere.

Strains of HIV-1 can be classified into four groups: the "major" group M,
the "outlier" group O and two new groups, N and P. These four groups
may represent four separate introductions of simian immunodeficiency
virus into humans.
Group O appears to be restricted to west-central Africa and group N - a
strain discovered in 1998 in Cameroon - is extremely rare. In 2009 a new
strain closely relating to gorilla simian immunodeficiency virus was
discovered in a Cameroonian woman. It was designated HIV-1 group
P. More than 90 percent of HIV-1 infections belong to HIV-1 group M
and, unless specified, Within group M there are known to be at least nine
genetically distinct subtypes of HIV-1. These are subtypes A, B, C, D, F,
G, H, J and K.

 Occasionally, two viruses of different
subtypes can meet in the cell of an infected
person and mix together their genetic material
to create a new hybrid virus. Many of these
new strains do not survive for long , but those
that infect more than one person are known as
(circulating recombinant forms)or CRFs.

 Are more subtypes likely to "appear"?
 It is almost certain that new HIV genetic
subtypes and CRFs will be discovered in the
future, and indeed that new ones will develop
as virus recombination and mutation continue
to occur. The current subtypes and CRFs will
also continue to spread to new areas as the
global epidemic continues.

 Does subtype affect disease progression?
 A study presented in 2006 found that
Ugandans infected with subtype D or
recombinant strains incorporating subtype D
developed AIDS sooner than those infected
with subtype A, and also died sooner, if they
did not receive antiretroviral treatment. The
study's authors suggested that subtype D is
more virulent because it is more effective at
binding to immune cells.

 Are there differences in transmission?
 It has been observed that certain
subtypes/CRFs are predominantly associated
with specific modes of transmission. In
particular, subtype B is spread mostly by
homosexual contact and intravenous drug use
(essentially via blood), while subtype C and
CRF A/E tend to fuel heterosexual epidemics
(via a mucosal route).

 Is it possible to be infected more than once?
 It was generally thought that individuals do
not become infected with multiple distinct
HIV-1 strains. Since then, many cases of
people co infected with two or more strains
have been documented.
 However, it is now thought that
"superinfection" occurs. In these cases, the
second infection occurs several months after
the first. Body's immune response to the first
virus is sometimes not enough to prevent
infection with a second strain, especially with
a virus belonging to a different subtype.

 Do HIV antibody tests detect all types, groups
and subtypes?
 Initial tests for HIV are usually conducted
using the EIA(ELISA) antibody test .
 Compared with first generation , third and
fourth generation EIA antibody tests are
significantly more accurate. the fourth
generation test detects HIV antibodies and
HIV-1 and HIV-2 infections.
 Although most HIV infections are HIV-1
group M, tests are also able to detect
infections with rare groups and subtypes.

 What are the implications for AIDS vaccine?
 The development of AIDS vaccine is affected
by the range of virus subtypes . In particular,
the occurrence of superinfection indicates that
an immune response triggered by a vaccine to
prevent infection by one strain of HIV may
not protect against all other strains. The
increasing variety of sub-types found within
countries suggests that the effectiveness of a
vaccine is likely to vary between populations,
unless an innovative method is developed
which guards against many virus strains.

 Transmission
When HIV enters your body through sexual contact,
transfusions with infected blood, or by injection
with a needle that has infected blood in or on it,
researchers believe that the virus attaches to a
specific type of immune system cell called
a dendritic cell. These cells are found
in mucocutaneous (mucosal membranes) areas that
line the mouth, the vagina, rectum, penis, and the
upper gastrointestinal tract. Scientists think that
these dendritic cells transport the virus from the site
of the infection to your lymph nodes where HIV
can infect other immune system cells.

 THE LIFE-CYCLE OF HIV IN YOUR CELLS
 HIV can infect multiple cells in your body, including
brain cells, but its main target is the CD4 lymphocyte,
also called a T-cell or CD4 cell. When a CD4 cell is
infected with HIV, the virus goes through multiple
steps to reproduce itself and create many more virus
particles.The process is broken up into the following
steps:
 Binding and Fusion: This is the process by which HIV
binds to a specific type of CD4 receptor and a co-
receptor on the surface of the CD4 cell. This is similar
to a key entering a lock. Once unlocked, HIV can fuse
with the host cell (CD4 cell) and release its genetic
material into the cell.

 Reverse Transcription: A
special enzyme called reverse transcriptase changes the
genetic material of the virus, so it can be integrated
into the host DNA.
 Integration: The virus’ new genetic material enters
the nucleus of the CD4 cell and uses an enzyme called
integrase to integrate itself into your own genetic
material, where it may “hide” and stay inactive for
several years.
 Transcription: When the host cell becomes activated,
and the virus uses your own enzymes to create more of
its genetic material—along with a more specialized
genetic material which allows it make longer proteins.

 Assembly: A special enzyme called protease cuts the
longer HIV proteins into individual proteins. When
these come together with the virus’ genetic material, a
new virus has been assembled.
 Budding: This is the final stage of the virus’ life cycle.
In this stage, the virus pushes itself out of the host cell,
taking with it part of the membrane of the cell. This
outer part covers the virus and contains all of the
structures necessary to bind to a new CD4 cell and
receptors and begin the process again.
 These steps of the life-cycle of HIV are important to
know because the medications used to control HIV
infection act to interrupt this replication cycle.

 We know that HIV can hide for long periods of time in
the cells of your body and that it attacks a key part of
your immune system – your T-cells or CD4 cells. Your
body has to have these cells to fight infections and
disease, but HIV invades them, uses them to make
more copies of itself, and then destroys them.
 Over time, HIV can destroy so many of your CD4 cells
that your body can't fight infections and diseases
anymore. When that happens, HIV infection can lead to
AIDS, the final stage of HIV infection.

 However, not everyone who has HIV progresses to
AIDS. With proper treatment, called “antiretroviral
therapy” (ART), you can keep the level of HIV virus in
the body low. ART is the use of HIV medicines to fight
HIV infection. It involves taking a combination of HIV
medicines every day. These HIV medicines can control
the virus so that you can live a longer, healthier life and
reduce the risk of transmitting HIV to others. Before
the introduction of ART in the mid-1990s, people with
HIV could progress to AIDS in just a few years. Today,
a person who is diagnosed with HIV and treated before
the disease is far advanced can have a nearly normal
life expectancy.

Immune system has different ways of fighting off
foreign invaders. When confronted with a virus, body
responds by activating specific processes of the
immune system. First body recognizes a
foreign antigen and delivers it to the lymph system,
where it is ingested by a macrophage.
 Then the macrophage processes the virus and displays
the antigens for that particular virus on its own exterior.
This antigen then signals a helper T- cell.
 Next the T-cell reads this signal and sounds the alarm
for other parts of immune system to respond.
 The B-cell responds to this call and comes to read the
antigen from the surface of the macrophage.

 The B cell then becomes activated and produces
millions of antibodies that are specific to the antigen.
These antibodies are released into the body to attach to
the virus particles.
 The antibodies attach to the antigens and hold on tight.
 These antibodies then send a signal to other
macrophages and other immune cells to come and
engulf and destroy the antibody and whatever it has
captured.
 The final stage of immune response involves the
suppressor T-cell. Once the number of invaders has
dropped significantly and the infection has resolved,
the suppressor T-cell will signal the other cells of the
immune system to rest.

 HIV disrupts this process by directly infecting
the helper T-cells. Your initial immune
response does get rid of a great deal of HIV,
but some of it manages to survive and infect
these important cells. Once the infected helper
T-cells are activated, they work to create new
viruses instead of doing the job they are
supposed to do in the immune system. In
addition, many helper T-cells are destroyed in
the HIV replication process.

 ACUTE INFECTION STAGE
 Within 2-4 weeks after HIV infection, people develop flu-
like symptoms, often described as “the worst flu ever.”
Symptoms can include fever, swollen glands, sore throat,
rash, muscle and joint aches and pains, fatigue, and
headache. This is called “acute retroviral syndrome”
(ARS) or “primary HIV infection.”
 During this early period of infection, large amounts of virus
are being produced in the body. The virus uses CD4 cells to
replicate and destroys them in the process. Because of this,
CD4 count can fall rapidly. Eventually immune response
will begin to bring the level of virus in the body back down
to a level called a viral set point. At this point, CD4 count
begins to increase, but it may not return to pre-infection
levels.
 It is important to be aware that people are at particularly
high risk of transmitting HIV to the sexual or drug using
partners during this stage because the levels of HIV in the
blood stream are very high.

 CLINICAL LATENCY STAGE
 Means a period where a virus is living or developing in a
person without producing symptoms. During the clinical
latency stage, people who are infected with HIV experience
no HIV-related symptoms, or only mild ones. (This stage is
sometimes called “asymptomatic HIV
infection” or “chronic HIV infection.”)
 During the clinical latency stage, the HIV virus continues
to reproduce at very low levels, although it is still active. If
you take ART, you may live with clinical latency for
several decades because treatment helps keep the virus in
check.For people who are not on ART, the clinical latency
stage lasts an average of 10 years, but some people may
progress through this stage faster.
 It is important to remember that people in this symptom-
free stage are still able to transmit HIV to others, even if
they are on ART, although ART greatly reduces the risk of
transmission.

 AIDS
 This is the stage of HIV infection when patients immune
system is badly damaged and become vulnerable to
infections and infection-related cancers called opportunistic
infections. When the number of CD4 cells falls below 200
cells per cubic millimeter of blood, are considered to have
progressed to AIDS. (In a healthy immune system, CD4
counts are between 500 and 1,600 cells/mm3.) people are
also considered to have progressed to AIDS if they develop
one or more opportunistic illnesses.
 People who progress to AIDS typically survive about 3
years. Once patient have a dangerous opportunistic illness,
life-expectancy without treatment falls to about 1 year.
However, if they are taking ART and maintain a low viral
load, then they may enjoy a near normal life span.
 people will most likely never progress to AIDS.

 FACTORS AFFECTING DISEASE PROGRESSION
 People living with HIV may progress through these
stages at different rates, depending on a variety of
factors, including their genetic makeup, how healthy
they were before they were infected, how soon after
infection they are diagnosed and linked to care and
treatment, whether they see their healthcare provider
regularly and take their HIV medications as directed,
and different health-related choices they make, such as
decisions to eat a healthful diet, exercise, and not
smoke.

 Factors that may shorten the time between HIV and
AIDS:
 Older age
 HIV subtype
 Co-infection with other viruses
 Poor nutrition
 Severe stress
 genetic background

 Factors that may delay the time between HIV and
AIDS:
 Taking antiretroviral therapy
 Staying in HIV care
 Closely adhering to doctor’s recommendations
 Eating healthful foods
 Taking care of themself
 Genetic background
 As noted above, when used consistently, ART prevents
the HIV virus from multiplying and from destroying
immune system. And there are other treatments that can
prevent or cure some of the illnesses associated with
AIDS, though the treatments do not cure HIV itself.

People living with HIV/AIDS
 Morbidity
 35.0 millionpeople living with HIV/AIDS worldwide
in 2013
 Mortality
 1.5 millionpeople died of AIDS-related illnesses
worldwide in 2013

 Global situation and trends:
 Since the beginning of the epidemic, almost 78
million people have been infected with the HIV virus
and about 39 million people have died of HIV.
Globally, 35.0 million [33.2–37.2 million] people are
living with HIV at the end of 2013. An estimated
0.8% of adults aged 15–49 years worldwide are
living with HIV, although the burden of the epidemic
continues to vary considerably between countries
and regions. Sub-Saharan Africa remains most
severely affected, with nearly 1 in every 20 adults
living with HIV and accounting for nearly 71% of
the people living with HIV worldwide.

 India has the third largest HIV epidemic in the
world. In 2013, HIV prevalence in India was an
estimated 0.3 percent. This figure is small compared to
most other middle-income countries but because of
India's huge population (1.2 billion) this equates to 2.1
million people living with HIV. In the same year, an
estimated 130,000 people died from AIDS-related
illnesses.
 Overall, India’s HIV epidemic is slowing down, with a
57 percent decline in new HIV infections between 2000
and 2011, and a 29 percent decline in AIDS-related
deaths between 2007 and 2011.

 HIV prevalence in India varies geographically. The
four states with the highest numbers of people living
with HIV (Andhra Pradesh, Karnataka, Maharashtra
and Tamil Nadu) are in the south of the country and
account for 53 percent of all HIV infections. However,
HIV prevalence is falling in these states. By
comparison, in some states in the north and northeast
of the country, the number of new HIV infections is
rising.

 Number of people (all ages) living with HIV
 Situation and trends
 As of 2013, the global number of people living with
HIV is 35.0 million [33.2 million–37.2 million],
compared to 29.8 million [28.1 million–31.9 million]
in 2001. This reflects continued transmission of HIV
despite reductions in incidence, and the benefits of
signiﬁcantly expanded access to antiretroviral, which
have helped to reduce the number of people dying from
AIDS-related causes, especially since 2004–2005.

 Number of women living with HIV
 The proportion of women living with HIV has
remained stable, at 50% of the global total. About 16
million adults living with HIV are women. Women
comprised 59% of the adults living with HIV in sub-
Saharan Africa in 2013, as they have for most of the
past decade.

 Prevalence of HIV among adults aged 15–49 (%)
 Since the beginning of the epidemic, almost 78 million
people have been infected with the HIV virus and
about 39 million people have died of HIV-related
causes.
 Globally, 35.0 million [33.2–37.2 million] people were
living with HIV at the end of 2013. An estimated 0.8%
of adults aged 15–49 years worldwide are living with
HIV, although the burden of the epidemic continues to
vary considerably between countries and regions. Sub-
Saharan Africa remains most severely affected, with
nearly 1 in every 20 adults living with HIV and
accounting for nearly 71% of the people living with
HIV worldwide.

 Number of deaths due to HIV/AIDS
 Expanded access to antiretroviral therapy (ART) and a declining incidence of HIV infection
have led to a steep fall globally in the number of adults and children dying from HIV-related
causes. The estimated 1.5 million [1.4 – 1.7 million] people dying from HIV globally in
2013 were 22% fewer than in 2009 and 35% fewer than when the number peaked in 2005.
Children (younger than 15 years) in 2013 had 31% fewer deaths from HIV compared with
2009 and 40% fewer deaths compared with 2005.
 This puts the world on track to exceed the target of reducing the number of people dying
from HIV-related causes by 25% by 2015 (compared with a 2009 baseline)*. Globally, ART
programmes averted an estimated 7.6 million [6.9 – 8.4 million] deaths between 1995 and
2013
 The drop in HIV-related mortality is especially evident in the regions with the greatest
burden of HIV infection, including the WHO African Region, home to about three in four
people dying from HIV-related causes in 2013. An estimated 1.1 million [1.0 – 1.3 million]
people died in the African Region from HIV-related causes in 2013, 24% fewer than the 1.5
million [1.4 – 1.6 million] in 2009.

India has the third highest number of
estimated people living with HIV in the
world. According to the HIV Estimations
2012, the estimated number of people living
with HIV/AIDS in India was 20.89 lakh,
with an estimated adult (15-49 age group)
HIV prevalence of 0.27% in 2011. India has
demonstrated an overall reduction of 57% in
the annual new HIV infections among adult
population from 2.74 lakh in 2000 to 1.16
lakh in 2011,

Indian HIV/ AIDS epidemic
[Important milestones]
1986 First report of HIV infections in sex workers in
Chennai, first report of AIDS in Mumbai
1989 HIV infection reported among intravenous
drug users in Manipur State
1991 Indian National AIDS Control Programme was
launched
2000-
01
India PMTCT feasibility studies initiated by
NACO
2001 Indian pharmaceutical companies marketed
ARV drugs with considerable price reduction

Phase I At risk
population
Female sex
workers
Intravenous
drug users
Phase II Bridge
population
Male STD
patients
Other drug
users
Phase III Low/ No risk
population
Spouses of male
STD pts
Spouses of
drug users
Phase IV Children of HIV
infected women
Children of HIV
infecteddrug
users
Commonest mode of HIV spread in India is by sexual route
Mother to child transmission is on the rise HIV spread among
intravenous drug users mostly in north-eastern states Blood
transfusion associated spread is on the decline

* Practice of sex work
* No. of sex partners
* Receptive anal sex
* Females in sex work (FSW)
* Men having sex with FSW recently
* Lack of formal education
* Persons living away from family
* Previous / present STDs
* Absence of circumcision

 Modes of transmission
Sexual 84.24%
Perinatal 26.1%
Blood 2.99%
IDUs 2.83%
Others 7.32%

Status of HIV epidemic in India

 Maharashtra 10797
 Gujarat 2141
 Karnataka 1617
 Tamil Nadu 18276
 Andhra Pradesh 2565
 Manipur 1238
 Nagaland 298

High prevalent States
States where HIV prevalence in antenatal women is 1% or
more.
Moderate prevalent States
States where the HIV prevalence in antenatal women is
less than 1% and prevalence in STD and other high risk
groups is 5% or more.
Low prevalent States
States where the HIV prevalence in antenatal women is
less than 1% and HIV prevalence among STD and other
high-risk group is less than 5%.

HIV Prevalence
STD% ANC%
Andhra Pradesh 26.6 1.5
Karnataka 16.4 1.13
Maharashtra 9.2 1.75
Manipur 10.5 1.75
Nagaland 7.4 1.25
Tamil Nadu 12.6 1.13

HIV Prevalence
STD% ANC%
Goa 15.0 0.5
Kerala 6.42 0.08
Mizoram 2.2 0.33

Prevalence New Infections
1998 3.5 m -
1999 3.7 m 0.2 m
2000 3.86 m 0.16 m
2001 3.97 m 0.11 m
2003 5.1m
Inference : New infections are declining

 Pulmonary tuberculosis (49.1%; median
duration of survival, 45 months)
 Pneumocystis carinii pneumonia(6.1%;
median duration of survival, 24 months)
 Cryptococcal meningitis (4.7%; median
duration of survival, 22 months)
 CNS toxoplasmosis (3%; median duration of
survival, 28 months)

 Among key affected groups, sex workers and men who
have sex with men have experienced a recent decline in
HIV prevalence while the number of people who inject
drugs living with HIV has remained stable.
 However, transgender people are emerging as a group
at high risk of HIV transmission. Moreover, in certain
parts of the country, migrants and long distance
truckers continue to act as bridge populations between
certain groups and the general population, fuelling the
HIV epidemic.

 Sex workers and HIV in India
 Number of female sex workers: 868,000
 HIV prevalence: 2.7 percent
 HIV prevention activities coverage: 84.5 percent
 HIV prevalence among female sex workers varies both
between and within states. For example, one study found
HIV prevalence among sex workers ranged between 2
percent and 38 percent (averaging at 14.5 percent) among
districts in the four high prevalence south Indian states of
Andhra Pradesh, Maharashtra, Tamil Nadu and Karnataka.
 Male sex workers are a group particularly vulnerable to
HIV who engage in high-risk behaviours. One study in
suburban Mumbai reported an HIV prevalence of 33
percent among this group with all of the individuals in the
study engaging in anal sex while 13 percent had never used
a condom.

 Men who have sex with men (MSM) and HIV in India
 Number of MSM: 427,000
 An outreach worker provides a client with HIV and
safe-sex practice information at Santa Cruz station - a
popular location with MSM
 In India, many MSM have female partners. A large
study in Andhra Pradesh found that 42 percent of MSM
were married, while 50 percent had sexual relations
with a woman in the previous three months. Just under
half reportedly had not used a condom during their last
sexual encounter.

 Hijras / transgender people and HIV in India
 Number of transgender people: unknown
 HIV prevention activities coverage: unknown .
 Hijras, (also know as Aravani, Aruvani or Jagappa in other
areas) are names given to individuals in South Asia who
are transgender. In India, past surveillance and monitoring
of groups at a high risk of HIV transmission have not
considered transgender people as a distinct group, often
including them in MSM data. However, since 2012, the
National AIDS Control Programme has collected data and
surveillance about hijras separately.
 The traditional background of hijras is linked to high-risk
behaviours such as alcohol and substance use. Lower
literacy levels act as a barrier to accessing HIV
information. Many hijras also report unfair treatment in
healthcare settings with staff lacking education on their
specific needs. Indeed.

 People who inject drugs (PWID) and HIV in India
 Number of PWID: 177,000
 HIV prevalence among PWID in India has remained
largely unchanged since 2007. 30 percent of PWID
reside in north-eastern states where injecting drug use
is the major route of HIV transmission. However, HIV
prevention efforts in this region have reduced the
number of new infections. By contrast, HIV prevalence
among PWID in north-western states is increasing.

 Migrant workers and HIV in India
 Number of migrants: 7.2 million
 HIV prevalence: 1 percent
 Research worldwide has linked migration to increases in
HIV transmission. In India, migrants act as a bridge
population spreading HIV between urban and rural areas,
and between high-risk and low-risk groups.
 Despite being an important driver of the HIV epidemic in
India, data on migrant sexual behaviour is limited.
Moreover, migrants have been found to have low risk
perception of HIV transmission compared with other high-
risk groups. For example, one study in Andhra Pradesh
found that 60 percent of female sex workers acknowledged
their risk to HIV infection compared with just 5 percent of
male migrants.

 Truck drivers and HIV in India
 Number of truckers: 2 million
 HIV prevention activities coverage: 48.4 percent 31
 A number of studies from India have reported the high
vulnerability of truckers to HIV transmission with many
engaging in high-risk behaviours - an estimated 36 percent
of sex worker clients are truckers. Time away from home
on the road, marital status, alcohol use, and income level
have all been associated with visiting sex workers.
 Moreover, knowledge of how HIV is transmitted is low
among this group.
 These factors, in combination with inconsistent condom
use, mean truckers act as a bridge population transmitting
HIV to their regular sexual partners and into the general
population.

 HIV testing and counselling (HTC) in India
In 2014, there were nearly 15,000 healthcare facilities
offering HTC. In the same year, 13 million general
users and 9.7 million pregnant women accessed HTC
respectively .
 In order to address this issue, one study has proposed
universal testing of the general population and more
intensive testing of high-risk groups on a 5-year cycle.
It is argued this would be cost-effective with models
indicating that up to $1900 would be saved per year of
life (YLS) in general and $1300 YLS among key
affected groups. Additionally, more people would know
their status and therefore actively seek treatment before
developing AIDS-related illnesses encouraging
behaviour change and decreasing viral load. 39

 The National AIDS Control Organisation (NACO) is the
body responsible for formulating policy and implementing
programmes for the prevention and control of the HIV
epidemic in India.
 In 1992, India's first National AIDS Control Programme,
NACP-I (1992-1999) was launched with NACO
responsible for its delivery.
 NACP-II (1999-2006) oversaw the formation of a National
Council on AIDS mainstreaming HIV and AIDS as a
development issue as opposed to a public health one.
 NACP-III (2007-2012) focussed on targeted interventions
to dramatically increase coverage among high-risk groups.
 NACP-IV (2012-2017), aims to reduce annual new HIV
infections by 50 percent through the provision of
comprehensive HIV treatment, education, care and
support for the general population and build on targeted
interventions for key affected groups and those at a high
risk of HIV transmission.

 Targeted interventions for key affected groups
 A key component of the National AIDS Control
Programme is the prevention of new HIV infections by
achieving an 80 percent coverage of key affected
groups with targeted interventions (TIs).
 TIs are implemented on the premise that prevention of
HIV transmission from key affected groups such as sex
workers to their male clients (for example) will lower
HIV transmission among their sexual partners - e.g.
women in the general population.

 Some of the most high profile interventions are listed below.
 Project Pehchan:Launched in October 2010 in order to tackle
the HIV epidemic among MSM, Transgender people and Hijra
in India to access HIV and other sexual and reproductive health
services. Supported by the Global Fund, the 5-year project
works with roughly 200 community based organisations across
17 states to reach over 450,000 MTH members.
 Avahan: Since 2003, the project has worked to reduce HIV
transmission among sex workers, MSM and transgender
people through the provision of education as well
as condom promotion, sexually transmitted infection
(STI) management, behaviour change communication,
community mobilisation and advocacy. The programme has
been highly effective with 36-68 percent of new HIV infections
averted across the four focus states in a seven-year period. In
2013, it was announced that over the previous 10 years, Avahan
had averted 57 percent of HIV infections in southern
India. Avahan is internationally recognised as a cost-effective,
successful, targeted HIV prevention programme.

 The Sonaguchi Project : Launched in 1992, the Project
promotes the use of healthcare services by sex workers to
reduce HIV prevalence. The project employs peer
educators to provide information, distribute condoms,
promote behaviour change and refer sex workers to health
clinics.Sex workers participate in all areas of the project
and since 1999, have been responsible for its operation. In
the same year, the Durbar Mahila Samanwaya evolved out
of the project as a union representing sex worker
rights. The project has been promoted as a model of ‘best
practice’ for other sex worker projects around the world.
 Project Kavach:Since 2004, the project has been working
to stop the spread of HIV among truckers and other high-
risk populations. The project reaches out to 21,000 truckers
annually and encourages behaviour change through street
plays, magic shows and peer education. It also provides
healthcare services such as HIV and STI treatment, HIV
testing and counselling as well as condom promotion.

 Link Worker Scheme
 The Link Worker Scheme, supported by the UNDP, is a
community-based outreach strategy working to
address HIV prevention, treatment, care and support of
hard-to-reach groups in rural India.
 Specifically, the scheme provides information
resources on HIV and STI prevention, condom
promotion and distribution, HTC and referral to
treatment.

 The Red Ribbon Express
 Launched in 2007, the Red Ribbon Express is an HIV
and AIDS awareness campaign train run by Indian
Railways.
 By 2013, the train had visited 23 states reaching more
than 10 million people with messages about HIV
prevention in rural parts of India. The train now also
provides HIV testing and counselling (HTC) services
and treatment for sexually transmitted infections
(STIs) Most recently, the campaign has targeted young
people.

 The Condom Social Marketing Programme
(CSMP)
 The Condom Social Marketing Programme (CSMP)
aims to promote safer sex by improving the
availability of condoms and by utilising multimedia to
encourage behaviour change. To date, two mass media
campaigns have been launched in Hindi as well as
other regional languages. By 2014, the CSMP had
distributed over 560 million condoms across 15 states
from over 50,000 outlets

 Harm reduction in India
 Under the National AIDS Control Programme, harm
reduction in India is delivered through a number of
means including needle and syringe programmes
(NSPs), opioid substitution therapy (OST) and peer
education in a variety of healthcare settings. These
interventions are typically delivered by non-
government organisations (NGOs) but are financially
supported by the Indian government. Roughly 80
percent of an estimated 186,000 PWID are thought to
be covered by existing programmes.

 NACO actively distributes free needles and syringes to
PWID through peer educators working for a number of
TIs. PWID are strongly encouraged to return used
injecting equipment and exchange it for new, clean
equipment. In 2012, 44 percent of equipment was
returned.
 Opioid Substitution Therapy (OST) was incorporated
into the harm reduction programme in 2008. To date,
there are 150 OST centres supporting nearly 18,000
PWID. There are plans to increase this number to over
300 equating to a 20 percent OST coverage for
PWID. One of the first pilot programmes was set up in
the largest prison complex in South Asia - Tihar prisons
in Delhi.

 Preventing mother-to-child transmission (PMTCT) in
India
 The Indian government is committed to eliminating
new HIV infections among children by 2015. India's
Prevention of Parent to Child Transmission of
HIV/AIDS (PPTCT) programme started in 2002. To
date, there are over 15,000 sites
offering PMTCT services.The programme
initiates antiretroviral treatment for all pregnant and
breastfeeding women living with HIV regardless of
CD4 count or stage of HIV infection.
 In 2013-2014, 9.7 million pregnant women accessed
HIV testing against a target of 13.2 million - a
coverage of 74 percent.

 GENERAL PRE-TEST AND POST-TEST
INFORMATION
 Counseling before and after an HIV test is important
because it provides critical information about HIV
itself and about the testing process.Many testing sites
do offer these services.

 Pre-test counseling sessions generally include the
following:
 Information about the HIV test—what it tests for, and how
long it will take you to get your results
 Information about how HIV is transmitted and how you
can protect yourself from infection
 Information about the confidentiality of your test results
 Once the results are available, you will usually be given the
results in private and in person.
 Post-test counseling generally includes:
 Clear communication about what your test result means
 HIV prevention counseling, if your results are negative
 A confirmatory test, called a Western blot test, if your
results are positive. The results of that test should be
available within 2 weeks.

 IF YOUR HIV TEST IS POSITIVE
 Your counselor will discuss what it means to live a
healthy life with HIV and how you can keep from
infecting others.
 Your counselor will also talk about treatments for HIV
and can link you to a physician for immediate care.
Getting into treatment quickly is important—it can
help you keep your immune system healthy and keep
you from progressing to AIDS.
 All HIV-positive test results must be reported to your
state health department for data tracking. Many states
then report data to the CDC, but no personal
information (name, address, etc.) is ever shared when
those data are reported.

 HIV PRE-TEST AND POST TEST COUNSELING FOR
PREGNANT WOMEN
 All pregnant women should be tested for HIV as early as
possible during pregnancy, and HIV screening should be
included in the routine panel of prenatal screening tests.
 If a pregnant woman declines to be tested for HIV, her
healthcare providers should explore and address her reasons for
declining HIV testing.
 Pregnant women should receive appropriate health education,
including information about HIV and its transmission, as a
routine part of prenatal care.
 Access to clinical care, prevention counseling, and support
services is essential for women with positive HIV test results.
 HIV screening should be repeated in the third trimester of
pregnancy for women known to be at high risk for HIV.
 Repeat HIV testing in the third trimester is also recommended
for all women in areas with higher rates of HIV or AIDS and for
women receiving healthcare in facilities with at least one
diagnosed HIV case per 1,000 pregnant women per year.

 TYPES OF HIV TESTS
 Antibody Tests: The most common HIV tests look for
HIV antibodies in the body, rather than looking for
HIV itself:
 Enzyme immunoassay (EIA) tests use blood, oral fluid,
or urine to detect HIV antibodies.
 Rapid HIV antibody tests also use blood, oral fluid, or
urine to detect HIV antibodies.
 If you get a positive result from either of these tests,
you will need to take another test, called a Western blot
test, to confirm that result.

 Antigen Tests
These tests are used to diagnose HIV infection
earlier—from 1-3 weeks after patient are first infected
with HIV. Antigen tests require a blood sample.
 PCR Test (Polymerase chain reaction test)
This test detects the genetic material of HIV itself, and
can identify HIV in the blood within 2-3 weeks of
infection.
 Babies born to HIV-positive mothers are tested with a
special PCR test, because their blood contains their
mother's HIV antibodies for several months. This
means they would test HIV-positive on a standard
antibody test—but a PCR test can determine whether
the babies have HIV themselves.

 Blood supplies in most developed countries are
screened for HIV using PCR tests. PCR tests are also
used to measure viral loads for people who are HIV-
positive.
 Home testing kits are HIV antibody tests that people
can take in the privacy of your own home. Currently
only one test, the Home Access HIV-1 Test System, is
approved by the FDA for this purpose. This is not a
true HIV testing kit, but a sample-collection kit. You
collect a sample of your blood by sticking your finger
with a sterile lancet, put the blood on a special
collection card in the kit, and send it back to laboratory
for testing. At a later date, you call the lab for your
results.

 TESTING FREQUENCY
 The CDC recommends that opt-out HIV screening be a part
of routine clinical care for all patients aged 13-64.
 People should get tested for HIV every at least every
year if :THEY
 Share needles/syringes or other equipment for injecting
drugs
 Have a history of sexually transmitted diseases (STDs)
 Have had unprotected sex (vaginal, anal, or oral) with
multiple or anonymous partners,unprotected sex with a
partner who did not know their own HIV status.
 If people or their partner plan to become pregnant, getting
an HIV test is very important.
 All women who are pregnant should be tested during
the first trimester of pregnancy.

 WHAT YOUR TEST RESULTS MEAN - NEGATIVE
TEST RESULT
 Studies have proven that both conventional and rapid HIV
tests are highly accurate when they show an HIV-positive
result.
 But a negative result may not always be accurate. It
depends on when you might have been exposed to HIV and
when you took the test.
 It takes time for seroconversion to occur. This is when the
body begins to produce the antibodies an HIV test is
looking for—anywhere from 2 weeks to 6 months after
infection. So if you have an HIV test with a negative result
within 3 months of your last possible exposure to HIV, the
CDC recommends that you be retested 3 months after that
first screening test.
 A negative result is only accurate if you have not had any
risks for HIV infection in the last 6 months—and a
negative result is only good for past exposure.

 WHAT YOUR TEST RESULTS MEAN - POSITIVE
TEST RESULT
 If your initial HIV test comes back positive, you will
automatically be offered a confirmatory test. If the
confirmatory test is also positive, you will be
diagnosed as “HIV-positive.”
 At this point, the person giving you your test results
will discuss what having HIV means for you and your
health. You will be informed about how the virus can
affect you and how to protect others from becoming
infected. You will also be informed about resources and
treatments available to you. Finally, you will be
referred to a medical professional for follow-up
treatment.

 NEXT STEPS IF YOU ARE HIV-POSITIVE
 If you are diagnosed with HIV, you should do the following
things:
 Find a doctor or licensed healthcare provider who has
experience treating HIV.
 Get screened for other sexually transmitted diseases
(STDs) and for TB (tuberculosis).
 Maintain a healthy lifestyle. Smoking, drinking too much,
or taking illegal drugs can weaken your immune system.
 Safer sex practices are very important. Condoms are very
effective in preventing HIV transmission when used
correctly and consistently.
 Tell your partner(s) about your HIV status before you have
any type of sexual contact (vaginal, anal, or oral) and don’t
share needles or syringes.

 Free antiretroviral treatment (ART) has been available
in India since 2004.
 At Indian ART clinics, people living with HIV can
access testing and counselling (HTC), nutritional
advice and treatment for HIV and opportunistic
infections. Patients are required to take a CD4
count test every six months.
 NACP-IV aims to make second-line ART free.
 The introduction of the new 2013 WHO treatment
guidelines is expected to make many more people
eligible for ART, making treatment access a priority
area. Moreover, shortages of both first-line and second-
line ARVs have become a feature in recent years.

 In India, as in many other parts of the world, people
living with HIV and AIDS face stigma and
discrimination in a variety of settings including
households, the community and workplaces. For
example, parents and in-laws can blame women for
infecting their husbands, while children can be denied
the right to go to school. Key affected groups such
as sex workers, hijras and MSM are stigmatised for
being members of a socially marginalised group as
well as their HIV status.
 Stigma and discrimination is also very common within
the healthcare sector. Negative attitudes among
healthcare staff prevent many people from disclosing
their status, while others will not seek treatment
altogether.

 "There is an almost hysterical kind of fear ... at all
levels, starting from the humblest, the sweeper or the
ward boy, up to the heads of departments, which make
them pathologically scared of having to deal with an
HIV positive patient.
 Establishing an HIV and AIDS management policy,
sensitising healthcare workers, mainstreaming HTC
and making post-exposure prophylaxis available to
staff have all been suggested as ways of reducing
stigma and discrimination among healthcare workers in
India.
 NACP-IV has made the elimination of stigma and
discrimination a major focus up until 2017, aiming to
utilise mass media campaigns and existing
interventions such as the Red Ribbon Express.

 Previously, efforts to tackle the HIV epidemic in India
relied heavily on multilateral and
bilateral funding. However, India has increasingly
taken responsibility for financing its HIV response and
in 2012, committed to financing 90 percent of its HIV
and AIDS programmes.
 The vast majority (67 percent) of the NACP-III budget
was spent on HIV prevention, with 17 percent going
to treatment, care and support.
 The proposed budget for NACP-IV is an estimated
$2.5 billion with $1.6 billion from the Indian
government and $0.6 billion coming from external
sources such as the World Bank and the Global Fund.

 Over the past decade, India has made significant
progress in tackling its HIV epidemic, especially in
comparison with other countries in the region. For
example, while new HIV infections have fallen by
more than half since 2001, the number of new HIV
cases in neighbouring Pakistan has increased eight-
fold.
 A major reason for the country's success has been the
sustained commitment of the Indian government
through NACO and its National AIDS Control
Programme. NACP III has been particularly effective
at targeting high-risk groups such as MSM, sex
workers and PWID to stem the wider epidemic.

 While antiretroviral treatment is free, uptake remains
low and requires a dramatic scaling up especially in the
wake of the new 2013 WHO treatment guidelines.
Moreover, stigma and discrimination remains a
significant barrier preventing key affected groups and
those at high risk of HIV transmission from accessing
vital healthcare services.
 However, hope has arrived in the form of an
"HIV/AIDS Bill" submitted to NACO in 2006 and
finally introduced to parliament in early 2014. The Bill
prohibits discrimination in employment, education,
healthcare, travel and insurance and calls for a legal
commitment by the government to provide free
antiretroviral treatment (ART). Moreover, it recognises
a person living with HIV right to privacy and
confidentiality about their HIV status.

 Lamivudine+Zidovudine
 Efavirenz 600mg
 Nevirapine 200mg
 Didanosine-EC 250mg
 Didanosine-EC 400mg
 Stavudine 30mg
 Stavudine 40mg
 Lamivudine 150mg
 Zidovudine 300mg
 Indinavir 400 mg

 Prevention of mother-to-child transmission
 In 2011, 839,600 pregnant women living with HIV in low- and middle income countries
received the most effective antiretroviral regimens -excluding single-dose nevirapine- to
reduce the risk of HIV transmission to their infants, including antiretroviral therapy for
their own health. This represents a coverage of 57% [51-64%] of those in need.
 Coverage of the most effective ARV regimens for PMTCT reached 70% in the WHO
Region of the Americas in 2011, up from 57% in 2010. In the WHO Western Pacific
Region, coverage also improved, from 6% in 2005 to 39% in 2011. Coverage has
remained fairly stagnant in the South-East Asia Region, where it was 16% in 2011.
Nevertheless, some countries in that region (Malaysia and Thailand, for example) have
achieved high coverage. In the WHO Eastern Mediterranean Region, coverage was
lower, at only 6% in 2011. The WHO African Region has shown tremendous progress,
with coverage increasing from 13% in 2005 to 59% in 2011. There are sub-regional
differences between eastern and southern Africa (71%) and western and central Africa
(26%). Overall progress in low- and middle-income countries overall mirrors the
progress observed in the WHO African Region, which accounts for most of the PMTCT
burden globally.
 As access to services for preventing the mother-to child transmission of HIV increased,
the annual number of children acquiring HIV infection stabilized in the early 2000s
before decreasing steeply in the past few years. An estimated 330 000 [280 000–390
000] children were newly infected with HIV in 2011, over 40% less than the peak of
560 000 [510 000–650 000] children newly infected annually in 2002 and 2003. The
number of children (younger than 15 years) living with HIV globally has levelled off in
the past few years and totalled 3.3 million
[3 100 000–3 800 000] in 2011; more than 90% were living in sub-Saharan Africa.

Targeted Interventions for High Risk Groups:
The main objective of Targeted Interventions (TI) is to
improve health-seeking behaviour of High Risk Groups
(HRG) and reduce their risk of acquiring Sexually
Transmitted Infections (STI) and HIV infections. High risk
groups under TI include Female Sex Workers (FSW), Men
who have Sex with Men (MSM), Transgenders (TG)/ Hijras
and Injecting Drug Users (IDU), and bridge populations
include high risk behaviour Migrants and Long Distance
Truckers. TI provides services such as behaviour change
communication, condom promotion, safe needles and
syringes (for people who inject drugs), STI care, referrals
for HIV testing, Syphilis testing and Referrel for ART.

Link Worker Scheme:
The Link Worker Scheme is a community-based outreach strategy to
address HIV prevention and care needs of HRG and vulnerable
population in rural areas. The specific objectives of the Scheme
include reaching out to these groups with information and knowledge
on prevention and risk reduction of HIV and STI, condom promotion
and distribution, providing referral and followup linkages for various
services including Counseling, testing and treatment of STI and
opportunistic infections through Link workers, creating an enabling
environment for PLHIV and their families, and reducing stigma and
discrimination against them. In partnership with various
Development Partners, the Link Worker Scheme has been expanded
and is being implemented in 17 States covering 163 highly vulnerable
districts.

STI/RTI Control and Prevention Programme
Syndromic case management of Sexually Transmitted Infections
(STI)/Reproductive Tract Infections (RTI) is being provided through
1,131 Designated STI/RTI Clinics (DSRC), branded as “Suraksha
Clinics”. A total of
67.68 lakh STI/RTI cases have been managed against the target of 68
lakh during 20132014. Of the 23 lakh DSRC attendees screened for
Syphilis, 14,507 (0.62%) were found to be sero-reactive. Of the 15 lakh
DSRC attendees referred to Integrated Counseling and Testing Centres,
18,959 (1.25%) tested positive for HIV
infection. To understand aetiology of different STI/RTI syndromes and to
identify emerging drug resistance, seven regional STI Training Research
and Reference Laboratories have been established in the country, and
additionally three such laboratories and 45 State Reference Centres are
getting inducted.Management
of STI/RTI among HRGs is a key prevention strategy and the programme
is offering quality standardised STI/RTI services to HRGs through

Condom Promotion:
The Department of AIDS Control has successfully
implemented its targeted Condom Social Marketing
Programme in 15 States in 2013-2014. During this year, 56.45
crore social marketing condom pieces were sold through
Social Marketing Organisations, by servicing/opening more
than 5.17 lakh retail outlets. Two mass media campaigns were
released on national scale in Hindi and regional languages.
The digital cinema screening platform was also included in
condom campaign media plan to reach out to the target
population in smaller towns. A training manual on condom
promotion was developed for TI NGOs and CBOs to provide
guidelines and road map towards effective implementation of
condom promotion programme.

Blood Transfusion Services:The change in nomenclature is to
broaden the horizon of blood safety to include transfusion
transmitted infections, immuno-hematology, quality
management systems, logistics and other
processes involved to improve the confidence in the “safe
blood In alignment with the same, the definition of
the ‘Voluntary Blood Donor’ has been reformulated as per the
WHO definition. New initiatives, such as development of a
Plasma Fractionation Centre, four Metro Blood Bank projects
for setting up Centres of Excellence in Transfusion Medicine,
and evolving a Policy on unutilised Plasma are being
aggressively taken up to improve and facilitate the availability
of essential therapeutic blood and plasma products for clinical
use across the country pertaining to access, quality and safety
of blood and blood products.

Care, Support and Treatment for PLHIV:
The Care, Support and Treatment programme provides
comprehensive services for PLHIV which include free ART,
psychosocial support, prevention and treatment of
Opportunistic Infections including tuberculosis, and also
facilitating home-based care. Ten Centres of Excellence and
seven paediatric Centres of Excellence provide tertiary-level
specialist care and treatment (second-line and alternative first-
line ART, management of complicated Opportunistic
Infections and specialised laboratory services).

Till March 2014, 7.68 lakh PLHIV were on First line ART at
425 ART Centres. Nearly one lakh children living with
HIV/AIDS are registered for HIV treatment and care services
at these ART centres and 42,015 of them are receiving free
ART. Currently, the care and support services are provided
through the Care and Support Centres which are
comprehensive units for treatment, support, positive living,
referral and linkages to need-based services and strengthening
enabling environment for PLHIV

Laboratory Services:
DAC has established a programme for improving, and strengthening the
capacity and quality of services of laboratories working towards
accreditation. Training on good laboratory practices is provided to all
technicians of ART centres operating CD4 machines. Further, faculty and
staff of HIV referral laboratories are trained through workshops in
‘Quality Management Systems . The assurance of quality in kit
evaluation and assessment of HIV testing services through

Information, Education & Communication:
The focus of IEC activities has been on promoting safe
behaviours, reducing HIV stigma and discrimination, demand
generation for HIV/AIDS services and condom promotion.
Mass media campaigns are synergised with other outreach
activities and mid-media activities. Folk media campaign is
scaled up in 32 States, Adolescence Education Programme is
being implemented in 23 States covering around 49 thousand
schools. Red Ribbon Clubs are functional in around 14
thousand colleges; these include 1,700 new RRC formed in
2013-2014. The National HIV/ AIDS Communication
Resource and Support Centre is a newly formed unit for
providing technical support in programme management,
training and implementation, knowledge management,
documentation, research and evaluation to the IEC Division.

AIDS Control Programme
(NACP-I)
as a comprehensive programme for prevention and
control of HIV/AIDS in India. The programme,
implemented during 1992-1999 with an IDA Credit of
USD 84 million, had the objective of slowing down
the spread of HIV infections so as to reduce morbidity,
mortality and impact of AIDS in the country. To
strengthen the management capacity, a National AIDS
Control Board (NACB) was constituted and an
autonomous National AIDS Control Organisation
(NACO) set up for project implementation.

NACP-II:
In November 1999, the second National AIDS
Control Programme (NACP-II) was launched
with World Bank credit support of USD 191
million. Based on the experience gained in
Tamil Nadu and a few other States, along with
the evolving trends of the HIV/AIDS epidemic,
the focus shifted from raising awareness to
changing behaviour, decentralisation of
programme implementation to the State level
and greater involvement of NGOs.

National AIDS Control Programme (NACP- III)
implemented during 2007-2012, was a scientifically well
evolved programme, grounded on a strong structure of
policies, programmes, schemes, operational guidelines, rules
and norms. Aimed at halting and reversing the HIV epidemic
in India by scaling-up prevention among HRG and general
population, and integrating them with Care, Support &
Treatment (CST) services. Thus, prevention measures for
those who are not infected and care, support & treatment
services for the infected and affected. Strategic Information
Management and institutional strengthening activities.

National AIDS Control Programme (NACP-IV)
Under the Department of AIDS Control aims to accelerate the
process of epidemic reversal and further strengthen the
epidemic response in India through a Cautious and well-
defined integration process over the period 2012-2017.
NACP-IV will focus on intensifying and consolidating
prevention services with a focus on high risk groups and
vulnerable population, increasing access, and promoting
comprehensive care, support and treatment services.
The objectives are to reduce new infections and provide
comprehensive care and support to all PLHIV and treatment
services for All those who require it.Thefivecross-cutting
themes that are being focused under NACP-IV
are quality, innovation, integration, leveraging
partnerships, and stigma and discrimination.

KEY STRATEGIES AND GUIDING PRINCIPlES OF
NACP-IV
The strategy and plan for NACP-IV have been developed
through an elaborate multi-stakeholder consultative planning
process for the period 2012-2017. The process has adopted an
inclusive, participatory and widely consultative approach with
15 working groups and 30 sub-groups covering all thematic
areas and involving around 1,000 representatives from Central
and State Governments, high risk group communities, people
living with HIV/AIDS, civil societies, subject experts, experts
from NRHM and other Government departments,
development partners and other stakeholders. Regional and
State level consultations, e-consultations and special studies/
assessments are also undertaken to develop the strategic plan.
The Planning Commission Steering Committee closely
oversee this entire process.

Strategy 1: Intensifying and Consolidating Prevention Services
Prevention will continue to be the core strategy of NACP-IV as more than 99% of
people in the country are HIV negative .
Accordingly, it is planned to cover 90% of HRGs through Targeted Interventions
implemented by NGO and CBOs. High-risk migrants, their spouses, truckers and other
vulnerable population will be accessed by collaborating with other departments,
voluntary groups, civil society networks, women groups and youth clubs.
Add on the existing network of ICTCs in high prevalence States and enhance coverage
in vulnerable States by establishing new HIV testing facilities up to CHC and PHC
levels. This is to ensure that ICTC, PPTCT and HIV/TB services are accessible to the
community. More efficacious multi-drug regimen for PPTCT will be scaled-up as an
effort towards elimination of new infections among children.
Condom promotion strategies will be strengthened through free distribution and social
marketing channels, non-traditional outlets, female condoms, etc.
The Programme will continue to link prevention with care, support and treatment.
Focus on strengthening of standardised STI/RTI management to HRG and vulnerable
population through designated STI clinics under the programme, NRHM service
delivery units and public and private sectors clinics.Explore.
Streamlining the coordination and management of blood banks and blood transfusion
services.

Strategy 2: Comprehensive Care, Support and Treatment
NACP-IV will implement comprehensive HIV care for all those who are in need of such
services and facilitate additional support systems for women and children. With a
wide network of treatment facilities and collaborative support from PLHIV and civil
society groups, it is envisaged that greater adherence and compliance would be possible.
Additional Centres of Excellence (CoEs) and upgraded ART Plus Centres will be established to
provide high-quality treatment and followup services, positive prevention and better linkages
with healthcare providers in the periphery. With increasing maturity of the epidemic, it is very
likely that there will be greater demand for second-line ART, Opportunistic Infections
management, etc., and NACP-IV will address these needs. It is proposed that the
comprehensive care, support and treatment of HIV/AIDS will inter alia include: (i) Anti-
Retroviral Therapy (ART) including second-line (ii) management of opportunistic infections
including TB in PLHIV, (iii) positive prevention and (iv) facilitating social protection and
insurance for PLHIV through linkages with concerned Departments/Ministries. The Programme
will explore avenues of public private partnerships. The Programme will enhance activities to
reduce stigma and discrimination at all levels particularly at healthcare settings.
Some of the illustrative care, support and treatment activities include the following:
• Scale-up of ART Centres, LACs, and COE ART services
• Strengthening follow-up of patients on ART and improving quality of Counseling
services at ART service delivery points
• Comprehensive care and support services for PLHIV through linkages
• Provision of guidelines and training to NRHM staff, for integration of HIV care, support and
treatment services in healthcare settings

Strategy 3: expanding IEC services for general population and high
risk groups with focus on behaviour change and demand generation
IEC has been an important component of the NACP. With the
expansion of services for Counseling and testing, ART, STI
treatment and condom promotion, demand generation
campaigns will be the focus of the NACP-IV communication
strategy. IEC will remain an important component of all
prevention efforts and will have focus on the following:
• 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
• Reaching out to vulnerable populations in rural settings
• Extending services to tribal groups and hard-to-reach
populations

Strategy 4: Strengthening Institutional Capacities
The programme management structures established under NACP will be
strengthened further to achieve the NACP-IV objectives. Programme
planning and management responsibilities will be enhanced at the
National, State, District and Facility levels to ensure high quality, timely
and effective implementation and supervision of field-level activities to
achieve desired programmatic 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. Sustaining the epidemic
response through increased collaboration and convergence, where
feasible, with other departments will be given a high priority during
NACP-IV. This will involve phased integration of the HIV services with
the routine public sector health delivery systems, streamlining
the supply chain mechanisms and quality control mechanisms and
building capacities of governmental and non-governmental institutions
and networks.

Strategy 5: Strategic Information Management System
Under NACP-IV, it is envisaged to have an overarching knowledge management
strategy that encompasses the entire gamut of strategic information activities starting
with data generation to dissemination and effective use. The strategy will ensure high
quality of data generation systems such as Surveillance, Programme Monitoring and
Research; strengthening systematic analysis, synthesis, development and dissemination
of knowledge products in various forms; emphasis on Knowledge Translation as an
important
element of policy making and programme management at all levels; and establishment
of robust evaluation systems for outcome as well as impact evaluation of various
interventions under the programme. The element of knowledge translation will be given
the highest priority to ensure making the link between knowledge and action at all
levels of the programme. The programme will focus strongly on building capacities of
Epidemiologists, Monitoring & Evaluation Officers, Statisticians as well as Programme
Managers with appropriate and simple methods and tools of analysis and modelling.
Institutional linkages will be fostered and strengthened to support programme for its
analytical needs, at National and State levels.

Targeted Interventions for High Risk Groups (Female Sex Workers, Men who have Sex
with Men, Transgenders/Hijras, Injecting Drug Users) and Bridge Population (Truckers &
Migrants)
• Needle-Syringe Exchange Programme and Opioid Substitution Therapy for IDUs
• Prevention Interventions for Migrant population at source, transit and destination
• Link Worker Scheme for HRGs and vulnerable population in rural areas
• Prevention & Control of S T I/R T I
• Blood Safety
• HIV Counseling & Testing Services
• Prevention of Parent to Child Transmission
• Condom promotion
• Information, Education & Communication and Behaviour Change Communication (BCC).
• Social Mobilisation, Youth Interventions and Adolescence Education Programme
• Mainstreaming HIV/AIDS response
• Work Place Interventions Care, Support & Treatment Services
• Laboratory services for CD4 Testing and other investigations
• Free First-line & Second-line Anti-Retroviral Therapy (ART) through ART centres and Link
ART Centres (LACs), Centres of Excellence (CoE) & ART plus centres.
• Paediatric ART for children
• Early Infant Diagnosis for HIV exposed infants and children below 18 months
• Nutritional and Psycho-social support through Care and Support Centres (CSC)
• HIV/TB Coordination (Cross-referral, detection and treatment of co-infections)
• Treatment of Opportunistic Infections
• Drop-in Centres for PLHIV networks

Why is it so difficult to cure HIV and AIDS
Curing AIDS means clearing the body of HIV virus that causes AIDS.
The virus replicates by inserting its genetic code into CD4 cells. The
infected cells produce numerous HIV particles and die soon afterwards.
Antiretroviral drugs interfere with this replication process reducing the
amount of HIV in a person’s body to extremely low levels. During
treatment, the concentration of HIV in the blood often falls so low that it
cannot be detected by the standard test (viral load test).
Unfortunately the most important problem is posed by “resting” CD4
cells. Once infected with HIV, these cells, instead of producing new
copies of the virus, lie dormant for many years. Current therapies cannot
remove HIV’s genetic material from these cells. Studies have found that
if treatment is removed then HIV can re-establish itself by leaking out of
these “viral reservoirs”.
A cure for HIV must either:
1) remove every single one of the infected cells (sterilising cure or
eradication)
2) control HIV effectively by keeping the virus dormant, after the

Purging the HIV reservoir
Many researchers believe the best hope for eradicating
HIV infection lies in combining antiretroviral
treatment with drugs that flush HIV from its hiding
places. The idea is to force resting infected CD4 cells
to become active, whereupon they will start producing
new HIV particles. The activated cells should soon die
or be destroyed by the immune system, and the
antiretroviral medication should 'mop up' the released
HIV. Chemical agents used to activate resting cells are
called antilatency agents.

Bone marrow transplants
In November 2008, a pair of German doctors made headlines
by announcing they had cured a man of HIV infection by
giving him a bone marrow transplant. The transplant - given as
a treatment for leukemia - used cells from a donor with a rare
genetic mutation known as Delta 32 that confers resistance to
HIV infection. Twenty months after the procedure, researchers
reported they could find no trace of HIV in the recipient's bone
marrow, blood and other organ tissues.
In a journal article published in December 2010, the doctors
concluded that the patient had indeed been cured of HIV
infection. Their evidence showed a successful reconstitution of
CD4 T cells at both the systemic level and in the gut mucosal
immune system.

Gene therapy
More recently, gene therapy has been viewed as
having the potential to engineer HIV control by
introducing cells resistant to the virus.
In 2014, a clinical trial using gene-editing techniques
successfully targeted and destroyed a gene in the
immune system of 12 people living with HIV,
increasing their resistance to the virus. However,
because of the invasive nature of stem cell treatment,
it is not viable for the majority of people living with
HIV as the body is likely to attack the donor cells.

Antibodies
All people living with HIV naturally respond to the virus by
producing antibodies. Most people's antibodies are unable to
kill HIV, however, the immune systems of a small minority
produce 'broadly neutralising antibodies', which can kill or
neutralise a wide range of HIV strains.
In 2014, one study detailed how a research team found and
identified these antibodies in a South African woman before
cloning them in a laboratory. Despite providing hope for gene
therapy in other people, these antibodies were unable to
destroy the HIV virus within her own body because HIV
mutates too quickly, so she is on antiretroviral treatment.

A multi-stage approach
Reservoir-purging drugs, which flush HIV out of hiding, are
unlikely to drive the virus out of the immune system or
produce a functional cure on their own. However, combining
them with treatment, which targets HIV-infected cells with
toxins, or a vaccine that intercepts the remaining HIV-infected
cells, may prove more effective.
Though vaccines can help contain HIV infection, often the
virus mutates too quickly for the immune system to respond
effectively. For this reason, an antibody component has been
suggested as a means of alerting the immune system more
quickly to HIV-infected immune cells.
The danger of a multi-stage approach is that by manipulating
the immune system, a slowly progressing infection may
develop into a faster one.

REDUCE YOUR RISK:
Lower Your Sexual Risk of HIV
When One Partner Is HIV+
Substance Abuse/Use
Pregnancy & Childbirth
Pre-Exposure Prophylaxis
Post-Exposure Prophylaxis
Blood Transfusions/Organ Donation

Refrences
: http://www.avert.org/hiv-aids-
india.htm#sthash.avYP695m.dpuf

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