NATIONAL

AIDS CONTROL
PROGRAMME - III
Speaker
[Link]
Assistant Professor
Department of Community Medicine
CHRI
MBBS FRESHERS
WELCOME PARTY
 NATIONAL
AIDS CONTROL
PROGRAMME - III
Speaker
[Link]
Assistant Professor
Department of Community Medicine
CHRI
Mythology & HIV
SODOM
 “…the country’s AIDS program has to
focus on sexual abstinence and faith,
rather than just condoms…”

- Health Minister, GOI

 The Deadly virus…
 Genus Lentivirus of
the family of
Retroviridae.
 Long-duration
illnesses with a long
incubation period.
 Ss +sense,
enveloped RNA
viruses
 Origin of HIV – the
Argument continues

 Hunter theory
 OPV theory
 Contaminated Needle
theory
 Colonialism theory
 Conspiracy theory –
“Special Cancer Virus
Programme”
1983
 Discovery of HIV Virus
 Case reports in
gay men
 PCP Pneumonia
 Kaposi Sarcoma

Robert Gallo Luc Montagnier

1986
 World events
CHERNOBYL
disaster

Space shuttle
CHALLENGER explodes
INDIA

First case of HIV

isolated in FSWs in
Chennai
 AIDS Control in INDIA
Calendar
 1987 - AIDS Task Force set up, National AIDS Comm.
 1990 - Medium Term Plan
 1992 - National AIDS Control Organisation
- Strategic Plan for HIV prevention
- National AIDS Control Programme I
 1999 - National AIDS Control Programme II
 2001
- National AIDS Prevention and Control Policy
- PM Vajpayee addressed parliament and
referred to HIV/AIDS as one of the most
serious health challenges facing the country
 Uncle SAM’s unjust
estimates
 2006 - UNAIDS estimate 5.6 million people living
with HIV in India
 2002 - CIA's National Intelligence Council
predicted 20 million to 25 million AIDS cases in
India by 2010
 India - “completely inaccurate figures”, and
accused those who cited them of “spreading
panic”.
 3 cheers to 3 surveys
 National Family Health Survey 3
 National Behaviour Surveillance Survey 2006
 HIV Sentinel Surveillance Survey 2006
 2006 figures collated by NACO, UNAIDS and
WHO - India’s adult AIDS prevalence rate to
be 0.36% ie about 2.5 million
 NFHS – 3 used Dried Blood
Spots

Blood spots
from a finger
prick were
collected on a
special filter
paper card
 HIV Prevalence by sex
Women Men Total
Sex (%) (%) (%)

Urban 0.29 0.41 0.35

Rural 0.18 0.32 0.25

India 0.22 0.36 0.28

Source :NFHS 3
 HIV Prevalence by State
State Total (%) Women (%) Men (%)
Manipur 1.13 0.76 1.59
Andhra Pradesh 0.97 0.76 1.22
Karnataka 0.69 0.54 0.86
Maharashtra 0.62 0.48 0.78
Tamil Nadu 0.34 0.40 0.27
Uttar Pradesh 0.07 0.05 0.10
Non-high
prevalence states 0.12 0.08 0.16
India 0.28 0.22 0.36
Source :NFHS 3
 HIV Prevalence in India by Age
Age Total (%) Women (%) Men (%)

15-19 0.04 0.07 0.01

20-24 0.18 0.17 0.19
25-29 0.35 0.28 0.43
30-34 0.54 0.45 0.64
35-39 0.37 0.23 0.53
40-44 0.30 0.19 0.41
45-49 0.33 0.17 0.48
50-54 NA NA 0.34
Source :NFHS 3
Routes of transmission
2%
6%
4%

4%

Sexual
Perinatal
Blood
IDU
Others

85%

Source :[Link]
Changing Face of Epidemic
Movement from …
 High risk groups to general population

 Urban to rural areas

 High prevalence states to all states

 Feminisation

 High vulnerability of youth

NACP - I
 1992-1999
 Objectives
 Slow down the spread of HIV
infections
 Reduce morbidity, mortality and

impact of AIDS in the country.

 Key outcomes
 State AIDS Cells (SACs) in 25 States and 7
UTs
 A well functioning blood safety programme
 Expansion of HIV sentinel surveillance
system
 Collaboration with NGOs on prevention
interventions and intensified communication
campaigns
NACP-II
 1999 - 2005
 Focus shifted from raising awareness to
 changing behaviour
 decentralization of programme
 implementation at the state level
 greater involvement of NGOs.
 Policy initiatives during
NACP-II
 National AIDS Prevention and Control Policy (2002)
 National Blood Policy
 Greater Involvement of People with HIV/AIDS (GIPA)
 Launching of the NRHM
 Launching of National Adolescent Education Programme
 Provision of anti-retroviral treatment ART
 Formation of an inter-ministerial group for mainstreaming
 Setting up of the National Council on AIDS, chaired by the
Prime Minister.
NACP III
 NACP - III
 2006-2011
 Overall goal of NACP-III is
 To halt and reverse the epidemic in India over
the next 5 years by integrating programmes
for prevention, care, support and treatment.
 Objectives of NACP III
1. Prevention of new infections in high risk groups
and general population
2. Providing greater care, support and treatment to
larger number of PLHA.
3. Strengthening the infrastructure, systems and
human resources at all levels
4. Strengthening the nationwide Strategic
Information Management System.
Specific objectives
To reduce new infections by:
 60% in high prevalence states to
reverse the epidemic
 40% in the vulnerable states to
stabilize the epidemic.
 Categorization of states
 High prevalence states
 >1.0 % HIV prevalence in general population
 Moderate prevalence states
 more than 5% HIV prevalence in high risk population
 Low prevalence states
 on the basis of vulnerability factors such as migration,
size of the population and weak health infrastructure,
 further classified as “Highly Vulnerable” and
“Vulnerable” states
Categorization of states
 District Prioritization
Category ANC Prev in HRG site Hot Number
Last 3 yrs prevalence Spots
A >1% 156
(in any 1 site)
B <1% >5% 39
(in all the sites) (in any 1 site)
C <1% <5% + 296
(in all the sites)
D <1% <5% _ 118
(in all the sites)
HRG = FSW, IDU, MSM, STD HOT SPOTS = Migrants, truckers, large aggregation
of factory workers, tourist
 District
Categorization
 National Health Programmes
in PARK’s Community Medicine
 Two humans ascended a certain geological
protuberance to collect a hydride of oxygen
whose quantity isn’t specified….one
member descends dramatically suffering
mechanical damage to the cranial part of
his anatomical structure. The second
member follows the first in a similar series
of rapid irregular disturbing movements.
 Simply it is…

Jack & Jill went up the hill

To fetch a pail of water
Jack fell down and broke his crown
While Jill came tumbling after
 OBJECTIVE 1
To prevent new infection
Strategies
1. Saturation of coverage of High Risk groups thro TIs
2. STD Control program
3. Voluntary Counseling and Testing
4. PPTCP
5. Universal precautions & PEP
6. Blood Safety
7. Condom program
8. Focussed efforts on women, children, young
people, migrants
 1. Targeted Interventions
 TIs are aimed to effect behaviour change through
awareness raising among the high risk groups and
clients of sex workers or bridge populations.
 Aimed to saturate three high risk groups with
information on prevention
 Address clients of sex workers with safe sex
interventions
 Build awareness among the spouses of truckers and
migrant workers, women aged 15 to 49 and children
affected by HIV or vulnerable population groups.
 Prevention and treatment of STIs
 2. Management of STI/RTI
 An estimated 5% adult population affected by
STDs, also has HIV infection.  
 STD services are expanded through its
integration with the RCH Programme.
 Capacity building of PHC, CHC doctors and the
private regional medical practitioners providing
STD services.
 [Link]
 VCTC and facilities providing PPTCT services are
remodelled as a hub or ‘Integrated Counselling and Testing
Centre’ (ICTC)
 An ICTC is a place where a person is counselled and tested
for HIV, of his own free will or as advised by a medical
provider. The main functions of an ICTC are:
 Conducting HIV diagnostic tests.
 Providing basic information on the modes of HIV transmission, and
promoting behavioural change to reduce vulnerability.
 Link people with other HIV prevention, care and treatment services.
 Located in OG dept. maternity homes, TB clinics
 4. Prevention of Parent to Child
Transmission of HIV/AIDS
 27 million annual pregnancies - 189,000 HIV +ve
 Aims to prevent the perinatal transmission
 Counselling and testing of pregnant women in the ICTCs.
 HIV + Pregnant women given a single dose of Nevirapine
at the time of labour; the newborn get a single dose of
Nevirapine immediately after birth
 Aims to reduce the proportion of infants infected with
HIV/AIDS by 50% by 2010.
5. Access to safe blood
 The specific objective of the blood safety
programme is
 to ensure reduction in the transfusion associated
with HIV transmission to 0.5%
 making available safe and quality blood within one
hour of requirement in a health facility.
 Serious mismatch between demand and
availability of blood in the country
 Initiatives
 Raise voluntary blood donation to 90 percent
 Establish blood storage centres in Community Health
Centres
 Quality management in blood transfusion services
 Sensitise clinicians on optimum use of blood, blood
components and products
 Provide refrigerated vans in 500 districts for networking
with blood storage centres
 Establish additional model blood banks in 22 states; 10 are
functional already
 Set up additional Blood Component Separation Units
(BCSU) in 80 tertiary care hospitals and separate at least 50
percent of the collection at all BCSUs (162) into
components
 Contd…
 Promote autologous blood donation
 Liaise with Indian Red Cross Society and Ministry of Youth
Affairs and Sports to promote voluntary blood donation among
the youth
 Set up 32 model blood banks in various states
 Liaise with the Indian Medical Council (IMC) to mandate the
requirement of a department of transfusion medicine in all
medical colleges and appropriate transfusion practices in the
syllabus of MD/MS clinical subjects
 Establish one additional plasma fractionation facility in the
country
 Establish four Centres of Excellence in blood transfusion
services in the four metros in order to cater to any region of the
country in time of a crisis
 Introduce accreditation of blood banks
 6. Condom promotion
 New management and distribution initiatives
 With a distribution target of 3.5 billion condoms every year
by 2010, NACO has galvanised condom promotion at three
levels
 free supply in STI/RTI clinics
 by way of TIs through social marketing, involving government
medical machinery at the state level
 by promoting and facilitating commercial sales through hitherto
unconventional sales outlets
 Condom Vending Machines (CVM)
 Female condoms
 “SPICE UP” – thicker, more lubricated condoms
 7. Interventions aimed at
Migrants
 Frequent movement between source and
destination areas.
 NGOs identify active volunteers from among them
and train them in spreading preventive messages
 Factory owners, construction companies and other
employers motivated to undertake preventive HIV
education activities
8. Universal precautions & PEP
 Accidental exposure like needle stick injury,
contact of open wound with blood and body fluids
 Universal precautions are best measures to
prevent the occupational exposure of health
workers
 PEP started immediately or <2 hrs, never >72 hrs
 Basic regimen – ZVD 300 bd + Lami 150 bd for 4
weeks
 OBJECTIVE 2
Care, Support, Treatment
Strategies
1. ART
2. Improve Rx access for Opportunistic
infections
3. Community care & support programs
4. Emphasis on Pediatric HIV
5. Improving quality of life of PLHA
 1. ART
 Successful viral suppression restores the immune
system and halts onset and progression of
disease as well as reduces chances of getting
OIs.
 Medication thus enhances both quality of life and
longevity.
 Adherence to ART is Critical
 ART is accessible to All
 Special emphasis given to the treatment of sero-
positive women and infected children.   
 Criteria for ART
CD4 (cell /mm3) Actions
< 200 Treat irrespective of clinical stage

200 – 350 Offer ART for symptomatic patients

Initiate Rx before CD4 drop below
200   cells/mm3
For asymptomatic people*
>350 Defer treatment in asymptomatic
persons
* If CD4 is between 200-250, this should be repeated in four weeks
and treatment to be considered in asymptomatic patients.
 ART Centres
 Located in medical colleges, district hospitals
and non-profit charitable institutions
providing care, support and treatment
services to PLHA.
 A PLHA network person at each of the ART
centre facilitates access to care and treatment
services at these centres.
 Also provide counselling and follow up on
treatment adherence
 2. Rx of OIs
 Asymptomatic initially; manifests by 6-8yrs
 As immunity falls, susceptible to various
opportunistic infections (OIs).
 At this stage, medical treatment and
psycho-social support is needed.
 NACP III - focus on low-cost care, support
and treatment of common OIs.
 3. Community Care Centres
 350 centres in partnership with PLHA
 Established based on the epidemiological profile and
PLHA load of the districts, and linked to the nearest
ART centre.
 The centres will provide
 counselling for drug adherence,
 nutritional needs,
 treatment support,
 referral and outreach for follow up,
 social support and legal services.
 Drug adherence & awareness
 4. Care and Support for
Children
 50,000 children below 15 years infected
every yr
 NACP–III plans to improve this through
 Early diagnosis and treatment
 Comprehensive guidelines on paediatric HIV care
 Special training to counsellors
 Linkages with social sector programmes
 Outreach and transportation subsidy
 Nutritional, educational, recreational and skill
development support
5. PLHA
 Right to education & employment
 Proper care and support in hospitals and
community
 Report to be kept confidential
 Women complete choice in pregnancy
 Awareness among health professionals to
avoid discrimination
 Make them partners in AIDS control
 OBJECTIVE 3
Strengthening Capacity building
Strategies
1. Capacity building of NACO, SACS,
District AIDS control units
2. Mainstreaming
3. Convergence with RCH, RNTCP &
other programs
 Mainstreaming
 HIV is impacted by activities and policies of
many sectors and hence impacts the efficiency
of many sectors.
 Mainstreaming HIV into core activities of
concerned sector is a necessary condition for
achieving the objectives of NACP-III.
 It will also help the sector achieve revenue and
efficiency targets
 Illustration
Structural rigidities in the road
transport system

Enforces timing restrictions on

truckers

Idle out their time in makeshift

residences

Exposed to the risk of HIV

 OBJECTIVE 4
Strengthen Nationwide
Information Management system,
M&E
Monitoring
 Day to day follow up of activities during
their implementation to ensure that
they are proceeding as planned and are
scheduled
Evaluation
 Collection and analysis of information to
determine program performance
 Monitoring  
 Data from sentinel surveillance and CMIS not
sensitive enough
 Strategic Information Management System (SIMS
)
at national and state levels to focus on strategic
planning, monitoring, evaluation, surveillance and
research.
 Aimed to provide effective tracking and response
to HIV epidemic.
 Assigns clear responsibilities to all programme
officers and facilitates data flow and feedback at
various levels.
 Evaluation & Research
Evaluation
 Tools are proposed to be developed in

consultation with the technical partners for the

evaluation of each of the proposed intervention.
Research  
 NACO - promoter and coordinator of research on

HIV/AIDS not only in India, but the entire South

Asia region
 Will enhance NACO’s knowledge and evidence

base of the various aspects of the epidemic.

 Surveillance
 Tracking the epidemic and provides direction to the
programme.
 PPTCT surveillance and ANC surveillance system to be
included in the programme.
 Surveillance for HIV infection comprises of four broad
areas:
 HIV Sentinel Surveillance
 AIDS Case Surveillance
 Behavioural Surveillance
 Sexually Transmitted Infections (STI) Surveillance
 IEC Activities
 Majority of the population is
unaffected
 So imperative for
communication to increase
awareness and effect
behaviour change
 Use of mass media
 Inter-sectoral collaboration
 Involvement of NGOs