National AIDS Control Programme

Dr. A. Revanth Kumar

Associate Professor
SIMS, Hapur
 Lesson Objectives
• To know about the extent of the problem of HIV/AIDS in India

• To learn about the evolution of India’s response to HIV/AIDS: NACP Phases I-V &
National Strategic Plan for HIV/AIDS & STI (2017-24) .

• To know about the goals, objectives & strategies of the programme.

• To know about the achievements of the programme.

 Milestones of the programme:
1986 – 1st case of HIV detected

- AIDS Task Force set up by the ICMR

- National AIDS Committee established under the MoHFW

1990 – Medium Term Plan launched for four states & the four metros

1992 – NACP-I launched to slow down the spread of HIV infection

- National AIDS Control Board constituted & NACO set-up

1999 – NACP-II begins, focusing on behaviour change, increased decentralization & NGO
involvement

- State AIDS Control Societies established

 Milestones of the programme:
2002 – National AIDS Control Policy adopted

- National Blood Policy adopted 2004 – Anti-retroviral treatment initiated

2006 – National Council on AIDS constituted under chairmanship of the Prime Minister

- National Policy on Pediatric ART formulated

2007 – NACP-III launched for 5 years (2007-2012)

2014 – NACP-IV launched for 5 years (2012-2017)

2017 – NACP-IV extended for another 5 years (2017-2021)

2017 – National Strategic Plan for HIV/AIDS and STIs 2017-2024

2021 – NACP-V launched for 5 years (2021-2026)

 Global estimates for Adults and Children, 2021
2008 2017 2021 2023
CATEGORY
(Range) (Range) (Range) (Range)

39.9 m
People living
33.4 m 36.9 m 38.4 m (36.1–44.6)
with HIV
(31.1–35.8) (31.1–43.9) (33.9–43.8) Adults: 38.6 m
(million)
Children: 1.4 m (<15 Yr)

2.7 m 1.5 m 1.3 m

New HIV 1.8 millions
(2.4–3.0) (1.1–2.0) (1–1.7)
infections (1.4–2.4)
~49% - W&G ~44% - Women & Girls

Deaths due 2.0 m 0.94 million 0.65 m 0.63m

to AIDS (1.7–2.4) (0.67–1.3) (0.51–0.86) (0.5–0.82)
 HIV estimates for India (2021)
Category 2007 2017 2021 2023
0.21%
HIV prevalence (15-49 years) 0.34% 0.25% 0.2% (0.17-.25)
(0.17-0.25)
HIV prevalence among men
0.40% 0.30% 0.22% 0.22%
(15-49 years)
HIV prevalence among
0.27% 0.22% 0.19% 0.19%
women (15-49 years)
Number of people living with
2.31 m 3.51 m 2.4 m 2.544 m
HIV (adults and children)
Number of Children living 3.8% of 4.87% of
70,000 63,000
with HIV (<15 years) total total
 Current Scenario
• HIV situation in the country is assessed and monitored through regular annual
sentinel surveillance established since 1992.

• There were 25.44 (21.68-30.38) lakh people living with HIV/AIDS at the end of 2023.

• Incidence (2023) – 68,450 (45.85-107.1k)

• Deaths (2023) – 35870 (24.32-54.4K)

• The estimated adult prevalence is greater among males (0.22%) than among females
(0.19%). 2021

• The overall HIV prevalence among High Risk Groups - IDU (6.3%), MSM (3.1%) &
FSW (1.6%) in 2015-17.
 Overview
• In India, after the 1st case of HIV, detected in Chennai in 1986, the virus spread rapidly across
the nation in both urban and rural areas.

• Since then, the HIV epidemic has traveled a long way, establishing itself with the greatest speed
in the six high prevalence states of Andhra Pradesh, Maharashtra, Manipur, Nagaland,
Karnataka and Tamil Nadu.

• The natural history of the HIV epidemic has played out in various forms - from the injecting
drug use - driven epidemic of the North East seen in Manipur and Nagaland, to the sex work-
driven epidemic of the south of India.

• Since, every country and every government needs to have a solution to deal with such an issue;
the government formulated the National AIDS Control Program.
 National AIDS Control Program (NAPC)
• 1985 GoI constituted a taskforce to study the problem of HIV/AIDS in India

• 1991-1999 – A comprehensive HIV/AIDS Control Project Phase I was launched during 8th 5-year
plan with an outlay of 222.6 crores with the assistance of World Bank & WHO.

• NAPC Phase I (1992)

• NAPC Phase II (1999-2005)

• NAPC Phase III (2007- 12)

• NACP Phase IV (2012-17)

• NACP Phase IV Extension (2017-21)

• National Strategic Plan for HIV/AIDS & STI (2017-24)

• NACP Phase V (2021-26)

 NACO Structure
Targeted Intervention & LWS

Basic Services – ICTC, PPTCT,

TB/HIV

Joint Secretary STI RTI Management

Addl Secretary
& DG NACO NACO
Blood Safety

Lab Services

Care Support & Treatment

IEC, M&E, BCC, Surveillance,

Research, Admin & Funds
 Phase 5
National AIDS Control Programme Phase I – V 2021 - 2026
• Intensify focus on HRGs
Phase 4 • Community participation
2013 - 2017 & BCC
05
• Reduce new infections by • Dolutegavir
50% (2007 Baseline of • Test & Treat & Viral Load
Phase 3 • Mission Sampark
NACP III)
2007 - 2012
• based on the
• Provide comprehensive 04 • Target 95-95-95
• Know status
care and support to all
experiences drawn persons living with • Diagnosed are on
Phase 2 Treatment
from NACP-I & II
1999 - 2006 • built upon their 03 HIV/AIDS and treatment
services for all those who • On treatment – viral
strengths. suspension
• aimed at reducing require it.
Phase 1 spread of HIV infection • NACP-III places the • Intensifying and
in India and strengthen highest priority on consolidating prevention
1992 - 1999 India's capacity to preventive efforts services, with a focus on
• objective to slow the spread
respond to HIV
epidemic on long term
02 while, at the same
time, seeks to
HRGs
• Increasing access and
of HIV to reduce future integrate promoting comprehensive
basis.
morbidity, mortality, and prevention with
• Scale-up of targeted care, IEC & Build Capacity
the impact of AIDS by Care, Support and
initiating a major effort in 01 interventions for HRGs
• Community Treatment
the prevention of HIV
networking &
transmission.
treatment programme
• Strengthen National HIV
• Decentralization by
Surveillance system
State AIDS control
• Preventive activities among
Societies
HRGs (SW, MSM, IDU,
Migrants & Truck Drivers)
• Blood Safety programmes.
 Significant Achievements of NACP - I & II
• Scaling up PMTCT and VCTC services especially in the high prevalence states.

• Increasing access to free ARV is one of the major achievements of NACP - II.

• Recognizing the need of care and support for people living with HIV and AIDS and
scaling up of Community Care Centers.

• The effectiveness of the condoms as one of the safest methods to prevent and control
the spread of HIV and other STIs has been well established.

• Initiating the process for developing draft legislation on HIV and AIDS.
Contd…

• Focus shifted from raising awareness to behavior change, from a national response
to a decentralized response and an increasing engagement of NGOs and networks of
people living with HIV/AIDS.

• The National AIDS Prevention and Control Policy and the National Council on AIDS
(NCA), chaired by the Prime Minister, provide policy guidelines and political
leadership to the response.
 Lesson learnt from Phase I & II
• The epidemic continues to progress with the following characteristics
• High risk groups to low risk groups
• Urban to rural areas
• High prevalence states to all states
• High vulnerability of young persons and women

• MSM and IUDs have not received appropriate attention

• Growing number of people living with HIV/AIDS has increased the need for

- care, support and treatment

 Phase - III (2007-2012)
• Phase-III (2007-2012) is based on the experiences and lessons drawn from NACP-I
and II, and was built upon their strengths.

• Its priorities and thrust areas were drawn up accordingly and include the following:

• Considering that more than 99 percent of the population in the country is free from
infection, NACP-III places the highest priority on preventive efforts while, at the
same time, seeks to integrate prevention with Care, Support and Treatment.
Contd.
• Sub-populations that have the highest risk of exposure to HIV receive the
highest priority in the intervention programs.
• Primary high priority include - Sex workers, Men-who-have-sex-with-men and
Injecting drug users.
• Second high priority in the intervention programs is accorded to long-distance
truckers, prisoners, migrants (including refugees) and street children.
• In the general population those who have the greater need for accessing prevention
services, such as Treatment of STIs, Voluntary counseling and testing and
Condoms, will be next in the line of priority.
Contd.
• NACP-III ensures that all persons who need treatment would have access to
prophylaxis and management of opportunistic infections.

• People who need access to ART will also be assured first line ARV drugs.

• Prevention needs of children are addressed through universal provision of

PPTCT services.

• Children who are infected are assured access to pediatric ART.

• NACP-III is committed to address the needs of persons infected and affected by

HIV, especially children.
Contd.
• NACP-III also planed to invest in community care centres to provide psycho-
social support, outreach services, referrals and palliative care.

• Socio-economic determinants that make a person vulnerable also increase the risk of
exposure to HIV.

• NACP-III will work with other agencies involved in vulnerability reduction such as
women's groups, youth groups, trade unions etc. to integrate HIV prevention into
their activities
Prevent new infections
Targeted interventions of high-risk group

• Essential elements:

• Access to behavior change communication (BCC)

• Prevention services (condoms, STI services, needles and syringes)

• Treatment services (STI services, drug substitution for IDU)

• Creation of enabling environment at project sites.

Scaling up interventions among general population
• STD control program

• Voluntary counseling and testing

• PPTCT program

• Universal precautions and Post exposure prophylaxis

• Blood safety

• Improved access to quality condoms

• Focused efforts on women, children and Young people

• Expanding HIV/AIDS response at workplace

• Focused efforts on migrants, mobile populations and in cross border areas

 STD Control Program
• An estimated 5% adult population affected by STDs, also have HIV infection.

• Limited diagnostic facilities to manage complicated STDs and drug resistance to major
STDs are the other issues of concern that NACP-III addresses

• Under NACP-III, a demand for STD services is generated through its awareness on
one hand and on the other STD services are expanded through its integration with the
Reproductive and Child Health Programme..
 Voluntary counseling and testing

• HIV counselling and testing services were started in India in 1997. There are now more
than 4000 Counselling and Testing Centres, mainly located in government hospitals.

• Under NACP-III, Voluntary Counselling and Testing Centres (VCTC) and facilities
providing Prevention of Parent to Child Transmission of HIV/AIDS (PPTCT) services are
remodelled as a hub or ‘Integrated Counselling and Testing Centre’ (ICTC) to provide
services to all clients under one roof.

• 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:
 PPTCT Program

• The Prevention of Parent to Child Transmission of HIV/AIDS (PPTCT) programme was

started in the country in the year 2002 following a feasibility study in 11 major hospitals in the
five high HIV prevalence states.

• Currently, there are more than 4000 Integrated Counselling and Testing Centres (ICTCs) in the
country, most of these in government hospitals, which offer PPTCT services to pregnant
women.

• Of these ICTCs, 502 are located in Obstetrics and Gynaecology Departments and in Maternity
Homes where the client load is predominantly comprised of pregnant women
 Blood safety
• NACO is committed to bridge the gap in the availability and improve quality of blood
under NACP-III. To achieve these objectives NACO plans to:
• Raise voluntary blood donation to 90 percent

• Establish blood storage centres in Community Health Centres

• Expand external quality assessment services for blood screening

• Quality management in blood transfusion services

• Sensitise clinicians on optimum use of blood, blood components and products

• Provide refrigerated vans in districts for networking with blood storage centres
contd.
• Liaise with Indian Red Cross Society and Ministry of Youth Affairs and Sports to promote voluntary
blood donation among the youth

• Set up 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

 Post exposure prophylaxis
• Post exposure prophylaxis (PEP) refers to comprehensive medical management to
minimise the risk of infection among Health Care Personnel (HCP) following potential
exposure to blood-borne pathogens (HIV, HBV, HCV).

• This includes counselling, risk assessment, relevant laboratory investigations based on

informed consent of the source and exposed person, first aid and depending on the risk
assessment, the provision of short term (four weeks) of antiretroviral drugs, with follow
up and support
 Improved access to quality condoms
• Under NACP-III condom promotion continues to be an important prevention strategy.
The programme seeks to:
• Increase condom use during sex with non-regular partner, which is the key to limiting HIV spread
through sexual route.
• Increase the number of condoms distributed by social marketing programmes.
• Increase the number of free condoms distributed through STI and STD clinics, reaching those
who are at the highest risk of acquiring or transmitting HIV.
• Increase access to condoms, especially to men who have sex with non-regular partners.
• Increase the number of commercial condoms sold.
• Increase the number of non-traditional outlets for socially marketed condoms, e.g., pan shops,
lodges, etc. in strategically located hotspots of solicitation
Care, Support and Treatment
 Care support and treatment
• Improved treatment access for opportunistic infections

• Continuation of care of Children affected and infected by HIV

• Integration of prevention with care, support & treatment

• Community care and support programs

• Collaboration with PLHA network

• Impact mitigation and linking it with livelihood support.

• Improving access to ART for PLHA, Children, quality of services

• Adherence to ART is Critical ART
• ART is Accessible to All

• 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
• There are 127 ART centres operating in the country as of June 2007.
• By 2012, 250 ART centres will become functional across the country in order to
provide people living with HIV/AIDS better access to treatment.
Strengthen the infrastructure, systems
and human resources
 Strengthen the infrastructure, systems and human
resources
• State AIDS control societies
• District aids prevention and control units
• Strengthening of the National AIDS control organization
• Capacity building
• Sustained technical training support to public and private agencies
• Mainstreaming HIV and partnership development
• Convergence with RCH, TB and MoHFW
• Coordination and partnership with donors
Strengthening strategic information
systems (SIMS)
 Objective 4: Strengthening strategic information
systems (SIMS)
• One nationwide strategic information system

• Strengthening the computerized management system (CMIS) and making it

more appropriate and user friendly

• Developing community friendly information systems

• Developing indicators for the state plans and institutional arrangement for
collecting, analyzing and monitoring progress

• Hardware and software procurements

 NACP - IV - Objectives

• Reduce new infections by 50% (2007 Baseline of NACP III)

• Provide comprehensive care and support to all persons living with HIV/AIDS and
treatment services for all those who require it.
 Key strategies

• Intensifying and consolidating prevention services, with a focus on High Risk

Groups (HRGs) and vulnerable population.

• Increasing access and promoting comprehensive care, support and treatment

• Expanding IEC services for (a) general population and (b) high risk groups with a
focus on behaviour change and demand generation.

• Building capacities at national, state, district and facility levels

• Strengthening Strategic Information Management System

 Key priorities under NACP IV
• Preventing new infections by sustaining the reach of current interventions and
effectively addressing emerging epidemics

• Prevention of Parent to Child transmission

• Focusing on IEC strategies for behaviour change in HRG, awareness among general
population and demand generation for HIV services

• Providing comprehensive care, support and treatment to eligible PLHIV

• Reducing stigma and discrimination through Greater involvement of PLHA (GIPA)

• De-centralizing rollout of services including technical support

 Key priorities under NACP IV
• Ensuring effective use of strategic information at all levels of programme

• Building capacities of NGO and civil society partners especially in states with
emerging epidemics

• Integrating HIV services with health systems in a phased manner

• Mainstreaming of HIV/ AIDS activities with all key central/state level Ministries/
departments will be given a high priority and resources of the respective departments
will be leveraged. Social protection and insurance mechanisms for PLHIV will be
strengthened.
Package of services provided under NACP IV
 Prevention Services
• Targeted Interventions for High Risk Groups and Bridge Population (Female Sex Workers
(FSW), Men who have Sex with Men (MSM), Transgenders/Hijras, Injecting Drug Users
(IDU), Truckers & Migrants)

• Needle-Syringe Exchange Programme (NSEP) and Opioid Substitution Therapy (OST) for
IDUs

• Prevention Interventions for Migrant population at source, transit and destination

• Link Worker Scheme (LWS) for HRGs and vulnerable population in rural areas

• Prevention & Control of Sexually Transmitted Infections/Reproductive Tract Infections

(STI/RTI)
 Prevention Services
• Blood Safety

• HIV Counseling & Testing Services 8. Prevention of Parent to Child Transmission

• Condom promotion

• Information, Education & Communication (IEC) & Behaviour Change

Communication (BCC).

• Social Mobilization, Youth Interventions and Adolescent 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 Treatment (ART) through ART centres and Link
ART Centres (LACs), Centres of Excellence (COE) & ART plus Centres.

• Pediatric ART for children

• Early Infant Diagnosis for HIV exposed infants and children below 18 months

• HIV-TB Coordination (Cross- referral, detection and treatment of co-infections)

• Treatment of Opportunistic Infections

• Drop-in Centres for PLHIV networks

 New Initiatives under NACP IV
• Differential strategies for districts based on data triangulation with due weightage to
vulnerabilities

• Scale up of programmes to target key vulnerabilities

• Scale up of Opioid Substitution Therapy (OST) for IDUs
• Scale up and strengthening of Migrant Interventions at Source, Transit & Destinations including roll out
of Migrant Tracking System for effective outreach
• Establishment and scale up of interventions for Transgenders (TGs) by bringing in community
participation and focused strategies to address their vulnerabilities
• Employer-Led Model for addressing vulnerabilities among migrant labour
• Female Condom Programme
 New Initiatives under NACP IV
• Scale up of Multi-Drug Regimen for Prevention of Parent to Child Transmission (PPTCT) in
keeping with international protocols

• Social protection for marginalized populations through mainstreaming and earmarking budgets
for HIV among concerned government departments

• Establishment of Metro Blood Banks and Plasma Fractionation Centre

• Launch of Third Line ART and scale up of first and second Line ART

• Demand promotion strategies specially using mid-media, e.g., National Folk Media Campaign &
Red Ribbon Express and buses (in convergence with the National Health Mission)
 NACP – V
• Builds on gamechanger initiatives of HIV & AIDS (Prevention & Control) Act 2017
Rules

• Test & Treat policy

• Universal Viral Load Testing

• Mission Sampark

• Community Based screening

• Transition to Dolutegravir
 NACP – V: 8 Guiding Principles

Leverage tech.
& innovation

Integrated
Break the silos, gender-
build synergies sensitive
response
Continue
High impact
Beneficiary & fostering
programme
Community in technical
management &
centre arrangements &
review
institutions
Strategic Enhance &
information harness
driven partnership
 Goal
• Reduce annual incidence & mortality by 80% by 2025-26 (baseline 2010)

• Attain dual elimination – vertical transmission & HIV/AIDS related stigma &
discrimination

• Universal access to quality STI/RTI services to Vulnerable Populations

 Objectives
95% of at-risk people – to use comprehensive prevention

95% HIV reactive people must know their status

95% of them must be on treatment

95% of them (on treatment) have suppressed viral load

95% of pregnant & lactating women have suppressed viral load
towards attainment of elimination of vertical transmission
<10% of PLHIV & Key population experience stigma &
discrimination
 Country scenario
Based on sentinel surveillance data, the HIV prevalence in adult population can be
broadly classified into three groups of States/UTs.

Group I • > 5% mark in HRG and >1% in antenatal women

• Maharashtra, TN, Karnataka, Andhra Pradesh, Manipur &
High Prevalence States Nagaland

Group II Moderate • >5% among HIG, but <1% in antenatal women

Prevalence States • Gujarat, Goa and Puducherry

Group III Low • < 5% in HRG and <1% among antenatal women - remaining states
Prevalence States
 Districts Categories
Based on sentinel surveillance data, according to epidemiological & vulnerability criteria,
Districts are classified into four groups.

A (156) • Prevalence in the district is > 1% ANC/PTCT anytime in any site in the
last 3 years

B (39) • Prevalence in the district is < 1% ANC/PTCT in all site in the last 3
years, But >5% in HRGs

C (296) • Prevalence in the district is < 1% ANC/PTCT in all sites in the last 3
years with <5% in STD clinics or HRG with known HOT SPOTS.

D (118)
• Prevalence in the district is < 1% ANC/PTCT in all sites in the last 3
years with <5% in STD clinics or HRG, with unknown HOT SPOTS
data.
National Strategic Plan for HIV/AIDS & STI
2017-2024
 Strategic Priorities
• Accelerate HIV prevention in key and at-risk populations to reduce HIV infection
trough a differential approach and upgrading of the package of services to make it more
relevant to specific populations and local settings.

• Scaling-up targeted interventions

• Designing appropriate response mechanism to address other ‘at risk’ populations

• Outreach through social networks

• Community-based Screening

• Specific points of integration with sexual and reproductive health.

• Community ownership and engagement will be stepped up during this period.

• NSP will also focus on further data analysis and triangulation of evidence to draw
epidemiological and programmatic conclusions.

• With regards to young people, NSP proposes a multi-pronged approach through

communication, sexual and reproductive health education and greater convergence
with the NHM adolescent programme.
• NSP envisages close linked interventions within the continuum of ‘prevention-testing-
treatment-care’ (PTTC) to include expanding quality assured HIV testing with universal
access to comprehensive HIV care.

• It will be achieved through a mix-model, including facility-based testing, mobile

centres, community-based testing for key and at-risk populations and introduction of
self-testing.

• The strategy will be inclusive of public and private health care, and seek greater
convergence with the NHM and other sectors with regard to wider public health and
social aspects.
 SDGs Target 3.3 – related to NACP – by 2030

Vision • Paving the way for an AIDS Free India

• Attain Universal coverage of:

✓ HIV Prevention,
Mission ✓ Treatment to care continuum of services that
are effective, inclusive, equitable & adapted to
needs

• Achieving ZERO new infections, ZERO AIDS

Goal related deaths & ZERO discrimination
Objectives & Outcomes of SDGs