Dr. A. K.Gupta Additional Project Director

Delhi State AIDS Control Society

HIV/AIDS GLOBAL, INDIAN & STATE SCENARIO AND ACTIVITIES OF DSACS

• 1981- Cases of unusual immune deficiency identified

in USA• 1982- Acquired Immune Deficiency Syndrome

(AIDS) defined for the first time• 1983-The Human Immune Deficiency Virus (HIV) identified as the cause of AIDS• 1983-In Africa, a heterosexual AIDS epidemic is

revealed• 1985-The first HIV antibody test becomes available• 1987-The WHO launches the Global AIDS

Programme

TIME LINE

TIME LINE (contd)• 1988-The first therapy for AIDS – zidovudine, or AZT approved for use in the USA• 1994- Highly Active Antiretroviral Treatment launched• 1996- First treatment regimen to reduce mother-to-child transmission of HIV• 1997-Brazil becomes the first developing country to provide antiretroviral therapy through its public health system•2001-Global Fund to fight AIDS, Tuberculosis and Malaria launched •2003-Launch of "3 BY 5" initiative -goal of reaching 3 mill people in developing world with ART by 2005

December 2009

Global estimates for adults and children, 2008

• People living with HIV 33.4 million [31.1 – 35.8 million]

• New HIV infections in 2008 2.7 million [ 2.4 – 3.0 million]

• Deaths due to AIDS in 2008 2.0 million [1.7 – 2.4 million]

December 2009

Total: 33.4 million (31.1 – 35.8 million)

Western & Central Europe

850 000850 000[710 000 – 970 000][710 000 – 970 000]

Middle East & North Africa

310 000310 000[250 000 – 380 000][250 000 – 380 000]Sub-Saharan Africa

22.4 million22.4 million[20.8 – 24.1 million][20.8 – 24.1 million]

Eastern Europe & Central Asia

1.5 million 1.5 million [1.4 – 1.7 million][1.4 – 1.7 million]

South & South-East Asia

3.8 million3.8 million[3.4 – 4.3 million][3.4 – 4.3 million]Oceania

59 00059 000[51 000 – 68 000][51 000 – 68 000]

North America1.4 million

[1.2 – 1.6 million]

Latin America2.0 million2.0 million

[1.8 – 2.2 million][1.8 – 2.2 million]

East Asia850 000850 000

[700 000 – 1.0 million][700 000 – 1.0 million]Caribbean240 000

[220 000 – 260 000]

Adults and children estimated to be living with HIV, 2008

December 2009

Over 7400 new HIV infections a day in 2008

• More than 97% are in low- and middle-income countries

• About 1200 are in children under 15 years of age

• About 6200 are in adults aged 15 years and older, of whom:

— almost 48% are among women— about 40% are among young people (15–24)

Indian Scenario • First case: 1986, Estimates 2007: 2.31 million PLHAs, • 86.5% -15-49 years age group (27.9 % in 15-29 and 58.6%

in 30-49 age groups)• Epidemic concentrated in H.R.Gs; Spreading From :

H.R.Gs to the general population & Urban to Rural areas• Feminization (39.3% - women) of epidemic• 7,50,500 HIV +VE Regd. In HIV Care At ART Centers • 3,50,000 Initiated on ART• 2,60,000 alive and on treatment

> 1 % antenatal women

HIV Prevalence reaches over 5% amongst high risk

group in Maharashtra and

Manipur

First case of HIV detected in

Chennai

1986 1990 1994

> 5 % high risk groups < 5 % high risk groups

1998 2001 2002

TIME LINE –INDIAN ACTIVITIES

1990-1992-AIDS Task Force (ICMR), National AIDS Committee , Medium Term Plan (1990-1992)

• 1992- NACP I• 1997-VCTC SERVICES• 1999-NACP PHASE II• 2002- NATIONAL PMTCT PROGRAMME • 2004- NATIONAL ART PROGRAMME• 2004- COMPREHENSIVE PPTCTC PROGRAMME• 2006- REVISED WHO ART GUIDELINES• 2007-NACP III LAUNCHED

Characteristics of Indian Epidemic

• Heterogeneous epidemic • A wide variation in HIV prevalence between

districts and intra districts even within the states

• A concentrated epidemic, focused in HRGs (CSWs,MSMs,IDUs)

• < 1% Prevalence

HIV & Nephrology 23-08-07

• Total population - 16 million, First case- 1988• Estimated PLHAs (2007)- 32,000 • Low prevalence state (Prevalence in Gen. population- 0.22%)• Highly vulnerable state- (Migrant labour- 0.88 million, Truckers stationed/day-35000)• Total high risk population ->1.00 Lakh (FSW-61261, MSM- 28999, IDU- 17173)• PLHAs detected at ICTCs/VCTCs since 2002- 34,759• HIV +VE Regd. In HIV Care At ART Centers : 33,473• No. Currently Alive & on ART-9624• LFU (7%), DIED (8%) OR TRANSERRED OUT TO ART CENTRES (21%) OF OTHER STATES.

DELHI SCENARIO

• DELHI STATE AIDS CONTROL SOCIETY- 1ST NOVEMBER, 1998 HAVING A STAFF OF 56 PROGRAMME OFFICERS & SUPPORT STAFF & HEADED BY PROJECT DIRECTOR.

• SERVICE OUTLETS – 93 ICTC CENTRES, 17 STI/RTI CLINICS, 9 ART CENTRES, 4 CCCs, 57DICs, 85 T.I PROJECTS FOR HRGs RUN BY NGOs, 21 BLOOD BANKS & 10 BSC, QA -4 SRLs.

• FUNDED BY NACO, GOI• SOCIETY & EC CHAIRED BY CHIEF SECY, GNCT OF DELHI• DELHI STATE AIDS COUNCIL CHAIRED BY HON’BLE C.M. OF

DELHI• GENERAL BODY – PRESIDENT HON’BLE HM

High Prevalence

(7)

Moderate Prevalence

(3)

Highly Vulnerable

(14)

Vulnerable States (14)

Tamil NaduAndhra PradeshMaharashtraKarnatakaNagaland Manipur

Gujarat GoaPondicherry

AssamBihar

DelhiHimachal PradeshKeralaMadhya PradeshPunjabRajasthanUttar PradeshWest BengalChhattisgarhJharkhandOrissaUttranchal

Arunachal PradeshHaryanaJammu & KashmirMeghalayaMizoramSikkimTripuraAndaman & Nicobar IslandsChandigarhDadra & Nagar HaveliDaman & DiuLakshadweep

HIV Prevalence : States Classified

CATEGORIZATION OF DISTRICTS IN DELHI

HIV & Nephrology 23-08-07

> 1% ANC/PPTCT prevalence in district in any time in any of the sites in the last 3 years (NIL Districts)

A

< 1% ANC/PPTCT prevalence in all the sites during last 3 years associated with > 5% prevalence in any HRG group (STD/CSW/MSM/IDU) (4 districts)

B

< 1% in ANC prevalence in all sites during last 3 years with < 5% in all STD clinic attendees or any HRG with known hot spots (Migrants, truckers, large aggregation of factory workers, tourist etc) (5 Districts)

C

< 1% in ANC prevalence in all sites during last 3 years with < 5% in all STD clinic attendees or any HRG OR No or poor HIV data With no known hot spots/unknown (nil-districts)

D

Categories of Districts In Delhi

Dynamics of HIV Transmission

GENERAL POPULATION

GENERAL POPULATION

Bridging Population

Clients, Truckers, migrant population etc.

High Risk Population

0.22%0.22% (2.6 -11%)

HIV Trend Among Ante Natal Cases

0.1

0.2

0.125

0.31 0.31

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

2003 2004 2005 2006 2007

HIV Trends among STD clinic attendees, IDUs, MSM and CSWs

4.08

7.6

4.38

9.8

22.8

10.212

20.4

11.73

2.72

5.62.64

0

5

10

15

20

25

2005 2006 2007

Perc

ent p

ositi

ve

STD IDUs MSM CSW

OTHERS

PERINATAL

I.D.Us

BLOOD TRANSFUSION

SEXUAL

RISK OF TRANSMISSION

• TRANSFUSION OF INFECTED BLOOD / BLOOD PRODUCTS-> 90%

• PERINATAL TRANSMISSION- 25-30% • SEXUAL ROUTE-(ORAL- 0.01%, VAGINAL -0.1%,

ANAL-0.5%)• PERCUTANEOUS NEEDLE STICK- 3: 1000 (0.3%)

•Targeted intervention-85

•STI Diagnosis & treatment-17

•Condom promotion

•Blood Safety-53

•ICTC-93

• IEC and social mobilisation

•AEP- launched

• PEP- all govt hospitals

•Mainstreaming-7 departments

•ART Centres-9

•CCCs-4

•DICs-7

• Holistic Approach-

Widow pension & jobs for PLHAs

1. PreventionOf New Infection 2. Care,

Support &

Treatment

3. InstitutionalStrengthening

Capacity building

4. Strategic ManagementInformation

system

• COE for ART-LNH

•Model Blood bank -DDUH

• Regional STD Lab-MAMC

• TSU for DSACS & Parivar Sewa for PPP STI clinics

• Training

•EQAS-4 SRLs

•Operational Research

•Programme management (CMIS & CPFMS)

• Surveillance-20 sites

•M & E

•Computerization of ICTCs & STI clinics• Common National reporting format

PREVELANCE OF HIV POSITIVITY• GENERAL POPULATION- INDIA : 0.36%, DELHI-

0.22% ( SENTINEL SURVEILLANCE ANC DATA 2007)

• HIGH RISK GROUPS- 2.64% to 11.73%• STI ATTENDACE: 4.38%• VULNERABLE POPULATION ATTENDING ICTC:

3.5% • TB PATIENTS HIV POSITIVE: 5%• TRUCKERS - 2.5% (TCI)

Natural History of HIV Infection

Initial Infection (lasting 4–8 weeks), Acute HIV Syndrome (lasting 1 week–3 months),HIV-Specific Immune Response (1–2 weeks), Clinical Latency (10 years, median), AIDS-Defining Illnesses (2 years on average),and Death

W.P.

Natural History of HIV-1 InfectionPrior to treatment

4-8 wks Up to 12 years 2-3 years

Initial Infection

Seroconversion

Asymptomatic Symptomatic AIDS

Death

1000

500

0

CD4+ Cells/L ARS

10%

60%

30%

Characteristic Viral Load ,CD4 & CD8 Changes Over Time In Cases with HIV Infection

CD4 COUNT

VIRAL LOAD

P24 Ag

CD8 COUNT

500

200

50

CD 4 COUNT & OPPORTUNISTIC INFECTIONS

The Changing Natural History Of HIV/AIDS In The 'HAART' Era

Dramatic reductions in the incidence of 1. Opportunistic Infections

2. HIV-related Malignancies 3. Kaposi's Sarcoma

4. Deaths in advanced AIDS cases

IMPACT OF ANTI-RETROVIRAL TREATMENT (DELHI STATISTICS)

AIDS DEATHS/CASES

Cumulative till 1999

2000 2001 2002 2003 2004 2005 2006 20072008 till Sept 2009

Cumulative deaths 118 142 169 201 230 237 283 363 526 602 668

Cumulative Cases 359 498 656 762 881 956 2421 4346 6409 6976 8027

% of Deaths 32.8 28.5 25.7 26.3 26 24.8 11.7 8.4 8.2 8.63 8.32

WHO Clinical Staging HIV Infection

Clinical Stage I:• Asymptomatic • Persistent Generalized lymphadenopathy

(PGL)

WHO CLINICAL STAGE II• Moderate unexplained weight loss (< 10% of body

weight). • Recurrent bacterial upper respiratory tract infections

(current event plus one or more in last six-month period). • Herpes zoster • Angular cheilitis • Recurrent oral ulcerations (two or more episodes in last

six mths. • Papular pruritic eruption • Seborrhoeic dermatitis• Fungal nail infections.

WHO CLINICAL STAGE III• Unexplained severe weight loss (> than 10% of body wt)• Unexplained chronic diarrhoea for longer than one month.• Unexplained persistent fever > one month• Oral candidiasis• Oral hairy leukoplakia.• Pulmonary tuberculosis (current).• Severe bacterial infection for example, pneumonia, meningitis,

empyema, pyomyositis, bone or joint infection, bacteraemia or severe pelvic infl ammatory disease.

• Acute necrotizing ulcerative gingivitis or necrotizingulcerative periodontitis.

• Unexplained anaemia, neutropenia or chronic (more than one month) thrombocytopenia

WHO CLINICAL STAGE IV• HIV wasting syndromei

• Pneumocystis carinii pneumonia • Recurrent bacterial pneumonia.• Chronic herpes simplex virus (HSV) infection (orolabial, genital or anorectal) of more than one

month, or visceral of any duration.• Oesophageal candidiasis. • Extra Pulmonary tuberculosis • Kaposi’s sarcoma. • Cytomegalovirus disease (other than liver, spleen or lymph node).• Central nervous system toxoplasmosis. • HIV encephalopathy. • Extrapulmonary cryptococcosis (including meningitis)• Disseminated nontuberculous mycobacteria infection. • Progressive multi focal leukoencephalopathy (PML). • Cryptosporidiosis (with diarrhoea lasting more than one month). • Disseminated mycosis (coccidiomycosis, histoplasmosis, penicilliosis) • Cerebral or non hodgkins Lymphoma, invasive cervical Carcinoma,• Recurrent non salmonella typhoid• HIV cardiomyopathy, nephropathy

SOCIO-ECONOMIC PROFILING OF PLHAsA STUDY WAS UNDERATKEN IN COLLABORATION WITH ILO AT TWO ART CENTRTERS (RML & LNH)SALIENT FEATURES: SAMPLE SIZE: 1171 PLHAs (816 MALES, 333 FEMALES & 22 TS/TGLNH: 584 PLHAs, RML:587 PLHAs90.9% PLHAs BELONG TO 16-45 YRS AGE GROUPSEX COMPOSITION: MALES 70%, FEMALES-28%, TS/TG-2%MARITAL STATUS: MARRIED-72%, WIDOW-12%, SINGLE-16%STATUS OF RESIDENCE: 62% FROM DELHI, 38% ARE MIGRANTS (UP,HARYANA)EDUCATIONAL STATUS: MAJORITY (61%)- LOW EDUCATION STATUS: 25%-ILLITERATE, 36% PRIMARY SCHOOL. ONLY 29%-SEC SCHOOL & 10% COLLLEGE GRADIATEEMPLOYMENT STATUS: > 51% -UNEMPLOYED (90% WOMEN, 50% TS/TG & 35% MEN); 12% DAILY WAGE, 37% REGULAR EMPLOYMENTOCCUPATIONAL BREAKUP OF EMPLOYED : SELF EMPLOYED/BUISENSS-34%, PVT SECTOR-35%, GOVT -8%, LABOUR-14%, FARMER-5%, HAWKERS-4%MONTHLY HOUSLEHOLD INCOME: 46.9% < RS. 2000/PM; 79.2% < RS. 4000/PM; 18.2% BETWEEN 4000-10,000/PM; 2.6% . > RS. 10,000/PM

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