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Today’s Agenda

India’s National AIDS Control Programme Reversing the Tide International AIDS Conference Washington D.C., U.S.A July 2012 Aradhana Johri Additional Secretary, National AIDS Control Organization Government of India. 1. Today’s Agenda. 1. 2. 3. 2.

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Today’s Agenda

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  1. India’s National AIDS Control ProgrammeReversing the TideInternational AIDS ConferenceWashington D.C., U.S.AJuly 2012AradhanaJohriAdditional Secretary, National AIDS Control OrganizationGovernment of India 1

  2. Today’s Agenda 1 2 3 2

  3. HIV in India...grim projections earlier, but a global success story today Early 2000’s….projections Today… 56% reduction in new infections over the last decade! 20-25 million people projected to be living with AIDS by 2010 (highest number in any country in the world) 0.31% adults infected 2.3 million people living with HIV Source: National Intelligence Council (2002) 'The Next wave of HIV/AIDS: Nigeria, Ethiopia, Russia, India and China', September, p.3 Source: HIV Estimations, 2010 & NACO’s ANC Sentinel Surveillance data. Consistent ANC sites for the age group 15-24 were analysed 3

  4. Reduced Deaths & More Efficient Case Detection Decline in estimated annual AIDS-related deaths with scale-up of ART Declining AIDS-related deaths Significant increase in baseline CD4 count at detection Source: HIV Estimations, 2010 4

  5. The Road Map 5

  6. Quadrupling of budget for HIV under NACP III ($ Million)… Additional 800m of extra budgetary support 6

  7. Ambitious Targets, Impressive Achievements 7

  8. Ambitious Targets, Impressive Achievements 8

  9. Ambitious Targets, Impressive Achievements 9

  10. Ambitious Targets, Impressive Achievements 10,515 10

  11. Ambitious Targets, Impressive Achievements 11

  12. Ambitious Targets, Impressive Achievements 12

  13. New Evidence…HSS 2010-11 India continues to portray a concentrated epidemic Source: 2010-11 NACO HIV Sentinel Surveillance – Provisional Findings 13

  14. New Evidence…HSS 2010-11 Further decline in HIV prevalence among different risk groups Declining trends at national level among general population, FSW & MSM Stable trends at national level among IDU Need to study trends among Migrants, Truckers and TG IDU FSW ANC MSM Source: 2010-11 NACO HIV Sentinel Surveillance – Provisional Findings Note: 3-yr moving averages based on consistent sites; ANC–385 sites, FSW–89 sites, MSM–22 sites, IDU–38 sites 14

  15. HIV Epidemics among FSW • Declining trends among FSW at national level and in all the states • Large size of FSW with higher HIV prevalence in high prevalence states • Vulnerability due to FSW also extends to source states for migration • Greater need to sustain the reach and quality of FSW interventions to consolidate the gains States with higher vulnerability among FSW Source: NACO HIV Sentinel Surveillance 2010-11 – Provisional Findings; NACO Mapping of HRG 2008-09;

  16. HIV Epidemics among MSM • Large size and higher levels of HIV among MSM in high prevalence states and low prevalence states of Gujarat, MP, West Bengal, Chhattisgarh, Delhi etc. • Need to saturate coverage among MSM through effective prevention services States with higher vulnerability among MSM Source: NACO HIV Sentinel Surveillance 2010-11 – Provisional Findings; NACO Mapping of HRG 2008-09;

  17. HIV Epidemics 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 UP • Focus on saturation with Needle-Syringe Exchange Programme and Scale-up of OST States with higher vulnerability among IDU Source: NACO HIV Sentinel Surveillance 2010-11 – Provisional Findings; NACO Mapping of HRG 2008-09;

  18. HIV Epidemics due to Migration • Rising trends in low prevalence states among ANC attendees despite low level, stable epidemics among HRG in these states • HIV prevalence – higher among rural ANC than urban; higher among those whose spouse is a migrant • Mapped migration corridors with large volumes of out-migration to high prevalence destinations • Need to increase coverage of migrants at destinations & along with their spouses at source States with higher vulnerability due to Migration Source: NACO HIV Sentinel Surveillance 2010-11 – 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. 2011. 11:S6;

  19. Emerging Vulnerabilities TRUCKERS TRANS-GENDERS (TGs) • Greater vulnerability among Truckers and Trans-genders • Need to generate more evidence on epidemic trends and transmission dynamics • Need to scale up and strengthen prevention interventions for Truckers & TG Source: 2010-11 NACO HIV Sentinel Surveillance – Provisional Findings

  20. Targeted Interventions Proven Cost-Effective • Districts with higher TI intervention intensity show greater declines than those with lower TI intensity • 2.7 million lives saved through TIs, cost of ~$100/ infection averted Source: Impact of Targeted Interventions on Heterosexual Transmission of HIV in India, Kumar R, Mehendale SM, Panda S; Sex Transm Infect 2011;87:354e361. doi:10.1136/sti.2010.047829, Prinja et al 20

  21. Today’s Agenda 1 2 3 21

  22. Guiding Principles 22

  23. The Route 23

  24. Consultative process for planning and implementation A community-centric approach 24

  25. The Route 25

  26. Management Focus… Leveraging Expertise Government programme delivered In-sourced support • Leveraging external skills through: • Technical Resource Groups • Technical Support Units • Academic partnerships • Core capabilities of government • Build on core health systems capabilities • Supplement with technical staff on contract • Partner with SACS • Contracts with management agencies Resulting in large improvements in service delivery… Eg: TI 26

  27. Management Focus… Standardization for scaleSome Examples… 27

  28. Flexible Modeling-Greater ImpactEg. Red Ribbon Express 28

  29. The Route 29

  30. Evidence-driven recasting of Migrant Strategy Migrants over-represented (80%) among HIV+ men (Ganjam) Linkages between source & destination Higher HIV Prevalence among Pregnant Women with a Migrant Spouse 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. 2011. 11:S6; NACO HIV Sentinel Surveillance 30

  31. Evidence Led… Roll out of OST ProgrammeSetting up of Link ART Centres * Projected as per scale-up plan OR to study Factors affecting ART Adherence Patients who travel >100 Kms/visit Patients who don’t come to ARTC due to long distance Patients who spend > Rs.100 / visit Patients who don’t come due to finan. reason 31

  32. Today’s Agenda 1 2 3 32

  33. Challenges and the way forward 33

  34. 1. Increased reliance on domestic financing in view of dwindling donor resources NACP-III: Expenditure till 31.03.2012; 2012-13: Budget Estimate

  35. 2. Balancing Prevention & Treatment Sustaining Prevention Focus & Addressing Emerging Epidemics Vs Growing need for ART

  36. 3. Convergence for Higher Impact Launch of PMTCT integration – mid-2008 Source: NACO-CMIS CHALLENGES • Competing priorities at state level • Scaling up integration initiatives • Ensuring availability of trained counselors / staff • Stigma in health care settings Complete integration Partial integration Coordination Value addition / linkages

  37. 4. Taking the lead…Policy Initiatives 37

  38. “Some of the key priority areas will be preventing new infections in hitherto low prevalence states while consolidating efforts in the high prevalence states” The Prime Minister, Dr. Manmohan Singh, at the Parliamentary Forum on HIV/AIDS, 2011 5. Sustained political will 38

  39. You must be the change you wish to see in the world… -- Mahatma Gandhi 39

  40. and we march on… Thank You! 40

  41. Resulting in large improvements in TI service delivery levels 41

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