1. 1 HIV/AIDS Scenario INDIA Dr Milind Kulkarni Dr DSA Karthickeyan

2. EstimatedRange People living with HIV33.4 million31.1 – 35.8 million New HIV infections in 2008 2.7 million2.4 – 3.0 million Deaths due to AIDS in 20082.0 million1.7 – 2.4 million Global estimates for Adults and Children, 2008

3. HIV estimates for India (2007) CategoryEstimation Total population1.027 billion HIV prevalence (15-49 years)0.34% HIV prevalence among men (15-49 years)0.40% HIV prevalence among women (15-49 years)0.27% Number of people living with HIV (adults and children) 2.31 million Number of Children living with HIV (>15 years)3.8% of total

4. Routes of Transmission of HIV

5. National AIDS Control Programme Phase III (NACP III) 2006 – 2011 Goal 1: Halt and reverse the epidemic in India over the next five years Reduce new infections by 60% in high prevalence states 40% in vulnerable states

6. Prevent new infections Increase proportion of PLHA receiving care, support, and treatment Strengthen capacity at district, state and national levels Build strategic information management systems National AIDS Control Programme Phase III (NACP III) 2006 – 2011 Goal 2:

7. Linkages for Care, Support & Treatment Home care Tertiary Health Care Integrated Counselling Testing The entry point Secondary Health Care Community Care Centres PLHA District Hospitals HIV Clinics Specialised Care facilities ART Centres Link ART CENTRES Primary Health Care NGO & Peer Groups

8. FacilitySanctionedFunctional ART Centres297228 Centres Of Excellence 10 LAC495197 CCC343262 Updated: July, 2009 Facilities for Care, Support & Treatment

9. Strengthening Referrals and linkages for improving Access to ART Services Guidelines for eligibility of ART have been revised for timely access to ART. Community out-reach services have been strengthened to follow up PLHA through counselors of ICTCs, out-reach workers of CCCs, PLHA networks and NGOs. Special attention is paid to pre-ART cases who missed follow-up visits, who missed ART doses, who are lost to follow-up and those with poor drug adherence. Long distances, considerable travelling time and costs to access ART for those living in rural and remote areas addressed through strategic locations of Link ART Centres

10. ICTC is the entry point for HIV-infected persons NACP phase III aims to halt and reverse the epidemic in India over the next five years, to scale up care and support services, and to strengthen capacity at all levels Link ART centres are developed in an attempt to provide ART nearer to patients homes Link ART centres are expected to enhance treatment adherence Key points

11. 11 Current National ART Regimens AZT, 3TC & NVP (For patients with Haemoglobin >8 gm/dl) d4T, 3TC & NVP (For patients with Haemoglobin <8 gm/dl) TDF, 3TC, & NVP in special situations only - when there is toxicity/other contra- indications to AZT or d4t EFV should be given as priority to persons receiving anti- tuberculous therapy

12. In this case, TDF+3TC as fixed dose combination will be provided, after consultation with the SACEP. Alternate to Zidovudine & Stavudine Alternate First line ART SACEP: State AIDS Clinical Expert Panel 12

13. RegimenDrug CombinationRemarks Regimen III Tenofovir + Lamivudine + Nevirapine For patients not tolerating Zidovudine and Stavudine Regimen III (a) Tenofovir + Lamivudine + Efavirenz Alternate First line ART Alternate to Zidovudine & Stavudine 13

14. RegimenDrug CombinationRemarks Regimen IV Zidovudine + Lamivudine + Lopinavir / Ritonavir For patients not tolerating both NVP & EFV Regimen IV (a) Stavudine + Lamivudine + Lopinavir / Ritonavir For patients not tolerating both NVP & EFV and Hb < 8 g% Alternate First line ART Alternate to Nevirapine & Efavirenz 14

15. Intolerance to both NVP and EFV: in this case, LPV/r as a substitution ARV will be provided upon review and approved by the SACEP. The patient shall be managed and provided LPV/r by the COE Mild toxicities do not require discontinuation of ART or drug substitution. This part is still in process of implementation Alternate to Nevirapine & Efavirenz Alternate First line ART SACEP: State AIDS Clinical Expert Panel

16. Challenges Initiation of ART Eligibility : <250 CD4 Count 2 nd Line ART Need for more patient High Risk Population Increasing prevalence of HIV 16

17. Challanges HIV/TB Co-Infection Diagnosis of MDR TB Diagnosis of Extrapulmonary TB(National program Diagnosing only Sputum Positive Pulmonary TB) PPTCT/PMTCT Triple Drug Regimen. Still NVP? 17

18. Thank you Mercy