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Www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Indian Experience with Treatment as Prevention Key approaches & challenges Dr. B.B.Rewari.

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Presentation on theme: "Www.ias2013.org Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Indian Experience with Treatment as Prevention Key approaches & challenges Dr. B.B.Rewari."— Presentation transcript:

1 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Indian Experience with Treatment as Prevention Key approaches & challenges Dr. B.B.Rewari MD,FRCP, FICP,FIACM,FIMSA WHO National consultant Care, Support and Treatment National Programme Officer (ART) National AIDS Control Organization India

2 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Presentation Outline  Current Epidemiological scenario  National Response  Improving access to testing  Linkage between testing and treatment  Retention in care  Moving towards NACP IV-Scale up needed  Challenges in Treatment as Prevention 2

3 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Declining Trends of HIV Epidemic in India Female: 39% of PLHIV; Children: 7% of PLHIV Source: Technical Report India HIV Estimates 2012, NACO & NIMS

4 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 District-wise Scenario of HIV/AIDS CategoryNACP-III Definition A> 1% ANC prevalence in any of the sites in the last 3 years B 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 spots D< 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 CategoryNACP-III A156 B39 C296 D118 New Districts 30 Total609

5 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Routes of HIV Transmission,

6 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 HIV Concentrated in HRG & Bridge Pop. Source: HIV Sentinel Surveillance – A Technical Brief, NACO

7 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 However, Regional Variations Exist… Distribution of Estimated New HIV Infections (2011) HP-South-4 HP-NE-3 India LP-North-7 LP-North-6 Declining 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 India Source: HSS & HIV Estimations 2012 Note: 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

8 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Declining trends, but higher levels… Declining trends among general population, FSW & MSM; Stable trends among IDU Note: 3-yr moving averages based on consistent sites; ANC–385 sites, FSW–89 sites, MSM–22 sites, IDU–38 sites Source: HIV Sentinel Surveillance – A Technical Brief, NACO Need to sustain efforts in High Prevalence areas to consolidate gains

9 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Emerging Vulnerabilities: IDU States with higher vulnerability among IDU  Higher levels of HIV among IDU in Punjab, Chandigarh, Delhi and Mumbai, in addition to North East  Emerging epidemics among IDUs in low prevalence states of Kerala, Orissa, MP, Bihar and Haryana  Focus on saturation with Needle- Syringe Exchange Programme & Scale- up of OST Source: NACO HIV Sentinel Surveillance – Provisional Findings; NACO Mapping of HRG ;

10 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Emerging Vulnerabilities: Migration States with higher vulnerability due to Migration  Rising trends in low prevalence states among ANC attendees despite low level, stable epidemics among HRG in these states  Mapped migration corridors with large volumes of out-migration to high prevalence destinations  HIV prevalence – higher among rural ANC than urban; higher among those whose spouse is a migrant  Need to strengthen coverage of migrants at transit & destinations & along with their spouses at source  Focus on IEC for general population  Need to strengthen coverage of migrants at transit & destinations & along with their spouses at source  Focus on IEC for general population Source: 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;

11 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 HIV/AIDS – India’s Response 1986: 1 st case of HIV detected in Chennai 1990: HIV/AIDS Cell set up in MoHFW 1992: NACP-I launched with a outlay of US$ 84 m 1992: National AIDS Control Organisation (NACO) established within MoHFW : NACP-II Budgetary outlay of US$ 191.9m : NACP-III Budgetary outlay of US$ 1.3 billion NACP IV ( ) on the anvil with projected outlay of more than US$ 2 billion

12 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 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 line ART Care &Support Centres HIV-TB Coordination Focus on PPTCT Treatment of Opportunistic Infections Prevention is the main stay High risk populations Low risk populations People living with HIV/AIDS Care, Support and Treatment NACP Strategies Institutional Strengthening Strategic Information Management

13 Kuala Lumpur, Malaysia, 30 June - 3 July % Reduction in New Infections ( ) with Scale-up of Prevention Strategies 29% Reduction in AIDS-related Deaths ( ) with Scale-up of Anti-Retroviral Treatment Evidence of Programme Impact Source: Technical Report India HIV Estimates 2012, NACO & NIMS

14 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Key Approaches towards Improving Access to testing and Treatment Services Designing for scale-upUse of Evidence for improved programEarly Initiation of ART ART for All - HIV/TB coinfection, Pregnant womenMaking ARV drugs affordableRetention in careAddressing programmatic & operational ChallengesInstitutionalizing quality assuranceSimplifying drug regimen while adopting newer guidelines 14

15 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 How we scaled up… 15 SCALE – expanded service delivery QUALITY assurance through institutional mechanisms PREVENTION focused Increased ACCESS to testing, care and treatment COMMUNITY and high risk groups at centre

16 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Significant Expansion of Service Delivery Source: NACO-CMIS

17 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Counseling & testing Services 1997: VCT services started in the country 2006: Integration of VCT and PPTCT as ICTC Special focus on key population and MARPs ICTCs have been set up, nearly half are facility integrated HIV testing offered to all ANC, TB patients and STI patients Still 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

18 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Scale 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

19 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Significant Expansion of PPTCT but still far away Source: NACO-CMIS

20 Kuala Lumpur, Malaysia, 30 June - 3 July 2013

21 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Trend in HIV testing of TB patients

22 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 The ART programme in India was launched on 1 st April 2004 at 8 institutions in 6 high prevalence states & Delhi Rapidly scaled up to network of 1100 ART centers and Link ART centers All PLHIV including children registered in HIV care are provided free diagnostic & treatment services Nearly 1.5 million PLHIV registered in HIV care 0.65 million are currently on ART Concept of Link ART centers evolved in 2008 for decentralization of services so as to facilitate easy access to services All ART centers linked to Care & Support Centers run by Positive networks and NGOs Care, Support & Treatment Programme in India

23 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Anti-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 approach  Standardized Free ART:  First line ARV drugs  Alternate first line ARV drugs  Second line ARV drugs  Free diagnosis & Treatment of Opportunistic Infections  Linkage to various social protection schemes of Govt.  Robust mechanism for Retention in Care

24 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Accessibility to ART services Three tier model of ART services evolved-CoE, ART centers, Link ART centers Need based and evidence based scale up to address concentrated epidemic in a geographically large & diverse country District-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 Centres Existing health care systems strengthened by providing additional technical, human, infrastructure support and additional laboratory investigation like CD4 tests under NACP

25 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Scale up of Treatment High level political commitment. 9 fold increase in ART provision in last 5 years 58% coverage of those in need as per spectrum model 85% coverage of those in need among those detected ART services available in 609/671 (90%) districts of country Strong partnership with PLHIV network and civil society 220 networks of PLHIV functional Plan to increase no. of ART facilities to nearly 2100 and provide ART to 1 million PLHIV in public sector over next 5 years

26 Kuala Lumpur, Malaysia, 30 June - 3 July 2013

27 Kuala Lumpur, Malaysia, 30 June - 3 July 2013

28 Kuala Lumpur, Malaysia, 30 June - 3 July 2013

29 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 linkage to CPT and ART - Trend

30 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Key Approaches towards Improving Access to Treatment Designing for scale-upUse of Evidence for improved programEarly Initiation of ART ART for All - HIV/TB co-infection, Pregnant womenMaking ARV drugs affordableRetention in careAddressing Programmatic & operational ChallengesInstitutionalizing quality assuranceSimplifying drug regimen while adopting newer guidelines

31 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Guidelines on initiation of ART in adult and adolescents WHO Clinical StageRecommendations HIV infected Adults & Adolescents Clinical Stage I and IIStart ART if CD4 < 350 cells/mm 3 Clinical Stage III and IVStart ART irrespective of CD4 count For HIV and TB co-infected patients Patients 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)

32 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 To 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 StageRecommendations HIV infected pregnant women Clinical Stage I and IIStart ART if CD4 < 350 cells/mm 3 Clinical Stage III and IVStart ART irrespective of CD4 count Multidrug ARV prophylaxis to be given to all HIV infected pregnant women if CD4 >350, during pregnancy & continued till breast feeding period is over Guidelines on initiation of ART in Pregnant women for Prevention of Mother to Child transmission

33 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 First line ART Regimens ( July 2012) ZIDOVUDINE NEVIRAPINE OR + LAMIVUDINE + OR Tenofovir EFAVIRENZ NRTI BackboneNNRTI

34 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Key Approaches towards Improving Access to Treatment Designing for scale-upUse of Evidence for improved programEarly Initiation of ART ART for All - HIV/TB co-infection, Pregnant womenMaking ARV drugs affordableRetention in careAddressing Programmatic & operational ChallengesInstitutionalizing quality assuranceSimplifying drug regimen while adopting newer guidelines 34

35 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Monitoring 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 region The 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.

36 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Key Approaches towards Improving Access to Treatment Designing for scale-upUse of Evidence for improved programEarly Initiation of ART ART for All - HIV/TB coinfection, Pregnant womenMaking ARV drugs affordableRetention in careAddressing Programmatic & operational ChallengesInstitutionalizing quality assuranceSimplifying drug regimen while adopting newer guidelines 36

37 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Risk factors and barriers for linkage and retention Retention Policy related factors Patient related factors Environmental & Social factors Operational /systemic factors

38 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Enhancing patient retention in HIV Care- How? Addressing Operational/systemic factors  Standard Operating Procedures for patient follow up  Standardized reporting & recording mechanism  Operational research commissioned to identify the factors  Data collected through M & E, research & field experience is used for: »updating standard operating procedures for the facilities »monitoring quality of care including CD4 test for all, early ART initiation, ART for all those eligible, LFU/Missed rates » for policy making, planning scale up and launching new initiatives to address the gaps for better outcomes –Structured training curriculums for all staff on issues related to HIV, SoPs & M & E systems

39 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 ….Enhancing patient retention in HIV Care- Facilitators Addressing Patient related factors Care coordinator appointed at all ART centers to make services more patient friendly and reduce stigma Scale 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 states CCC and DLN outreach workers involved in patient tracking and monthly meeting held between CCC & ART centre for exchange of lists and information Laisoning with other ministries & departments so that PLHIV can take benefits of existing social protection schemes

40 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Key Approaches towards Improving Access to Treatment Designing for scale-upUse of Evidence for improved programEarly Initiation of ART ART for All - HIV/TB coinfection, Pregnant womenMaking ARV drugs affordableRetention in careAddressing Programmatic & operational ChallengesInstitutionalizing quality assuranceSimplifying drug regimen while adopting newer guidelines 40

41 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 NACP IV ( )strategies Evidence based approach – focus on key districts Scale up to CHC level across the country Focus on HRGs, Bridge population, TB and STI patients Universal coverage for ANC population Meaningful involvement of private sector

42 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 NACP-IV – Targets (ICTC) COMPONENT Year 1Year 2Year 3Year 4Year Number of Stand Alone ICTC 5219 Facility Integrated ICTC (Govt) F-ICTC (PPP Model) Number of Tests (in million) No of pregnant mothers tested under PPTCT (in million) (Out of the above) No of HIV +ve mother and child receiving prophylaxis 18,06024,08025,43528,44530,100

43 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 NACP IV will provide “Universal access to comprehensive, equitable, stigma-free, quality care, support and treatment services to all PLHIV using an integrated approach”. NACP IV-Way forward in Treatment

44 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Target Baseline NACP IV (March 2012) Year Year Year Year Year No of ART Centers (cumulative) No of Link ART Centres 800 1,000 1,200 1,300 1,400 1,500 No of PLHIV (adults&Children) on ART (cumulative) 632,345735,467815,130903,656953,91410,500,00 PLHIV requiring Second Line ART 10,00016,00025,00035,00050,00060,000 Next Five Years………

45 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Need for further decentralization and expansion of ART services but up to what level ?? Sustainability Universal access will lead 2 fold increase in PLHA on ART Increasing need for 2 nd line as ART programme matures 2 nd line failure? What further ? Increased costs of ARV in view of introduction of newer drugs Quantifying the quality of care at ART centers- quarterly indicators to judge the quality of care at ART centers- leading to accreditation of ART centres Challenges Ahead

46 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Prevention Treatment Most Important challenge with % population uninfected

47 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Sustainability - A critical agenda In NACP III, donor funding accounted for 86% and domestic funding only 14% in total AIDS spending This will reverse in NACP IV now Incremental 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.

48 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Need for further decentralization and expansion of ART services but up to what level ?? Quality issues Additional Numbers on ART, CD 4 cut off 500—12 to 20% VL in first Line ART, feasibility, costs Need for third line drugs Newer drugs—patented, rising costs Additional consideration with New Guidelines on ART (2013)

49 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Data from2 Indian sites in HPTN 052 did not show any difference in two arms, sample size small Need for OR studies to see feasibility of TsAP in terms of acceptability, increased burden at centers and cost Addressing challenges of long term adherence in PLHIV who are asymptomatic and do not require ART for their own health, toxicity?? Drug Resistance TsAP for whom ? – Sero-discordant couples – No data about TsAP among IDU, none in HPTN 052 study – Only 37 HIV discordant MSM couples in the study – No information on peno-anal sex among heterosexuals Whom to Focus in concentrated epidemic settings- Sero discordant or Key Populations—evidence? Treatment as Prevention

50 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 HRGs found HIV Positive and Linked to ART during (till Dec, 2012) – NACO CMIS Good linkages of key population to testing and care but retention remains an issue.

51 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Test, Link & Treat – leaky Cascade

52 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Estimated ART Needs & Unmet Need among adults

53 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Accessibility to ART services- Large country with different capacities of health systems in different states Loss from detection to enrollment in HIV care Late detection of HIV, base line CD –initially 119; now 188 for males and 250 for females Already burdened health systems Sustainability- sharp decline in donor funding Treatment fatigue & retention in care Routine Prevention strategies versus treatment as prevention Issues to consider while we strive for treatment as prevention

54 Kuala Lumpur, Malaysia, 30 June - 3 July 2013 Thank You


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