hiv/aids in india

HIV/AIDS in IndiaHIV/AIDS in India

A presentation by Dr. Kakrani to the workshop A presentation by Dr. Kakrani to the workshop held Jan. 1 & 2, 2010 at the Pune Union of held Jan. 1 & 2, 2010 at the Pune Union of Working Journalists Hall in Navi Peth sponsored Working Journalists Hall in Navi Peth sponsored by the University of Miami and Indiana University by the University of Miami and Indiana University titled, “Strengthening Media Professionalism and titled, “Strengthening Media Professionalism and the NGO-Media Interface in India, and Sri Lanka the NGO-Media Interface in India, and Sri Lanka for HIV/AIDS Coveragefor HIV/AIDS Coverage

Dr.A.L.Kakrani, MDDr.A.L.Kakrani, MD

Dean, Faculty of MedicineDean, Faculty of Medicine

Dr DY Patil University &Dr DY Patil University &

Professor & Head, Department of Medicine Professor & Head, Department of Medicine

Dr D Y Patil Medical College, Hospital & Research CentreDr D Y Patil Medical College, Hospital & Research Centre

Pimpri, Pune 411018 Pimpri, Pune 411018

Phone: College & Hospital : Phone: College & Hospital :

91-20-27423690/27420307 Ext 18591-20-27423690/27420307 Ext 185

Residence: 91-20-25880873Residence: 91-20-25880873

Mobile: 09823972424Mobile: 09823972424

e-mail:e-mail: [email protected]

Res Address: 201,Vishakha,DSK Akashganga,Res Address: 201,Vishakha,DSK Akashganga,

New DP Road, Aundh,New DP Road, Aundh,

Pune 411007Pune 411007

2.39 2

3.64

6.01

85.96

Sexual

IDUs

Blood and BloodProducts

Perinatal

Others

Probable Sources of Transmission in AIDS Cases in India (July, ’05)

Transition Map of HIV prevalenceTransition Map of HIV prevalenceEvolution of HIV from 1986 to 2002Evolution of HIV from 1986 to 2002

> 1 % antenatal women

HIV Prevalence reaches over 5% amongst high risk

group in Maharashtra and Manipur

1.74 m infectedFirst case of HIV

detected in Chennai

1986 1990 1994

> 5 % high risk groups < 5 % high risk groups

4.58 m. Indians living with HIV

3.5 m. infected

1998 2001 2002

4.01 m. infected 4.58 m. infected3.5 m. infected

1998 2001 2002

4.01 m. infected 4.58 m. infected

5.13 Million Indians Living with HIV/AIDS

Decline in HIV incidence Decline in HIV incidence According to NACO's newer estimates, the According to NACO's newer estimates, the

prevalence of HIV/AIDS in India has to be scaled prevalence of HIV/AIDS in India has to be scaled down from about 0.9 per cent to one in 300 or down from about 0.9 per cent to one in 300 or 0.36 per cent, or to 2-3.1 million with an average 0.36 per cent, or to 2-3.1 million with an average of 2.5 millions from the government's 2006 of 2.5 millions from the government's 2006 estimate of 5.2 million. estimate of 5.2 million.

Why are these numbers more accurate? The credibility of the new HIV prevalence figures

is very high because they are derived from not one but three authoritative sources.

Additional 'sentinel' surveys sites, NHFC-3 & Additional 'sentinel' surveys sites, NHFC-3 & NBSS & IBBASNBSS & IBBAS

Times of India Times of India LEADER ARTICLE: Don't Be Misled On AIDS LEADER ARTICLE: Don't Be Misled On AIDS

10 Jul 2007, Pallava Bagla10 Jul 2007, Pallava Bagla

It may be premature to start celebrating that It may be premature to start celebrating that number of people infected with HIV has come number of people infected with HIV has come down by half to 2.47 million as per the latest down by half to 2.47 million as per the latest estimate released by the government. estimate released by the government.

The government went in for a different approach The government went in for a different approach in 2006. Earlier, it would restrict itself to 'sentinel' in 2006. Earlier, it would restrict itself to 'sentinel' surveys, This time, the government decided to surveys, This time, the government decided to supplement these surveys with community data.supplement these surveys with community data.

Prabhat Jha of the Center for Global Health Prabhat Jha of the Center for Global Health Research, Toronto, says, "It is hard to know how Research, Toronto, says, "It is hard to know how much of this drop is due to a new computer much of this drop is due to a new computer programme rather than the efforts of the AIDS programme rather than the efforts of the AIDS control programme". control programme".

Start of National AIDS Start of National AIDS Control Programme Control Programme

(NACP) was first step (NACP) was first step towards the control of towards the control of HIV spread in IndiaHIV spread in India

NACP Phase INACP Phase I

Started in 1992 with Emphasis on Started in 1992 with Emphasis on Epidemic monitoring by surveillance Epidemic monitoring by surveillance Awareness generation through information Awareness generation through information

, education & communication, education & communicationEnsuring blood safetyEnsuring blood safety

This led to a firm footing for NACP Phase IIThis led to a firm footing for NACP Phase II

Objectives of NACP Phase IIObjectives of NACP Phase II(1999-2004-extendable(1999-2004-extendable ))

Reduce the rate of growth of Reduce the rate of growth of HIV infection in IndiaHIV infection in India

Strengthen India’s capacity Strengthen India’s capacity to respond to HIV/AIDSto respond to HIV/AIDS

NACP-III2007 till date

Prevent infection through coverage of high-risk groups with targeted interventions and scaled up interventions in the general population.

Provide greater care, support and treatment to larger number of PLHA.

Strengthen the infrastructure, systems and human resources in prevention, care, support and treatment programmes at district, state and national levels.

Strengthen the nationwide Strategic Information Management System.

NACP III ExpenditureNACP III Expenditure

Antiretroviral TherapyAntiretroviral Therapy

Till date the only hope Till date the only hope for long term survival of for long term survival of HIV AIDS patients is use HIV AIDS patients is use

of of

Antiretroviral TherapyAntiretroviral Therapy

Antiretroviral Therapy (ART)Antiretroviral Therapy (ART)

ART for HIV disease has transformed ART for HIV disease has transformed the common perception about HIV the common perception about HIV from being a rapidly fatal disease to from being a rapidly fatal disease to some what more manageable chronic some what more manageable chronic diseasedisease

Risk of Opportunistic Infections is Risk of Opportunistic Infections is minimized & many non- infectious minimized & many non- infectious complications are reducedcomplications are reduced

Global Response on HIV AIDSGlobal Response on HIV AIDS

Millennium Development Goal (MDG) By Millennium Development Goal (MDG) By

2015: halt and begin to reverse the spread of 2015: halt and begin to reverse the spread of

HIV/AIDS.HIV/AIDS.

June 2001: UN General Assembly Special June 2001: UN General Assembly Special

Session “call to action” Session “call to action” HIV/AIDS is a global HIV/AIDS is a global

emergency, it undermines socio-economic emergency, it undermines socio-economic

development& poses a challenge to full development& poses a challenge to full

enjoyment of human rightsenjoyment of human rights

Global Response on ARTGlobal Response on ART

April 2002:WHO released guidelines for ART in April 2002:WHO released guidelines for ART in

resource limited settings, includes 10 ART drugs in resource limited settings, includes 10 ART drugs in

the list of “ Essential Medicines” for all countries, the list of “ Essential Medicines” for all countries,

put pressure on Pharma Industries for cost put pressure on Pharma Industries for cost

reductionreduction

Sept 03: WHO/UNAIDS: lack of ARV access is Sept 03: WHO/UNAIDS: lack of ARV access is

“Global Health Emergency”“Global Health Emergency”

11stst December 2003: WHO/UNAIDS revised “3 by 5” December 2003: WHO/UNAIDS revised “3 by 5”

Initiative launchedInitiative launched

11stst Dec 2003, GOI announced free ART from 1/4/04 Dec 2003, GOI announced free ART from 1/4/04

In February 2004,NACO has prepared the document for ART Guidelines in consultation with clinicians in public & private sector , technical experts from GOI, DGHS, WHO,UNAIDS, donors, CII, Pharma industry, network of HIV Positive, paramedical groups & NGOs. The document will be reviewed from time to time

ART Programme in IndiaART Programme in IndiaStarted after 3x5 initiative by WHO in 2003Started after 3x5 initiative by WHO in 2003Govt of India decided to provide free Govt of India decided to provide free

access to ART for 100,000 PLHA by 2005 access to ART for 100,000 PLHA by 2005 but only 33000 could be enrolledbut only 33000 could be enrolled

GOI plans to expand the program up to GOI plans to expand the program up to district level to cover 3 lac PLHA by 2012 district level to cover 3 lac PLHA by 2012 through 250 centres across Indiathrough 250 centres across India

Program is largely supported by Program is largely supported by GFATMGFATM (Global Fund for AIDS,TB & Malaria )(Global Fund for AIDS,TB & Malaria )

Public Private Partnership is encouragedPublic Private Partnership is encouraged

Pressures To Increase The Enrollments For Pressures To Increase The Enrollments For ART Are Inevitable & May Interfere With The ART Are Inevitable & May Interfere With The

Rationale Use & Cause Gaps in Drug Rationale Use & Cause Gaps in Drug DeliveryDelivery

National ART DataNational ART DataNovember 2009November 2009

AdultsAdults 269948269948

PediatricsPediatrics 1802018020

Total casesTotal cases 287968287968

CD4 machinesCD4 machines 174174

ART CentresART Centres 230230

Second line Anti-retroviral Therapy

Second line anti-retroviral therapy (ART) was rolled out under the National ART Programme on January 1, 2008 on a pilot basis at the JJ Hospital, Mumbai and GHTM, Tambaram.

Its access has expanded to 10 Centres of

Excellence which have necessary expertise and laboratory facilities to initiate and monitor it.

Out of 687 patients who were evaluated, 274 were put on second line ART & 49 counselled

Link ART CentresLink ART Centres

Link ART Centres help decongest big ART centres & reduce patient's time & costs

It is planned to have 650 LACs under NACP-III. & A total of 334 LACs were sanctioned of which 68 are functional with 170 trained staff members

Thailand Vaccine trialThailand Vaccine trial

For the first time a vaccine against AIDS has shown efficacy in humans. Although modest, it is very encouraging for the scientific community.

With one third of protected persons only, “this vaccine will not allow us to control the AIDS epidemic, But it is a very strong signal to the scientific community: it shows that we can vaccinate against HIV no vaccine against AIDS has so far shown efficacy in humans.

Types of HIV CounsellingTypes of HIV Counselling

PreventionPrevention Risk reduction, behavior changeRisk reduction, behavior change

VCT: Pre-test/Post-test VCT: Pre-test/Post-test ARTART

ART readinessART readiness Adherence Adherence

Crisis interventionCrisis intervention Grief and bereavementGrief and bereavement Peer counsellingPeer counselling

Median Survival after AIDS Median Survival after AIDS Diagnosis in Brazil (1989-2001)Diagnosis in Brazil (1989-2001)

58

18

5

0

10

20

30

40

50

60

70

1982-1989 1990-1995 1996-2001

Year of AIDS Diagnosis

Surv

ival

(in

mon

ths)

Chequer et al, 1992; Marins et al. 2002

Introduction of universal access to HAART in Brazil

Number of AIDS deaths (registered and estimated) considering the actions of National AIDS Program Brazil, 1989 to

2002

* Estimated deaths after 1999, using real trend

89 90 91 92 93 94 95 96 97 98 99 '00 '01 '02Year of Death

0

5

10

15

20

25

30

35

Thousand

Registered*1

Estimative without NAP actions

1994-2002: 90,962 avoided deaths

Projected without NAP actions

Registered with NAP actions

Coping with increased expenditure (Maharashtra)

19

1110

5

1

65

6

0

2

4

6

8

10

12

14

16

18

20

Used pastsavings

Borrowedfrom others

Mortgagedassets

NGO support Sale of assets Loan fromEmployer

StoppedMedicines

Others

Source, ILO New Delhi, 2003

Stigma and discriminationStigma and discrimination

In Health Care SystemIn Health Care System Confidentiality breachConfidentiality breach Mandatory testing – pre operative, ANC Mandatory testing – pre operative, ANC Refusal of invasive procedures or surgery, when Refusal of invasive procedures or surgery, when

needed including elective caesarian sectionneeded including elective caesarian section Refusal of treatment for PLHARefusal of treatment for PLHA In EmploymentIn Employment Due to misconceptions, risk of frequent absenceDue to misconceptions, risk of frequent absence In Educational institutesIn Educational institutes

HIV TB Co-InfectionHIV TB Co-Infection HIV infection is the most powerful risk factor for HIV infection is the most powerful risk factor for

progression from TB infection to disease. progression from TB infection to disease. An individual with dual infection of HIV-TB has more than An individual with dual infection of HIV-TB has more than

50% lifetime risk of developing TB as compared to 10% 50% lifetime risk of developing TB as compared to 10% in TB infected person without HIV infection. in TB infected person without HIV infection.

The rate of progression of TB is also 30 times more rapid The rate of progression of TB is also 30 times more rapid in an HIV infected person. in an HIV infected person.

TB accelerates the progression of HIV by causing a six-TB accelerates the progression of HIV by causing a six-seven-fold increase in viral load. seven-fold increase in viral load.

It shortens the survival period of an HIV infected It shortens the survival period of an HIV infected individual and is a cause of death for one in three cases individual and is a cause of death for one in three cases of AIDS.of AIDS.

HIV AIDS Bill 2005HIV AIDS Bill 2005

The HIV/AIDS bill, aimed at preventing discrimination and protecting the rights of people living with the disease, is 'under finalisation', union Health and Family Welfare Minister Ghulam Nabi Azad said on Tuesday 2009

'The draft of the bill on HIV/AIDS is at present under finalisation. However, no firm date can be indicated at this stage,' he said in a written reply to a question on when the bill was going to be introduced in parliament.

Indian EstimatesIndian Estimates

India had an estimated 1.8 – 2.9 million HIV positive persons in 2007, with an estimated adult HIV prevalence of 0.34%(Males 0.43% & females 0.29%

HIV Prevalence among the high risk groups (HRG) is very high compared to that among the general population, India continues to be in the category of concentrated epidemic.


47 districts (48 sites) have shown >5% HIV Prevalence among FSW, which also include FSW sites in low prevalence states namely West Bengal, Bihar and Gujarat FSW sites

in Pune, Mumbai and Thane have shown > 30% HIV prevalence among FSW. Among FSW, there is a decline in South Indian States reflecting the impact of interventions


Except Andhra Pradesh with HIV Prevalence of 1%, all other states have shown < 1% Prevalence among ANC Clinic attendees. 10 districts have shown a very high prevalence of 3% among ANC clinic attendees.

Expanded surveillance among MSM has revealed more than 5% HIV prevalence in Karnataka (17.6%), Andhra Pradesh (17%), Manipur (16.4%), Maharashtra (11.8%), Delhi (11.7%), Gujarat (8.4%), Goa (7.9%), Orissa (7.4%), Tamil Nadu (6.6%) and West Bengal (5.6%).

The Red Ribbon Express Project is the world’s largest mass mobilization campaign on HIV/AIDS. covering 27000 kms & 6.2 million people from Dec

07 to Dec 08

Maharashtra DataMaharashtra DataNovember 2009November 2009

Total VCTCs 606Total VCTCs 606 Reactivity Rate 0.54%Reactivity Rate 0.54% (old data 0.1.09%)(old data 0.1.09%) Total +ve reported cases 421578Total +ve reported cases 421578Total ART Centres 41Total ART Centres 41 On ART 68460 (Pediatric cases 4967)On ART 68460 (Pediatric cases 4967)Total CD4 machines 22Total CD4 machines 22Total Blood Banks 307Total Blood Banks 307

http://www.nacoonline.org

Quick links-publications-news letter, this is Quick links-publications-news letter, this is available in English & Hindi available in English & Hindi

http://www.mahasacs.org

Nirdhar in Marathi news letter on web siteNirdhar in Marathi news letter on web site International information is available on International information is available on

Unaids, WHO & UNICEF websitesUnaids, WHO & UNICEF websites

hiv/aids in india

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