HIV/AIDS GLOBAL, INDIAN & STATE SCENARIO AND ACTIVITIES OF DSACS

1. Dr. A. K.Gupta Additional Project Director Delhi State AIDS Control Society HIV/AIDS GLOBAL, INDIAN & STATE SCENARIO AND ACTIVITIES OF DSACS

2. TIME LINE • 1981- Cases of unusual immune deficiency identified • in USA • 1982- Acquired Immune Deficiency Syndrome (AIDS) • defined for the first time • 1983-The Human Immune Deficiency Virus (HIV) • identified as the cause of AIDS • 1983-In Africa, a heterosexual AIDS epidemic is revealed • 1985-The first HIV antibody test becomes available • 1987-The WHO launches the Global AIDS Programme

3. TIME LINE (contd) • 1988-The first therapy for AIDS – zidovudine, or AZT • approved for use in the USA • 1994- Highly Active Antiretroviral Treatment launched • 1996- First treatment regimen to reduce mother-to-child • transmission of HIV • 1997-Brazil becomes the first developing country to • provide antiretroviral therapy through its public • health system • 2001-Global Fund to fight AIDS, Tuberculosis and Malaria • launched • 2003-Launch of "3 BY 5" initiative -goal of reaching 3 • mill people in developing world with ART by 2005

4. Global estimates for adults and children, 2008 • People living with HIV33.4 million[31.1 – 35.8 million] • New HIV infections in 20082.7 million [ 2.4 – 3.0 million] • Deaths due to AIDS in 20082.0 million[1.7 – 2.4 million]

5. Adults and children estimated to be living with HIV, 2008 Eastern Europe & Central Asia 1.5 million [1.4 – 1.7 million] Western & Central Europe 850 000 [710 000 – 970 000] North America 1.4 million [1.2 – 1.6 million] East Asia 850 000 [700 000 – 1.0 million] Middle East&North Africa 310 000 [250 000 – 380 000] Caribbean 240 000 [220 000 – 260 000] South & South-East Asia 3.8 million [3.4 – 4.3 million] Sub-Saharan Africa 22.4 million [20.8 – 24.1 million] Latin America 2.0 million [1.8 – 2.2 million] Oceania 59 000 [51 000 – 68 000] Total: 33.4 million (31.1 – 35.8 million)

6. Over 7400 new HIV infections a day in 2008 • More than 97% are in low- and middle-income countries • About 1200 are in children under 15 years of age • About 6200 are in adults aged 15 years and older, • of whom: • almost 48%are among women • about 40% are among young people (15–24)

7. Indian Scenario First case: 1986, Estimates 2007: 2.31 million PLHAs, 86.5% -15-49 years age group (27.9 % in 15-29 and 58.6% in 30-49 age groups) Epidemic concentrated in H.R.Gs; Spreading From : H.R.Gs to the general population & Urban to Rural areas Feminization (39.3% - women) of epidemic 7,50,500 HIV +VE Regd. In HIV Care At ART Centers 3,50,000 Initiated on ART 2,60,000 alive and on treatment

8. 1998 2001 2002 1986 1990 1994 HIV Prevalence reaches over 5% amongst high risk group in Maharashtra and Manipur First case of HIV detected in Chennai > 1 % antenatal women > 5 % high risk groups < 5 % high risk groups

9. TIME LINE –INDIAN ACTIVITIES • 1990-1992-AIDS Task Force (ICMR), National AIDS • Committee , Medium Term Plan (1990-1992) • 1992- NACP I • 1997-VCTC SERVICES • 1999-NACP PHASE II • 2002- NATIONAL PMTCT PROGRAMME • 2004- NATIONAL ART PROGRAMME • 2004- COMPREHENSIVE PPTCTC PROGRAMME • 2006- REVISED WHO ART GUIDELINES • 2007-NACP III LAUNCHED

10. Characteristics of Indian Epidemic • Heterogeneous epidemic • A wide variation in HIV prevalence between districts and intra districts even within the states • A concentrated epidemic, focused in HRGs (CSWs,MSMs,IDUs) • < 1% Prevalence HIV & Nephrology 23-08-07

11. DELHI SCENARIO • Total population - 16 million, First case- • 1988 • Estimated PLHAs (2007)- 32,000 • Low prevalence state (Prevalence in Gen. • population- 0.22%) • Highly vulnerable state- (Migrant labour- • 0.88 million, Truckers stationed/day-35000) • Total high risk population ->1.00 Lakh • (FSW-61261, MSM- 28999, IDU- 17173) • PLHAs detected at ICTCs/VCTCs since 2002- 34,759 • HIV +VE Regd. In HIV Care At ART Centers : 33,473 • No. Currently Alive & on ART-9624 • LFU (7%), DIED (8%) OR TRANSERRED OUT TO ART CENTRES (21%) OF • OTHER STATES.

12. DELHI STATE AIDS CONTROL SOCIETY- 1ST NOVEMBER, 1998 HAVING A STAFF OF 56 PROGRAMME OFFICERS & SUPPORT STAFF & HEADED BY PROJECT DIRECTOR. SERVICE OUTLETS – 93 ICTC CENTRES, 17 STI/RTI CLINICS, 9 ART CENTRES, 4 CCCs, 57DICs, 85 T.I PROJECTS FOR HRGs RUN BY NGOs, 21 BLOOD BANKS & 10 BSC, QA -4 SRLs. FUNDED BY NACO, GOI SOCIETY & ECCHAIRED BY CHIEF SECY, GNCT OF DELHI DELHI STATE AIDS COUNCIL CHAIRED BY HON’BLE C.M. OF DELHI GENERAL BODY – PRESIDENT HON’BLE HM

13. HIV Prevalence : States Classified

14. CATEGORIZATION OF DISTRICTS IN DELHI

15. Categories of Districts In Delhi HIV & Nephrology 23-08-07

16. Dynamics of HIV Transmission High Risk Population GENERAL POPULATION GENERAL POPULATION 0.22% 0.22% (2.6 -11%) Bridging Population Clients, Truckers, migrant population etc.

17. HIV Trend Among Ante Natal Cases

19. PERINATAL OTHERS I.D.Us BLOOD TRANSFUSION SEXUAL

20. RISK OF TRANSMISSION • TRANSFUSION OF INFECTED BLOOD / BLOOD PRODUCTS-> 90% • PERINATAL TRANSMISSION- 25-30% • SEXUAL ROUTE-(ORAL- 0.01%, VAGINAL -0.1%, ANAL-0.5%) • PERCUTANEOUS NEEDLE STICK- 3: 1000 (0.3%)

21. 1. Prevention Of New Infection 2. Care, Support & Treatment 3. Institutional Strengthening Capacity building 4. Strategic Management Information system • Targeted intervention-85 • STI Diagnosis & treatment-17 • Condom promotion • Blood Safety-53 • ICTC-93 • IEC and social mobilisation • AEP- launched • PEP- all govt hospitals • Mainstreaming-7 departments • COE for ART-LNH • Model Blood bank -DDUH • Regional STD Lab-MAMC • TSU for DSACS & Parivar Sewa for PPP STI clinics • Training • EQAS-4 SRLs • Operational Research • ART Centres-9 • CCCs-4 • DICs-7 • Holistic Approach- • Widow pension & jobs for PLHAs • Programme management (CMIS & CPFMS) • Surveillance-20 sites • M & E • Computerization of ICTCs & STI clinics • Common National reporting format

22. PREVELANCE OF HIV POSITIVITY • GENERAL POPULATION- INDIA : 0.36%, DELHI-0.22% ( SENTINEL SURVEILLANCE ANC DATA 2007) • HIGH RISK GROUPS- 2.64% to 11.73% • STI ATTENDACE: 4.38% • VULNERABLE POPULATION ATTENDING ICTC: 3.5% • TB PATIENTS HIV POSITIVE: 5% • TRUCKERS - 2.5% (TCI)

23. Natural History of HIV Infection Initial Infection (lasting 4–8 weeks), Acute HIV Syndrome (lasting 1 week–3 months), HIV-Specific Immune Response (1–2 weeks), Clinical Latency (10 years, median), AIDS-Defining Illnesses (2 years on average),and Death

24. Natural History of HIV-1 InfectionPrior to treatment Seroconversion Death Initial Infection Asymptomatic Symptomatic AIDS 1000 CD4+ Cells/L 500 ARS 0 Up to 12 years 4-8 wks 2-3 years W.P.

25. 10% 60% 30%

26. Characteristic Viral Load ,CD4 & CD8 Changes Over Time In Cases with HIV Infection CD8 COUNT P24 Ag CD4 COUNT VIRAL LOAD

27. CD 4 COUNT & OPPORTUNISTIC INFECTIONS 500 200 50

28. The Changing Natural History Of HIV/AIDS In The 'HAART' Era Dramatic reductions in the incidence of 1. Opportunistic Infections 2. HIV-related Malignancies 3. Kaposi's Sarcoma 4. Deaths in advanced AIDS cases

29. IMPACT OF ANTI-RETROVIRAL TREATMENT (DELHI STATISTICS)

30. WHO Clinical Staging HIV Infection Clinical Stage I: • Asymptomatic • Persistent Generalized lymphadenopathy (PGL)

31. WHO CLINICAL STAGE II • Moderate unexplained weight loss (< 10% of body weight). • Recurrent bacterial upper respiratory tract infections (current event plus one or more in last six-month period). • Herpes zoster • Angular cheilitis • Recurrent oral ulcerations (two or more episodes in last six mths. • Papularpruritic eruption • Seborrhoeic dermatitis • Fungal nail infections.

32. WHO CLINICAL STAGE III • Unexplained severe weight loss (> than 10% of body wt) • Unexplained chronic diarrhoea for longer than one month. • Unexplained persistent fever > one month • Oral candidiasis • Oral hairy leukoplakia. • Pulmonary tuberculosis (current). • Severe bacterial infection for example, pneumonia, meningitis, empyema, pyomyositis, bone or joint infection, bacteraemia or severe pelvic inflammatory disease. • Acute necrotizing ulcerative gingivitis or necrotizing ulcerative periodontitis. • Unexplained anaemia, neutropenia or chronic (more than one month) thrombocytopenia

33. WHO CLINICAL STAGE IV • HIV wasting syndromei • Pneumocystiscarinii pneumonia • Recurrent bacterial pneumonia. • Chronic herpes simplex virus (HSV) infection (orolabial, genital or anorectal) of more than one month, or visceral of any duration. • Oesophageal candidiasis. • Extra Pulmonary tuberculosis • Kaposi’s sarcoma. • Cytomegalovirus disease (other than liver, spleen or lymph node). • Central nervous system toxoplasmosis. • HIV encephalopathy. • Extrapulmonarycryptococcosis (including meningitis) • Disseminated nontuberculousmycobacteria infection. • Progressive multi focal leukoencephalopathy (PML). • Cryptosporidiosis (with diarrhoea lasting more than one month). • Disseminated mycosis (coccidiomycosis, histoplasmosis, penicilliosis) • Cerebral or non hodgkins Lymphoma, invasive cervical Carcinoma, • Recurrent non salmonella typhoid • HIV cardiomyopathy, nephropathy

34. SOCIO-ECONOMIC PROFILING OF PLHAs A STUDY WAS UNDERATKEN IN COLLABORATION WITH ILO AT TWO ART CENTRTERS (RML & LNH) SALIENT FEATURES: SAMPLE SIZE: 1171 PLHAs (816 MALES, 333 FEMALES & 22 TS/TG LNH: 584 PLHAs, RML:587 PLHAs 90.9% PLHAs BELONG TO 16-45 YRS AGE GROUP SEX COMPOSITION: MALES 70%, FEMALES-28%, TS/TG-2% MARITAL STATUS: MARRIED-72%, WIDOW-12%, SINGLE-16% STATUS OF RESIDENCE: 62% FROM DELHI, 38% ARE MIGRANTS (UP,HARYANA) EDUCATIONAL STATUS: MAJORITY (61%)- LOW EDUCATION STATUS: 25%-ILLITERATE, 36% PRIMARY SCHOOL. ONLY 29%-SEC SCHOOL & 10% COLLLEGE GRADIATE EMPLOYMENT STATUS: > 51% -UNEMPLOYED(90% WOMEN, 50% TS/TG & 35% MEN); 12% DAILY WAGE, 37% REGULAR EMPLOYMENT OCCUPATIONAL BREAKUP OF EMPLOYED : SELF EMPLOYED/BUISENSS-34%, PVT SECTOR-35%, GOVT -8%, LABOUR-14%, FARMER-5%, HAWKERS-4% MONTHLY HOUSLEHOLD INCOME: 46.9% < RS. 2000/PM; 79.2% < RS. 4000/PM;18.2% BETWEEN 4000-10,000/PM; 2.6% . > RS. 10,000/PM

35. THANK YOU