|Year : 2012 | Volume
| Issue : 2 | Page : 65-71
An insight into HIV/AIDS epidemic in India and India's response
Turlapati L. N. Prasad
Department of AIDS Control, National Technical Support Unit, NACO, MoHFW, New Delhi, India
|Date of Web Publication||11-Jul-2012|
Turlapati L. N. Prasad
Technical Expert - STI, Department of AIDS Control, National Technical Support Unit, NACO, MoHFW, New Delhi
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Prasad TL. An insight into HIV/AIDS epidemic in India and India's response. J NTR Univ Health Sci 2012;1:65-71
| Introduction|| |
The 1 st case of HIV was detected in Chennai in 1986, an HIV / AIDS Cell was set up in MoHFW in 1990. The phase I of National AIDS Control Program (NACP), was launched in 1992 along with establishment of National AIDS Control Organization (NACO) within MoHFW. The 2 nd phase of NACP lasted between 1999 and 2006.
Over time, the focus has shifted from raising awareness to behavior change, from a national response to a more decentralized response and to increasing involvement of NGOs and network of people living with HIV / AIDS (PLHA). NACP's phase-III has the overall goal of halting and reversing the epidemic in India over the 5-year period (2007 - 2012). It has placed highest priority on preventive efforts while at the same time, seeking to integrate prevention with care, support, and treatment through a 4-pronged strategy:
Mainstreaming and partnerships are the key approaches to facilitate multi-sectoral response, engaging a wide range of stakeholders. Private sector, civil society organizations, networks of people living with HIV/AIDS and government departments, all have a crucial role in prevention, care, support, treatment, and service delivery. Technical and financial resources of the development partners are leveraged to achieve the objectives of the program.
- Preventing new infections in high risk groups and general population through saturation of coverage of high risk groups with targeted interventions and scaled up interventions in the general population.
- Providing greater care, support, and treatment to larger number of PLHA.
- Strengthening the infrastructure, systems and human resources in prevention, care, support, and treatment programs at the district, state, and national levels.
- Strengthening the nationwide strategic information management system.
What is driving HIV epidemic in India
The primary drivers of HIV epidemic in India are unprotected paid sex / commercial female sex work, unprotected sex between men who have sex with men, and injecting drug use. Men who buy sex are the single most powerful driving force in India's HIV epidemic and form the country's largest infected population group. These men, then, transmit the infection to their low risk wives in the society. Long-distance truckers and single male migrants constitute a significant proportion of men who buy sex. However, men who have sex with men, injecting drug users, and single male migrants are emerging as important risk groups in many states.
Routes of Transmission
Based on program data, unprotected sex (87.4% heterosexual and 1.3% homosexual) is the major route of HIV transmission, followed by transmission from parent to child (5.4%) and use of infected blood and blood products (1.0%). While injecting drug use is the predominant route of transmission in north eastern states, it accounts for 1.6% of HIV infections.
| Prevention Strategies|| |
- Targeted Interventions for High Risk Groups (FSW, MSM, IDU, Truckers and Migrants): These are preventive interventions working with focused client populations in a defined geographic area where there is a concentration of one or more high risk groups. The interventions are implemented by non-governmental organizations / community-based organizations (CBOs) and peer-led, and functions based on NACO guidelines.
- Link worker scheme (LWS) for rural HRG and Vulnerable population: The scheme was introduced to reach out to rural HRGs, their partners, and other vulnerable groups and to link them with HIV / AIDS and related services. Under the short-term, "meso-level" strategy, the services established through the LWS are being linked to local health governance system at 3 levels - village, district, and working with different departments. This will again ensure mainstreaming of the HIV response and thus ensure project sustainability.
- Prevention and Control of STI / RTI: Enhanced Syndromic Case Management (ESCM), with minimal laboratory tests, is the cornerstone of STI / RTI management under NACP III. An estimated 3 crore episodes of STI / RTI occur every year in the country. The infrastructure and facilities in designated STI / RTI clinics have been strengthened; one counselor is provided to each of these designated clinics to strengthen the counseling and behavior change amongst the STI / RTI patients. Pre-packed STI / RTI color-coded kits have been provided for free supply at all government STI / RTI clinics and at TI NGOs. NACO has branded the STI / RTI services as "Suraksha Clinic" and has developed a communication strategy for generating demand for these services. STI / RTI services are being promoted through specially designed TV and radio campaigns to address issues of fear and reluctance in seeking treatment.
- IEC, Social Mobilization, and Mainstreaming: IEC cuts across all program components of NACP-III. The focus is on moving to behavior change communication from only awareness creation.
- Red Ribbon Express: The RRE is the world's largest mass mobilization campaign on HIV / AIDS. Phase- III launched on 12 Jan, 2012. Scheduled to cover 162 stations across 23 states in 1 year.
- National Folk Media Campaign: with Key Messages on: HIV transmission, prevention, and myths relating to HIV / AIDS, care support and treatment, stigma and discrimination. The campaign covers 476 districts in 23 states through 30,330 performances.
- North-east culture specific youth capturing multi-media campaign to cover all states in the north-east.
- NACO sponsored 50 episodes on HIV / AIDS in the tele-serial "Kyonki Jeena Isika Naam Hai," covering migrants, truckers, and children living with HIV.
- General information booklets, brochures, folders, and short films were produced and were made available to the target populations through service centers, fairs, exhibitions, and outreach activities such as Red Ribbon Express and IEC vans.
- The Adolescence Education Program (AEP) is a key intervention to build life skills of the young people and to help them cope with negative peer pressure, develop positive behavior, improve sexual health, and prevent HIV infections.
- Mainstreaming HIV for a multi-sectoral response
- Convergence with NRHM: Strengthening convergence of National AIDS Control Program (NACP) with the National Rural Health Mission (NRHM) has been approved by Ministry of Health and Family Welfare and shared with the states for implementation. It emphasizes optimal utilization of existing NRHM resources for strengthening NACP services and vice versa.
- Tribal Action Plan (TAP): An amount of `. 5 lakh per ITDP has been allocated for IEC activities in high vulnerable tribal districts and for training of grass root health functionaries. Out of the total 192 ITDP areas, 65 are in category A and B districts where the TAP has been rolled out.
- Condom promotion: With nearly 86% of HIV infections transmitted through unprotected sex, significant efforts have been made by NACO to increase the awareness and usage of condoms to prevent the transmission of HIV / AIDS. NACO has been promoting consistent condom usage through a multi-phase mass media campaign to increase demand. These campaigns evolved from the previous year's theme of normalization and were based on enhancing risk perceptions in 3 stages i.e. risk awareness, prioritization, and consistent condom usage. Condom Vending Machine (CVM) were installed with the objective of addressing embarrassment and to make available the condoms round the clock. These CVMs are installed in the major states / cities of the country. NACO is implementing the female condom program through Hindustan Latex Limited Family Planning Trust in 4 states: Andhra Pradesh, Tamil Nadu, West Bengal, and Maharashtra.
- Blood safety: Objective of the blood safety program is to ensure the provision of safe and quality blood and reduction in the transfusion-associated HIV transmission to less than 0.5%. Access to safe blood is the primary responsibility of NACO. This is ensured through a network of 1,149 blood banks including 171 blood component separation units, and 28 model blood banks. There are still 23 districts in the country with no facilities for supply of safe blood, and these are now being addressed on a priority basis. In order to promote rational use of blood, 82 blood component separation units have been established.
- Counseling and Testing Services (ICTC): There are 9,459 ICTCs by end of January 2012 including 4,973 F- ICTC integrated into the health system at CHC / PHC level. No. of clients counseled and tested annually for HIV increased from 78 lakh during 2007 - 08 to 161 lakh during 2011 - 12.
Prevention of Parent to Child Transmission - Number of pregnant women counseled and tested annually increased from 35.1 lakh in 2007-08 to 70.87 lakh in 2011 - 12. 11,074 mother-baby pairs were given single dose Nevirapine during 2011-12.
- HIV-TB co-infection: TB is the most important opportunistic infection among PLHIVs and main cause of death among them. The HIV positivity among TB patients varies across the states and districts in the country between 1 to 13%, and is related to HIV prevalence in the general population. HIV-TB program level collaboration is a key strategy adopted by the department of AIDS control and central TB division. Overall objective of these activities is to decrease morbidity and mortality due to TB among PLHIV and to decrease the impact of HIV among TB patients by offering HIV test to all TB patients registered under RNTCP, decentralized provision of cotrimoxazole prophylactic therapy (CPT) to all HIV-infected TB patientsdetected and linkage of all HIV infected TB patients to HIV care, support, and ART. For close monitoring the progress there is systematic recording and reporting of above activities in RNTCP MIS.
- Laboratory services: The assurance of quality in test kit evaluation, assessment of HIV testing services through implementation of External Quality Assurance System (EQAS), CD4 testing has been addressed in NACP-III with focus. National AIDS Research Institute at Pune functions as an apex laboratory for conducting the EQAS. QASI, Canada was identified as a provider of the CD4 EQAS.
- Another key activity to ensure quality of testing is development of systems for reporting and investigating 'exceptions': A system of reporting the panel results has been developed where the State Reference Laboratories report the discordant test results along with the name of the testing center, which is giving discordant results for corrective action, and the same is conveyed to the respective National Reference Laboratories (NRL). The same is done at the NRL level where the SRLs are assessed and the final report is compiled at the Apex lab, which is shared with NACO annually. The manufacturer along with NACO and the licensing authorities are informed for further necessary actions
| Care, Support, and Treatment Strategies|| |
- There are 342 ART centers and 685 Link ART centers as of January 2012 across country. Program offers both first line and second line ART. 4,86,173 PLHAs are receiving free ART from these centers as of January 2012. 4208 PLHAs are receiving free 2 nd line ART.
- The Community Care Centers (CCC) have been set up in the non-government sector with the main objective of providing psycho-social support, ensure drug adherence, and provide home-based care. CCCs are linked with ART centers.
- Care of exposed child and early infant diagnosis: Addressing HIV / AIDS in children, especially infants below 18 months is a significant global challenge. HIV-infected infants are the most vulnerable of all patients. HIV-infected infants frequently present with clinical symptoms in the first year of life. Where diagnostics, care, and treatment are not available, studies suggest that 35% of infected children die in the first year of life, 50% by their second birthday, and 60% by their third birthday. A critical priority in caring for HIV-infected infants is accurate and early diagnosis of HIV.
| HIV Surveillance and HIV Estimation in India|| |
HIV Sentinel Surveillance 2010
HIV Sentinel Surveillance is the most important tool to monitor HIV epidemic in the country. Surveillance data are also used for estimating key epidemiological parameters, such as HIV burden, new infections, and deaths due to AIDS as well as important program parameters such as need for ART and PPTCT. Surveillance is a vital component of strategic information that provides useful inputs for setting up priorities, planning interventions, resource allocation, and evaluation of impact under the National AIDS Control Program (NACP).
HIV Estimations 2010
National AIDS Control Organization undertakes estimation of HIV burden in the country every year using the data from the annual rounds of HIV Sentinel Surveillance (HSS) among high risk groups and general population. National Institute of Medical Statistics (ICMR), New Delhi is the nodal agency for developing national estimates of HIV prevalence and burden in India.
In 2010 round of HIV estimations, Estimation Projection Package (EPP) was used, which is specially designed to estimate the HIV burden in low and concentrated epidemics. EPP gives more emphasis to new infections and allows the user to see the incidence patterns and distribution of incidence among the various sub-populations / risk groups in a national projection. EPP also takes into consideration the impact of provision of anti-retroviral therapy, which increases survival of people living with HIV.
Reprioritization of districts using data triangulation: has been completed, and reprioritization of districts based on HIV vulnerability is under development.
Strategic information management
Effective utilization of all available information and evidence-based planning and implementation brought the need for establishment of the Strategic Information Management Unit (SIMU) under NACP- III. It is set up at national level and at state levels. SIMU assist NACP in tracking the epidemic and the effectiveness of the response and help assess how well NACO, SACS and all partner organizations are fulfilling their commitment to meet agreed objectives. Strategic Management Unit comprises 3 basic divisions - program monitoring, research and evaluation, and the surveillance and epidemiology.
Computerized management information system reporting
Routine data collection under the program is done through Computerized management information system (CMIS). Monthly reports are received from 35 State AIDS Control Societies (SACS) on various components of HIV program- on various components - anti-retroviral treatment center, blood bank, community care center, Integrated Counseling and Testing Center (ICTC), sexually transmitted infection clinic, and targeted intervention facilities.
Strategic information management system
It was developed as a mechanism for improving on the CMIS. Strategic information management system (SIMS) is a web-based integrated monitoring and evaluation system. Data transfer mechanisms shall be improved by using the web-enabled application, and efficient data management rights (Access Rights Control) from reporting unit to national level will be there. It will provide evidence to track the progression of epidemic with respect to demographic characteristics, geographical area including GIS support. This system will enable individual level data collection for key program areas. With the implementation of SIMS application, efficiency of computerized M&E system and quality of data will improve substantially.
Website of the National Aids Control Organization
The Strategic Information Management Division regularly update National Aids Control Organization (NACO) website by taking input / material from different divisions of NACO, SACS, other government departments, and partners. It ensures timely update of the content on the website and that the content uploaded are correct and authentic. Official website of NACO (www.nacoonline.org) provides access to all the documents pertaining to policy, strategy, and operational guidelines under the program.
India's knowledge hub
The Department of AIDS control is in the process of developing a knowledge hub with the support of UNAIDS, which will not only act as one source for all information related to HIV for laypersons, health personnel, implementing agencies, researchers and scientists, but also provide a discussion forum for stakeholders for exchange of ideas.
The India HIV knowledge hub website is a strategic initiative for advancing programmers' and implementers' informed decision making abilities via comprehensive quantitative and qualitative information. This knowledge hub will have - Data., E-Library, resources for learning., discussion forums., success stories., important announcements; IEC resources.
The main objective of the research agenda under NACP-III is to position NACO as the leading national body, promoting and coordinating research on HIV /AIDS nationally and in the South Asia region. A standard 'Format for Proposal Submission' has been developed, which can be downloaded from the NACO website: http://nacoonline.org/upload/Research/Format%20for%20proposal%20submission.doc), in which, research proposals are to be submitted to NACO.
Network of Indian institution for HIV/AIDS research ( niihar0 ): was constituted to facilitate and undertake HIV/AIDS research. 42 Institutions are members of the NIIHAR Consortium as on February 2011.
NACO Research Fellowship Scheme (NRFS) for MD / M.Phil / Ph.D students: The NACO Research Fellowships will provide financial assistance to pursue research, ultimately leading to attainment of higher professional degrees, under experienced academicians and researchers. Any young scientist, below 35 years of age at the time of applying and enrolled in full-time MD / M.Phil / Ph.D degree program in relevant disciplines from any recognized Indian University / Institute, can apply for the fellowship to carry out research relevant to HIV / AIDS in bio-medical / clinical, epidemiological, and social disciplines. A total of 20 fellowships shall be awarded every year for financial assistance. 13 students were awarded fellowships as part of the second round of the NACO Fellowship Scheme in 2010.
| Capacity Building|| |
Developing the capacity of the SACS and NACO in technical as well as managerial aspects in implementation of program is a major thrust area NACP III. To ensure uniform standards of services, adherence to operational guidelines and treatment protocols, training is provided to various personnel using standard curriculum, training modules, and tools through identified institutions
Capacity Building Workshop on Ethics in HIV / AIDS Research: NACO in collaboration with UNICEF is organizing a series of 3-day Capacity Building workshops on Ethics in HIV / AIDS research for young researchers.
| Support Mechanisms to Ensure Quality of Interventions|| |
Technical support unit/s
A National Technical Support Unit (NTSU) as well as state TSUs has been established to provide techno-managerial support to program as well facilitates the designing, planning, implementation, and monitoring of program in the states.
District aids prevention and control units
Under NACP III, a major structural reform is initiated by constituting District AIDS Prevention and Control Units (DAPCUs) with a team of field functionaries in A and B category districts in India. The main objective of DAPCU is to take district-specific initiatives and take up activities to integrate with formal health infrastructure and do mainstreaming with the other departments in the district.
North eastern states
- DAPCUs are coordinating and monitoring units and are an extension of SACS at the district level.
- DAPCUs are expected to play a key role in integration of NACP with NRHM and work closely with other line departments in government setup to mainstream the HIV / AIDS Programs.
In order to address the special needs for program planning, implementation, capacity building, monitoring, and reporting of North Eastern states of India, the National AIDS Control Organization has established the regional office at Guwahati, Assam.
| Impact of Program Interventions on HIV Incidence and Prevalence|| |
It is estimated that India had approximately 1.2 lakh new HIV infections in 2009 as against 2.7 lakh in 2000. About 56% reduction in new infections in the last decade is due to scaled-up prevention activities. Of the 1.2 lakh estimated new infections in 2009, the 6 high prevalence states account for only 39% of the cases while the states of Odisha, Bihar, West Bengal, Uttar Pradesh, Rajasthan, Madhya Pradesh, and Gujarat account for 41% of new infections.
Adult HIV prevalence
The adult HIV prevalence at national level has continued its steady decline from estimated level of 0.41% in 2000 to 0.31% (0.25% - 0.39%) in 2009. The adult prevalence was 0.25% among women and 0.36% among men in 2009. All the high prevalence states show a clear declining trend in adult HIV prevalence. A clear decline is also evident in HIV prevalence among the young population (15 - 24 years) at national level, both among men and women. However, rising trends are noted in some states including Odisha, Assam, Chandigarh, Kerala, Jharkhand, and Meghalaya.
Among the states, Manipur has shown the highest estimated adult HIV prevalence (1.40%), followed by Andhra Pradesh (0.90%), Mizoram (0.81%), Nagaland (0.78%), Karnataka (0.63%), and Maharashtra (0.55%). Besides these states, Goa, Chandigarh, Gujarat, Punjab, and Tamil Nadu have shown estimated adult HIV prevalence greater than national prevalence (0.31%) while Delhi, Odisha, West Bengal, Chhattisgarh and Puducherry have shown estimated adult HIV prevalence of 0.28% - 0.30%. All other states / UTs have lower levels of HIV [Figure 1].
|Figure 1: Declining trends of HIV prevalence in General Population and High Risk Groups Strategic Approach and Key Achievements Evidence-based approach Source: HSS 2010-11 Provisional Findings|
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People living with HIV/AIDS
The total number of people living with HIV / AIDS (PLHA) in India is estimated at 24 lakh (19.3 - 30.4 lakh) in 2009. Children under 15 years account for 3.5% of all infections while 83% are the in age group 15 - 49 years. Of all HIV infections, 39% (9.3 lakhs) are among women. The 4 high prevalence states of South India (Andhra Pradesh - 5 lakhs, Maharashtra - 4.2 lakhs, Karnataka - 2.5 lakhs, Tamil Nadu - 1.5 lakhs) account for 55% of all HIV infections in the country. West Bengal, Gujarat, Bihar, and Uttar Pradesh are estimated to have more than 1 lakh PLHA each and together account for another 22% of HIV infections in India. The states of Punjab, Odisha, Rajasthan, and Madhya Pradesh have 50,000 - 1 lakh HIV infections each and together account for another 12% of HIV infections. These states, in spite of low HIV prevalence, have large number of PLHA due to the large population size [Figure 2].
|Figure 2: Decline in No. of PLHA as a result of greater decline in new infections, despite increased survival of PLHA due to ART Source: HIV Sentinel Surveillance, 2008-09|
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Using globally-accepted methodologies and updated evidence on survival to HIV with and without treatment, it is estimated that about 1.72 lakh people died of AIDS related causes in 2009 in India.
| What is Next?|| |
The fourth phase of NACP is focusing on sustaining the gains, continued emphasis on prevention to protect the 99.97% uninfected population with a focus on access to care and support without stigma and discrimination to PLHIV. Promoting risk perception and responsible behavior through strategic communication and promoting better use of data for evidence-based planning leading to low cost high impact public health program.
| Acknowledgements|| |
I thank Sri Sayan Chatterjee, IAS, Secretary & Director General, NACO and Ms Aradhana Johri, IAS, Additional secretary, NACO for permitting to use the data for writing this Guest editorial.
[Figure 1], [Figure 2]