Presentation on theme: "National Programme Officer (ART) National AIDS Control Organization"— Presentation transcript:
1National Programme Officer (ART) National AIDS Control Organization Indian Experience with Treatment as Prevention Key approaches & challengesDr. B .B .RewariMD,FRCP, FICP,FIACM,FIMSA WHO National consultant Care , Support and TreatmentNational Programme Officer (ART)National AIDS Control OrganizationIndia
2Presentation Outline Current Epidemiological scenario National ResponseImproving access to testingLinkage between testing and treatmentRetention in careMoving towards NACP IV-Scale up neededChallenges in Treatment as Prevention
3Declining Trends of HIV Epidemic in India Female: 39% of PLHIV; Children: 7% of PLHIVSource: Technical Report India HIV Estimates 2012, NACO & NIMS
4District-wise Scenario of HIV/AIDS CategoryNACP-IIIA156B39C296D118New Districts30Total609CategoryNACP-III DefinitionA> 1% ANC prevalence in any of the sites in the last 3 yearsB< 1% ANC prevalence in all the sites during last 3 years with > 5% prevalence in any HRG site (STD/FSW/MSM/IDU)C< 1% ANC prevalence in all sites during last 3 years with < 5% in all STD clinic attendees or any HRG, with known hot spotsD< 1% 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
6HIV Concentrated in HRG & Bridge Pop. Source: HIV Sentinel Surveillance – A Technical Brief, NACO
7However, Regional Variations Exist… HP-NE-3HP-South-4Distribution of EstimatedNew HIV Infections (2011)IndiaLP-North-7LP-North-6Declining trends in high prev. states of South & North East, but still at higher levels;Stable to rising trends in low prev. states of Central & North IndiaSource: HSS & HIV Estimations 2012Note: 3-yr moving averages based on consistent sites; India – 385; HP-South-4 (AP,TN,KR,MH) – 233, HP-NE-3 (MN,NG,MZ) – 31, LP-North-6 (BI,DL,HP,PJ,RJ,UP) – 45, LP-North-7 (AS,CH,GJ,HR,JH,OR, UK) – 33
8Declining trends, but higher levels… Declining trends among general population, FSW & MSM;Stable trends among IDUNeed to sustain efforts in High Prevalence areas to consolidate gainsSource: HIV Sentinel Surveillance – A Technical Brief, NACONote: 3-yr moving averages based on consistent sites; ANC–385 sites, FSW–89 sites, MSM–22 sites, IDU–38 sites
9Emerging Vulnerabilities: IDU Higher levels of HIV among IDU in Punjab, Chandigarh, Delhi and Mumbai, in addition to North EastEmerging epidemics among IDUs in low prevalence states of Kerala, Orissa, MP, Bihar and HaryanaFocus on saturation with Needle-Syringe Exchange Programme & Scale-up of OSTStates with higher vulnerability among IDUSource: NACO HIV Sentinel Surveillance – Provisional Findings; NACO Mapping of HRG ;
10Emerging Vulnerabilities: Migration Rising trends in low prevalence states among ANC attendees despite low level, stable epidemics among HRG in these statesHIV prevalence – higher among rural ANC than urban; higher among those whose spouse is a migrantMapped migration corridors with large volumes of out-migration to high prevalence destinationsNeed to strengthen coverage of migrants at transit & destinations & along with their spouses at sourceFocus on IEC for general populationStates with higher vulnerability due to MigrationSource: NACO HIV Sentinel Surveillance – Provisional Findings; Source: Population Council Study -- Reference: Saggurti N, Mahapatra BB, Swain SN, Jain AK. Male out-migration and sexual risk behavior in India: Is the place of origin critical for HIV prevention programs?. BMC Public Health :S6;
11HIV/AIDS – India’s Response 1986: 1st case of HIV detected in Chennai1990: HIV/AIDS Cell set up in MoHFW1992: NACP-I launched with a outlay of US$ 84 m1992: National AIDS Control Organisation (NACO) established within MoHFW: NACP-II Budgetary outlay of US$ 191.9m: NACP-III Budgetary outlay of US$ 1.3 billionNACP IV ( ) on the anvil with projected outlay of more than US$ 2 billion
12NACP Strategies Prevention is the main stay Care, Support and TreatmentHigh risk populationsLow risk populationsPeople living with HIV/AIDSTargeted Interventions for High Risk Groups (FSW, MSM, IDU, Truckers & Migrants)Link Worker Scheme for rural populationPrevention & Control of Sexually Transmitted InfectionsIEC, Social Mobilization & MainstreamingCondom promotionBlood safetyCounselling & Testing Services (ICTC, PPTCT, HIV/TB)First line & second line ARTCare &Support CentresHIV-TB CoordinationFocus on PPTCTTreatment of Opportunistic InfectionsICTC: Integrated Counseling and Testing Centres about 5000 in numbersPPTCT: Prevention of Parent to Child Transmission Centres for antenatal mothersOpportunistic infections are mainly tuberculosis, chronic diarrhoea, skin infections, pneumonias, fungal and viral infections like herpes etcStrategic Information ManagementInstitutional Strengthening
13Evidence of Programme Impact 57% Reduction in New Infections ( ) with Scale-up of Prevention Strategies29% Reduction in AIDS-related Deaths ( ) with Scale-up of Anti-Retroviral TreatmentSource: Technical Report India HIV Estimates 2012, NACO & NIMS
14Key Approaches towards Improving Access to testing and Treatment Services Designing for scale-upUse of Evidence for improved programEarly Initiation of ARTART for All - HIV/TB coinfection, Pregnant womenMaking ARV drugs affordableRetention in careAddressing programmatic & operational ChallengesInstitutionalizing quality assuranceSimplifying drug regimen while adopting newer guidelines
15COMMUNITY and high risk groups at centre How we scaled up…PREVENTION focusedCOMMUNITY and high risk groups at centreQUALITY assurance through institutional mechanismsIncreased ACCESS to testing, care and treatmentSCALE – expanded service delivery
16Significant Expansion of Service Delivery NACP-III AchievementsScale up of counseling and testing services to 195 lakh persons through 10,515 centres ( : Total lakh :81.9 lakh general clients & 62.8 lakh pregnant women by Jan 2013)Scale up of prevention of parent to child transmission of HIV through testing of lakh pregnant women and provision of Nevirapine to around 13,000 mother baby pairs. (( : 9,451 pregnant women detected +ve & 96.4% received Niverapine, up to Dec 2012)Estimated Pregnancies (2011) – 296 lakh; Pregnant women tested (2011) – lakh (16.5% of all pregnancies); Estimated HIV positive Pregnant women (2011) – 38,204; Pregnant women detected positive (2011) – 15,362 (40% of estimate); Pregnant women covered by Niverapine (2011) – 13,013 (85% of detections).3. No. of blood units screened for HIV increased from 53 lakhs to 93 lakhs in 2012; and 90% of them were collected through voluntary blood donation ( : 45.3 lakh units collected & 83.3% through VBD by Jan 2013)4. Scale up of Treatment services with over 13 lakh registered for treatment and 5.2 lakh persons receiving free treatment, including over 25,000 children; This is provided through a network of 1,112 ART centres & Link ART Centres. ( : 6.05 lakh by Dec 2012)Estimated no. of PLHIV (2011): 20,88,641; Cumulative no. of PLHIV Detected at ICTC (Dec 2012): 22,94,647; Cum. No. of PLHIV registered at ART centres (Dec 2012): lakh; Cum. No. of PLHIV alive & on ART (Dec 2012): 6,04,987Source: NACO-CMIS
17Counseling & testing Services 1997: VCT services started in the country2006: Integration of VCT and PPTCT as ICTCSpecial focus on key population and MARPsICTCs have been set up, nearly half are facility integratedHIV testing offered to all ANC , TB patients and STI patientsStill around 40% do not know their status: NACP IV strategies for scale up at least to CHC level across the country and 24X7 PHCs in high prevalence districts
18Scale up of HIV Testing Facilities (ICTCs) 5018 facility integrated ICTCs in the Government facilities & 964 ICTCs under Public Private Partnership model currently functional, besides 4533 Stand alone ICTCs
19Significant Expansion of PPTCT but still far away Source: NACO-CMIS
22Care, Support & Treatment Programme in India The ART programme in India was launched on 1st April 2004 at 8 institutions in 6 high prevalence states & DelhiRapidly scaled up to network of 1100 ART centers and Link ART centersAll PLHIV including children registered in HIV care are provided free diagnostic & treatment servicesNearly 1.5 million PLHIV registered in HIV care0.65 million are currently on ARTConcept of Link ART centers evolved in 2008 for decentralization of services so as to facilitate easy access to servicesAll ART centers linked to Care & Support Centers run by Positive networks and NGOs22
23Anti-retroviral Treatment (ART): Policy Package Free Diagnostic services (CD4 count and other baseline tests) --CD 4 count twice a year or earlier if required, Viral load –targeted approachStandardized Free ART:First line ARV drugsAlternate first line ARV drugsSecond line ARV drugsFree diagnosis & Treatment of Opportunistic InfectionsLinkage to various social protection schemes of Govt.Robust mechanism for Retention in Care
24Accessibility to ART services Three tier model of ART services evolved-CoE , ART centers, Link ART centersNeed based and evidence based scale up to address concentrated epidemic in a geographically large & diverse countryDistrict-wise ICTC data for sero-positives detected is analysed and geographic locations and catchment areas are mapped to select the sites for setting up ART CentresExisting health care systems strengthened by providing additional technical, human, infrastructure support and additional laboratory investigation like CD4 tests under NACP
25Scale up of Treatment High level political commitment. 9 fold increase in ART provision in last 5 years58% coverage of those in need as per spectrum model85% coverage of those in need among those detectedART services available in 609/671 (90%) districts of countryStrong partnership with PLHIV network and civil society220 networks of PLHIV functionalPlan to increase no. of ART facilities to nearly 2100 and provide ART to 1 million PLHIV in public sector over next 5 years
30Key Approaches towards Improving Access to Treatment Designing for scale-upUse of Evidence for improved programEarly Initiation of ARTART for All - HIV/TB co-infection, Pregnant womenMaking ARV drugs affordableRetention in careAddressing Programmatic & operational ChallengesInstitutionalizing quality assuranceSimplifying drug regimen while adopting newer guidelines
31Guidelines on initiation of ART in adult and adolescents Guidelines on initiation of ART in adult and adolescentsWHO Clinical StageRecommendationsHIV infected Adults & AdolescentsClinical Stage I and IIStart ART if CD4 < 350 cells/mm3Clinical Stage III and IVStart ART irrespective of CD4 countFor HIV and TB co-infected patientsPatients with HIV and TB co-infection(Pulmonary/ Extra-Pulmonary)Start ART irrespective of CD4 count and type of tuberculosis (Start ATT first, initiate ART as early as possible between 2 weeks to 2 months, when TB treatment is tolerated)
32HIV infected pregnant women Guidelines on initiation of ART in Pregnant women for Prevention of Mother to Child transmissionTo prevent transmission of infection from positive mothers to newborns, it has been decided to use multidrug ARV regimen and provide ART/ARV prophylaxis to all positive pregnant women irrespective of CD count. (Option B)WHO Clinical StageRecommendationsHIV infected pregnant womenClinical Stage I and IIStart ART if CD4 < 350 cells/mm3Clinical Stage III and IVStart ART irrespective of CD4 countMultidrug ARV prophylaxis to be given to all HIV infected pregnant women if CD4 >350, during pregnancy & continued till breast feeding period is over
33First line ART Regimens ( July 2012) ZIDOVUDINE NEVIRAPINEOR LAMIVUDINE ORTenofovir EFAVIRENZNRTI BackboneNNRTI
34Key Approaches towards Improving Access to Treatment Designing for scale-upUse of Evidence for improved programEarly Initiation of ARTART for All - HIV/TB co-infection, Pregnant womenMaking ARV drugs affordableRetention in careAddressing Programmatic & operational ChallengesInstitutionalizing quality assuranceSimplifying drug regimen while adopting newer guidelines
35Monitoring and supervision Significant increase in number of facilities providing ART and the decentralization necessitated the need for a strong monitoring & supervisory structure .Realizing the need for Uniformity and Quality of care , NACO appointed Regional Coordinators (RC) for Care, Support & Treatment services in different parts of country . They are mandated to travel for at least days a month to the ART centers and LAC in their regionThe RC’s (and SACS officials) visit allotted ART Centres at least once in two months and send regular weekly and monthly reports to NACO. They also mentor the sites on technical issues during the visit and through e- communication.Special focus is given on centers which have high LFU/ death rate etc or are facing some operational problems .
36Key Approaches towards Improving Access to Treatment Designing for scale-upUse of Evidence for improved programEarly Initiation of ARTART for All - HIV/TB coinfection, Pregnant womenMaking ARV drugs affordableRetention in careAddressing Programmatic & operational ChallengesInstitutionalizing quality assuranceSimplifying drug regimen while adopting newer guidelines
37Risk factors and barriers for linkage and retention Policy related factorsPatient related factorsEnvironmental & Social factorsOperational /systemic factorsThis categorization will help the counsellor in addressing each barrier. For example, a client related barrier can be addressed with the client himself/herself. If required support can be sought from family members or friends or other providers. When the barrier is related with counsellor, he/she may need to modify the approaches in an appropriate way. If it is something with other providers or is a problem with the society, the counsellor may have limited scope of intervention. However, client should be helped to reduce the impact upon him/her and continue the treatment.
38Enhancing patient retention in HIV Care- How? Addressing Operational/systemic factorsStandard Operating Procedures for patient follow upStandardized reporting & recording mechanismOperational research commissioned to identify the factorsData collected through M & E, research & field experience is used for:updating standard operating procedures for the facilitiesmonitoring quality of care including CD4 test for all, early ART initiation, ART for all those eligible, LFU/Missed ratesfor policy making , planning scale up and launching new initiatives to address the gaps for better outcomesStructured training curriculums for all staff on issues related to HIV, SoPs & M & E systems
39….Enhancing patient retention in HIV Care- Facilitators Addressing Patient related factorsCare coordinator appointed at all ART centers to make services more patient friendly and reduce stigmaScale up and decentralization of ART services done so as to improve accessibility to services.50% concession in rail fare and free bus travel in many statesCCC and DLN outreach workers involved in patient tracking and monthly meeting held between CCC & ART centre for exchange of lists and informationLaisoning with other ministries & departments so that PLHIV can take benefits of existing social protection schemes
40Key Approaches towards Improving Access to Treatment Designing for scale-upUse of Evidence for improved programEarly Initiation of ARTART for All - HIV/TB coinfection, Pregnant womenMaking ARV drugs affordableRetention in careAddressing Programmatic & operational ChallengesInstitutionalizing quality assuranceSimplifying drug regimen while adopting newer guidelines
41NACP IV ( )strategiesEvidence based approach – focus on key districtsScale up to CHC level across the countryFocus on HRGs, Bridge population, TB and STI patientsUniversal coverage for ANC populationMeaningful involvement of private sector
42NACP-IV – Targets (ICTC) COMPONENTYear 1Year 2Year 3Year 4Year 5Number of Stand Alone ICTC5219Facility Integrated ICTC (Govt)24005600640072007600F-ICTC (PPP Model)8121050112012601330Number of Tests(in million)16.822.423.626.428.0No of pregnant mothers tested under PPTCT (in million) (Out of the above)8.411.211.813.214.0No of HIV +ve mother and child receiving prophylaxis18,06024,08025,43528,44530,100
43NACP IV-Way forward in Treatment NACP IV will provide “Universal access to comprehensive, equitable, stigma-free, quality care, support and treatment services to all PLHIV using an integrated approach”.
44Baseline NACP IV (March 2012) Next Five Years………TargetBaseline NACP IV (March 2012)YearYearYearNo of ART Centers (cumulative)340400450500550600No of Link ART Centres8001,0001,2001,3001,4001,500No of PLHIV (adults&Children) on ART (cumulative)632,345735,467815,130903,656953,91410,500,00PLHIV requiring Second Line ART10,00016,00025,00035,00050,00060,000
45Challenges AheadNeed for further decentralization and expansion of ART services but up to what level ??SustainabilityUniversal access will lead 2 fold increase in PLHA on ARTIncreasing need for 2nd line as ART programme matures2nd line failure? What further ?Increased costs of ARV in view of introduction of newer drugsQuantifying the quality of care at ART centers- quarterly indicators to judge the quality of care at ART centers- leading to accreditation of ART centres
46Most Important challenge with 99.73 % population uninfected TreatmentPreventionPrevention no doubt requires a larger focus particularly in our context but care, support and Treatment is also an important pillar and with new evidence on treatment as prevention, the balance between two is also important
47Sustainability - A critical agenda In NACP III, donor funding accounted for 86% and domestic funding only 14% in total AIDS spendingThis will reverse in NACP IV nowIncremental rise in treatment costs with increased testing and coverage– What would be impact of interventions like TIs, which may not be quantifiable but have been instrumental in reducing new infections.
48Additional consideration with New Guidelines on ART (2013) Need for further decentralization and expansion of ART services but up to what level ?? Quality issuesAdditional Numbers on ART, CD 4 cut off 500—12 to 20%VL in first Line ART, feasibility, costsNeed for third line drugsNewer drugs—patented, rising costs
49Treatment as Prevention Data from2 Indian sites in HPTN 052 did not show any difference in two arms, sample size smallNeed for OR studies to see feasibility of TsAP in terms of acceptability, increased burden at centers and costAddressing challenges of long term adherence in PLHIV who are asymptomatic and do not require ART for their own health, toxicity?? Drug ResistanceTsAP for whom ?Sero-discordant couplesNo data about TsAP among IDU , none in HPTN 052 studyOnly 37 HIV discordant MSM couples in the studyNo information on peno-anal sex among heterosexualsWhom to Focus in concentrated epidemic settings- Sero discordant or Key Populations—evidence?
50HRGs found HIV Positive and Linked to ART during 2012-13 (till Dec, 2012) – NACO CMIS Good linkages of key population to testing and care but retention remains an issue.
53Issues to consider while we strive for treatment as prevention Accessibility to ART services-Large country with different capacities of health systems in different statesLoss from detection to enrollment in HIV careLate detection of HIV, base line CD –initially 119; now 188 for males and 250 for femalesAlready burdened health systemsSustainability- sharp decline in donor fundingTreatment fatigue & retention in careRoutine Prevention strategies versus treatment as prevention53