HIV Situation in India Dr Sunil Gaikwad

HIV/AIDS In India Approximate population of India: 1.21 billion (Census 2011 ) 1986: First case of HIV detected in Chennai Estimated number of HIV/AIDS cases in India (2009) : 2.39 million [Females- 39% and children- 3.5% ] Adult HIV prevalence: 0.31% 10% of the world's HIV/AIDS population live in India New annual HIV infections has declined by more than 50 percent during the last decade, 2.7 lakh in 2000 to1.2 lakh in 2009. Majority of infected individuals are in 15 – 45 yrs age group, Male- female ratio – 2 : 1 Every year in India, over 100,000 pregnant women with HIV give birth NACO Annual report 2010-11

High prevalence states Four south Indian states Andhra Pradesh Maharashtra Karnataka and Tamil Nadu Contributes 55% of all HIV infections NACO Annual report 2010-11

Routes of Transmission of HIV, India, 2010-11 NACO Annual report 2010-11

National AIDS Control Programme Phase III (NACP III) 2007 - 2012: Halt and reverse the epidemic in India by 2012 Reduce new infections by 60% in high prevalence states 40% in vulnerable states Increase proportion of PLHA receiving care, support and treatment Strengthen the infrastructure, systems and human resources in prevention, care, support and treatment programmes at district, state and national levels. Build strategic information management systems NACO Annual report 2010-11

India’s response to the epidemic 1,385 under various State AIDS Control Societies (SACS) Targeted Interventions projects: 1,127 Blood Banks & 155 Blood Component Separation Units Access to safe blood: 1,038 designated STI/RTI clinics, + 90 new Syndromic Case Management Laboratory support for CD4 211 CD4 machines 5,233 stand-alone ICTCs, 1,632 facility integrated ICTCs. Counselling and testing services: NACO Annual report 2010-11

ICTC Voluntary HIV testing with appropriate pre-and post- test counseling Confidentiality No Test & Treat Approach

ART in India Free ART roll out programme – Dec 2004 Current status [Jun 2011] ART centers - 313 PLHA receiving ART from Govt - 428638 including 25071 children , PLHA receiving ART from private sector- approx1,50,000. COE: providing second line ART : 10 centres of excellence and covers 1929 patients PLHA registered : 40 % of the estimated 2.39 million pts. have been identified and registered in ART clinics across the country NACO Annual report 2010-11

ART scale up in India NACO Annual report 2010-11

Antiretroviral drugs available in India (2011) NRTIs Zidovudine Stavudine Tenofovir Lamivudine Didanosine Abacavir NNRTIs Nevirapine Efavirenz PIs Atazanavir Lopinavir/Ritonavir Darunavir Indinavir Nelfinavir Integrase inhibitors Raltegravir

Antiretroviral drugs available free through the public health care delivery First line antiretroviral therapy (therapy naïve) Zidovudine/Lamivudine/Nevirapine Stavudine/Lamivudine/Nevirapine Zidovudine/Lamivudine/Efavirenz Stavudine/Lamivudine/Efavirenz Tenfovir/Emtricitabine/NVP or EFV* Second line antiretroviral therapy (treatment experienced) : Zidovudine/Lamivudine/Tenofovir/Atazanavir/Ritonavir * Alternative first line therapy

NACO Guidelines 2007 Preferred regimen AZT + 3TC + NVP Alternative regimen AZT + 3TC + EFV d4T + 3TC + NVP/EFV Other options TDF + 3TC/FTC + NVP/EFV PI’s not recommended for first line therapy

CRITERIA FOR STARTING ANTIRETROVIRAL THERAPY

NACO 2009 WHO 2010 Classification of HIV-associated clinical disease WHO STAGE CD4 NOT AVAILABLE CD4 AVAILABLE Asymptomatic 1 Do not treat Treat if CD4 <250 Mild symptoms 2 Advanced symptoms 3 Treat Consider treatment if CD4 <350 and initiate ART before CD4 drops below 200 Severe/advanced symptoms 4 Treat irrespective of CD4 count Classification of HIV-associated clinical disease WHO STAGE CD4 AVAILABLE Asymptomatic 1 CD4 <350 /mm3 Initiate ART CD4 > 350/mm3 Defer unless HBV/HCV Rx HIV nephropathy Cytotoxic therapy Mild symptoms 2 Advanced symptoms 3 Treat irrespective of CD4 count Severe/advanced symptoms 4

Challenges Low Health seeking behavior Stigma Diagnosis of OI Early diagnosis of PTB & EPTB in HIV Diagnosis of MDR and XDR tuberculosis among PLHA First line ART Raising cut of for ART initiation to CD4 350 cells cu mm. Need for introduction of viral load, drug resistance and TDM in the ART programme. Resistance to first line ART drugs PMTCT- Single dose NVP

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