current hiv situation in india and national aids control programme an overview

NACO HCP - ORIENTATION PROGRAMME FOR DOCTORS

Venue : Government Thiruvarur Medical College and Hospital, Thiruvarur

Date : 26-12-2013 & 27-12-2013

Resource Persons :

Dr. Asika Beham, M.D., H.O.D. - Microbiology, GTMCH, Thiruvarur

Dr. T.S. Santhi, M.D., H.O.D. – Medicine, GTMCH, Thiruvarur

Dr. A. Annamalai Vadivoo, M.B.B.S., F.H.M., ART Medical Officer, Thiruvarur

Current HIV Situation in Indiaand

National AIDS Control Programme

An Overview



Session Objectives

By the end of the session, we will be able toLearn current HIV situation in IndiaUnderstand NACO’s objectives and approaches tocontrol HIV IndiaKnow the National guidelines in detecting HIV in adultsand children (including infants)Discuss NACO’s comprehensive HIV care and initiationof first line ART in adults & childrenLearn the linkages and referral in the NationalProgramme to retain PLHIV under Care, Support andTreatment foldUnderstand NACO’s efforts to scale up CST services

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Estimated Range

People living with HIV 34.2million 31.8–35.9million

New HIV infections in 2011 2.5million 2.2–2.8million

Deaths due to AIDS in 2011 1.7million 1.6–1.9million

Global estimates for Adults and Children2011

3National AIDS Control Programme

Disease Burden of HIV in India

Provisional estimates place the number of peopleliving with HIV in India in 2011 at 20.9 lakhs withan estimated adult HIV prevalence of 0.27 percent

Available evidence on HIV epidemic in India showsa declining trend at national level

The epidemic is concentrated among high risk grouppopulations and is heterogeneous in its spread

Heterosexual route of transmission accounts for87% of HIV cases detected

Source: HIV Estimations,2008-09

National AIDS Control Programme 4

Declining Trends of HIV Epidemic in India

Control Programme

Female: 39% of PLHIV; Children: 7% of PLHIV

National AIDS Source: TechnicalReport India HIV Estimates 2012, NACO & NIMS

Category NACP-IIIDefinition

A >1%ANC prevalence in any of the sites inThe last 3 years

B<1%ANC prevalence in all the sites duringLast 3 years with >5% prevalence in any HRGsite(STD/FSW/MSM/IDU)

C<1%ANC prevalence in all sites during last 3Years with <5%in all STD clinic attendees orAny HRG,with known hots pots

D<1%ANC prevalence in all sites during last 3Years with <5% in all STD clinic attendees orAny HRG or poor HIV data with noKnown hot spots

Category NACP-III

A 156

B 39

C 296

D 118

NewDistricts 30

Total 609


District-wise Scenario of HIV/AIDS

Routes of Transmission of HIV

NACO Annual Report 2009-2010



Goal :Halt and reverse the epidemic in India

Objectives:Prevention of new infections: Saturate High Risk Groupcoverage and scale up of interventions for Generalpopulation

Increased proportion of PLHIV receiving care, supportand treatment

Strengthening capacities at district, state and nationallevels


•Targeted Interventions for High Risk Groups (FSW, MSM,IDU, Truckers & Migrants)•Link Worker Scheme for rural population•Prevention & Control of Sexually Transmitted Infections•IEC, Social Mobilization & Mainstreaming•Condom promotion•Blood safety•Counselling & Testing Services (ICTC, PPTCT, HIV/TB)

• First line & second lineART

• Care &Support Centres

• HIV-TB Coordination

• Focus on PPTCT

• Treatment ofOpportunistic Infections

Prevention is the mainstay

High riskpopulations

Low riskpopulations

People living withHIV/AIDS

Care, Support and Treatment

Institutional StrengtheningStrategic Information Management

NACP Strategies


Prevention Strategies

Targeted Interventions for High Risk Groups(FSW, MSM, IDU, Truckers & Migrants)

Link Worker Scheme for rural population

Prevention & Control of Sexually Transmitted Infections

IEC, Social Mobilisation & Mainstreaming

Condom promotion

Blood safety

Counselling & Testing Services (ICTC, PPTCT, HIV/TB)


Linkages of ICTC: Gateway to HIV CareSTI

ServicesWalk-inClients

PreventionServices

TargetedInterventions

TBServices

ART CentresCD4 testing,

Care, support & treatment

AntenatalCare

Onsite Services: PPTCT, TB/HIV, Basic OIManagement, TB and STI Care, Reproductive

and Child Health, Routine and EmergencyMedical Care

STI and TB Clients,Pregnant Women, Key

Populations, andGeneral Populations

Referred

Integrated Counselling and Testing Centres (ICTC):HIV Counselling and Testing

PLHIV linked to care, supportand treatment services

through referrals to

Referral to home and community basedcare


Integrated Counselling & Testing CentresSingle window service for:

Pre-test counselling before HIV testing

HIV testing and providing results of the test

Post-test counselling to both positive and negative persons

Condom promotion and distribution

Identification for HIV+ pregnant women

Providing prophylaxis for prevention of transmission from mother tochild

Prophylactic (Cotrimoxazole) to HIV exposed children

Education regarding infant feeding

Referral to ART Centre for investigation and treatment

Cross referral between RNTCP and ICTCsNational AIDS Control Programme 12

Tests for Diagnosing HIV

Screening Tests: Antibody Tests

Rapid tests

Enzyme linked immunosorbentassays (ELISA)

Confirmatory/Supplemental Tests

2nd/3 rd Rapid /ELISA tests toconfirm 1st HIV test

Same blood sample is utilised forperforming the tests for identifyingHIV antibodies (Strategy III)


Report

A1+,A2+,A3+ ReactivetoHIVAb

A1-(or)A1+,A2-,A3- NonReactivetoHIVAb

A1+,A2-,A3+(or)A1+,A2+,A3- Indeterminate

HIV Testing Strategy IIIFirst Test A1

A1 Reactive

Second Test A2

A1 Non Reactive

Third Test A3

A2 Reactive A2 Non Reactive A3 Reactive A3 Non Reactive


Birth6 weeks 14 weeks

10 weeks 6 months9 months

12 months18 months

DNA PCR

DNA PCR for allHIV exposedinfants

HIV Antibody test followed byDNA PCR if HIV+

Final confirmatoryAntibody Test for allHIV exposed infants at18 months, irrespectiveof earlier testing results /treatment status

All HIV infected and / or symptomatic infants / childrenare to be referred to ART centre

Early HIV detection in Infants & Children

Schedule of visits at ICTC


National AIDS Control ProgrammeComprehensive HIV Care

The overall goal is to improve the survival andquality of life of PLHIV with Comprehensive HIV careTo ensure Free Diagnostic servicesTo provide appropriate pre ART care and Treatment ofOpportunistic InfectionsTo widen Access to ART:

Standardised combination of ARV therapyRegular and secured supply of ARV drugsEmphasis on Treatment adherence

To enhance capacity building and strengthen linkagesand monitoring of care, support & treatment servicesRobust Monitoring & Evaluation system


Bacterial Viral Fungal Parasites

Tuberculosis Varicella Zoster Candida Toxoplasma

RespiratoryPathogens:

Streptococcus H.influenza

Herpes simplex Pneumocystisjiroveci(PCP)

Intestinal:CryptosporidiumIsosporaMicrospora

Intestinal:Salmonella,

ShigellaCytomegalovirus Cryptococcus Giardia

Entamoeba

Human papiloma PenicilliumM. Leishmania

Ebstein BarrVirus(OralHairyLeukoplakia;Lymphoma)

Histoplasmacapsulatum

JC Virus(PML)

Common OIs seen in India


CD

4 ce

ll co

unt

Association between OIs & CD4 Count

PCP; Oesophageal Candidiasis;Mucocutaneous Herpes

Toxoplasmosis; Cryptococcosis;Cryptosporidiosis;PML; CMV; MAC

Herpes Zoster

Tuberculosis

Oral Candidiasis

Time


Eligible for ART

ART preparedness counselling, Address verification,Identification of care giver (family / communitysupport), CPT (if eligible), Treatment of active OIs,ART initiation in TB co-infected

Enrolled in ART Enrolment Register

Enrolment in HIV care (New patients)Detected HIV Positive at ICTC

• Enrolment in HIV Care at ART Centre / LAC plus Filling up of HIV Care Register,White card, Green book

• Counselling, Screening for OIs (including TB), STIs and other co-infections• WHO staging, initial work up (Baseline investigations)

Patient revisits when reports of investigations (including CD4) are available

Not eligible as per ART Guidelines

Continued in Pre-ART Care


Based on WHO Clinical Staging and CD4 Count

WHOClinical Staging CD4 (cells/cu.mm)

I and II Treat if CD4 Count <350

III and IV Treat irrespective of CD4 Count

Initiation of ARTin Adults and Adolescents

National Guidelines, 2011


Type ofTuberculosis

EligibleClinical StagingAnd CD4 Counts

Timing of ARTIn relation to start ofTB treatment

Pulmonary TB(StageIII) Start ART

Irrespective ofAny clinicalstageorIrrespective ofCD4 counts

Start ATT first;Start ART as soon asTB treatment istolerated(after 2 weeks &Before 2 months)

Extrapulmonary TB(StageIV)

Initiation of ARTin PLHIV with TB Co-infection


Co-infectionWHO

ClinicalStaging

CD4(cells/cu.mm)

HIV-HBV or HIV-HCVco-infection without anyEvidence of chronic activeHepatitis

I and II Start ART at CD4 Count<350

III & IV Start ART irrespectiveOf CD4 Count

HIV-HBVorHIV-HCVco-infection with documentedEvidence of chronic activeHepatitis

All Clinicalstages

Start ART IrrespectiveOf any CD4 count

Preferred regimen for PLHIV with HBVorHCVco-infection:Tenofovir+Lamivudine+Efavirenz

Initiation of ART in PLHIV withHepatitis B or Hepatitis C Co-infection


NRTIsNNRTI BoostedProtease

Inhibitors

NRTI NtRTI

Zidovudine(AZT)Stavudine(d4T)Lamivudine(3TC)Abacavir(ABC)

Tenofovir(TDF)

Nevirapine(NVP)Efavirenz(EFV)

Atazanavir(ATV)/Ritonavir(RTV)Lopinavir(LPV)/Ritonavir(RTV)

ARV Drugs available inNational AIDS Control Programme


Regimen NationalARTRegimen Preference

RegimenI Zidovudine+Lamivudine+Nevirapine

First line regimen for patients withHb>9gm/dl and not onConcomitant ATT

RegimenI(a) Tenofovir+Lamivudine+Nevirapine

First line regimen for patients withHb<9gm/dl and not onConcomitant ATT

RegimenII Zidovudine+Lamivudine+Efavirenz

First line regimen for patients withHb>9gm/dl and on concomitantATT

RegimenII(a) Tenofovir+Lamivudine+Efavirenz

•First line regimen for patientsWith Hb <9gm/dl and onConcomitant ATT•First line regimen for all patientsWith HepatitisB & HepatitisCco-infection•First line regimen for pregnantwomen, with no exposure tosd-NVP in the past

NACO First line ART Regimens for HIV-1 infection


Clinical and Immunological Criteriafor starting ART in Children

All infants and young children under 24 months of agewith confirmed HIV infection should be started on ART,irrespective of clinical or immunological stage

Children >24 Months-upto 5 years of age:

Initiate ART for all clinical stage 3 and 4, irrespective of CD4count or percentage

CD4 less than 25 % for CLHIV with Clinical stages 1 & 2

Children >5 years of age:

Follow CD4 count as in Adult ART Guidelines


PaediatricRegimen

Regimen Remarks

RegimenPI Zidovudine+Lamivudine+Nevirapine

Preferred paediatric regimenFor children with Hb >9g/dl

RegimenPI(a) Stavudine+Lamivudine+Nevirapine For children with Hb < 9g/dl

RegimenPII Zidovudine+Lamivudine+Efavirenz

Preferred for children on anti-TBtreatment;Hb>9g/dl andage>3 yr and weight >10kg

RegimenPII(a) Stavudine+Lamivudine+Efavirenz

For children on anti-TB treatmentTuberculosis treatment;Hb<9g/dl andage>3 yr and weight>10kg

1.Efavirenz is the preferred drug over Nevirapine, whenever children are beingTreated with Rifampicin containing drug regimen for TB coinfection

2.In Children aged <3 years and in children weighing <10Kg, Efavirenz is contraindicated.

Paediatric First line ART Regimens


MonitoringTool WhentoMonitor?

Body weight Every Visit

Treatment Adherence Every Visit

Clinical Monitoring&T-Staging Every Visit

Hb*, TLC,DLC,ALT(SGPT)** Every6-months

CD4 Count Every 6-months,Or earlier, if required

Routine Monitoring & Follow up of ART


*Hb checked on 15th day after initiation on Zidovudine** ALT checked on 15th day , when patients on Nevirapine

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Modifying / Changing TherapyDue to adverse drug effects / intolerance /Drug Interaction

Due to occurrence of tuberculosis

Due to treatment failure


Substitution vs. SwitchSubstitution:

Single drug replacement of individual ARV (usuallywithin the same class) refers to SUBSTITUTION ofindividual drugs for toxicity, drug-drug interactions,or intolerance; which does not indicate a second lineregimen being used.

Switch:

Failure refers to the loss of antiviral efficacy andtriggers the SWITCH of the entire regimen fromfirst to second line. It is identified by clinical and/orimmunological and/or virological monitoring.


Terms of Reference toState AIDS Control Expert Panel

Review referred cases for alternative first line ART

Review and decide all cases referred by the referring ARTcentre for second-line ART provision

for finding the eligibility for viral load testing

for starting second line ART, if found eligible

Mentoring referring ART centres and ensuring highquality case management of PLHIV

Documentation and follow up of all patients registered forSACEP review


Public HealthInfrastructure

Selected Medicalcolleges

Medical collegeand District Level

Hospital

Sub-District levelhospitals &

CHC

Three-Tier Model of HIV Treatment Service

CoE& ARTPlus

Centres(43)

ART Centres(400)

Link ART Centres and LAC Plus Centres( 850)

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LAC LACLACplus

LACplus

Care &SupportCentres

CoE (10)pCoE (7)

ART plus (26)(SACEP)

ARTCentres

(400)

840

UpdatedApril, 2013

CST Services: Referral and Linkages

FunctionsOut Reach working andTracing of LFU


Functions1. ART: Monthly Distribution2. Monitoring and Drug Adherence3. Treating Minor OIs

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ICTCLAC

LAC plus

ARTCentres

Centres ofExcellence,

pCoE &ART pluscentres

Network of PLHIV / District level Network of Positive People (DLN+)

CST Services: Referral and Linkages

HIV-TB linkages: RNTCP


UpdatedApril, 2013

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UpdatedApril, 2013

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Evidence of Programme Impact57% Reduction in New Infections

(2000-11) with Scale-up of PreventionStrategies

29% Reduction in AIDS-related Deaths(2007-11) with Scale-up of Anti-Retroviral

Treatment

National AIDS Control ProgrammeSource: Technical Report India HIV Estimates 2012, NACO & NIMS

Issues and Challenges

Low referrals from ICTC to ART centresEarly Infant DiagnosisEnrollment of children under ART carePre-ART care and Follow upTimely and Early initiation of ARTEnsuring optimal (>95%) adherence to ARTTracking patients Lost to follow up (LFU)Second line ART initiationLinkages with RNTCP and other local networksIrrational ART Prescriptions outside National Programme



Key PointsThe estimated number of people living with HIV in Indiain 2011 is placed at 20.9 lakhs

NACP phase III aims to halt and reverse the epidemicin India, to scale up care and support services and tostrengthen capacity at all levels

ICTC is the entry point for providing comprehensivecare and support to the HIV-infected persons

ART services are being expanded to provide treatmentnearer to patients' residence

Process of decentralisation and appropriate referraland linkage services ensure PLHIV of comprehensivecare in the existing health delivery system

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Health & Medicine

current hiv situation in india and national aids control programme an overview