Indian Experience with Treatment as Prevention Key approaches & challenges

1. Indian Experience with Treatment as Prevention Key approaches & challenges Dr. B .B .Rewari MD,FRCP, FICP,FIACM,FIMSAWHO National consultant Care , Support and Treatment National Programme Officer (ART) National AIDS Control Organization India

2. Presentation Outline • Current Epidemiological scenario • National Response • Improving access to testing • Linkage between testing and treatment • Retention in care • Moving towards NACP IV-Scale up needed • Challenges in Treatment as Prevention

3. Declining Trends of HIV Epidemic in India Female: 39% of PLHIV; Children: 7% of PLHIV Source: Technical Report India HIV Estimates 2012, NACO & NIMS

4. District-wise Scenario of HIV/AIDS

5. Routes of HIV Transmission, 2012-13

6. HIV Concentrated in HRG & Bridge Pop. Source: HIV Sentinel Surveillance 2010-11 – A Technical Brief, NACO

7. However, Regional Variations Exist… HP-NE-3 HP-South-4 Distribution of Estimated New HIV Infections (2011) India LP-North-7 LP-North-6 Declining trends in high prev. states of South & North East, but still at higher levels; Stable to rising trends in low prev. states of Central & North India Source: HSS 2010-11 & HIV Estimations 2012 Note: 3-yr moving averages based on consistent sites; India – 385; HP-South-4 (AP,TN,KR,MH) – 233, HP-NE-3 (MN,NG,MZ) – 31, LP-North-6 (BI,DL,HP,PJ,RJ,UP) – 45, LP-North-7 (AS,CH,GJ,HR,JH,OR, UK) – 33

8. Declining trends, but higher levels… Declining trends among general population, FSW & MSM; Stable trends among IDU Need to sustain efforts in High Prevalence areas to consolidate gains Source: HIV Sentinel Surveillance 2010-11 – A Technical Brief, NACO Note: 3-yr moving averages based on consistent sites; ANC–385 sites, FSW–89 sites, MSM–22 sites, IDU–38 sites

9. Emerging Vulnerabilities: 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 Haryana • Focus on saturation with Needle-Syringe Exchange Programme & 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;

10. Emerging Vulnerabilities: 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 strengthen coverage of migrants at transit & destinations & along with their spouses at source • Focus on IEC for general population 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;

11. HIV/AIDS – India’s Response • 1986: 1st case of HIV detected in Chennai • 1990: HIV/AIDS Cell set up in MoHFW • 1992: NACP-I launched with a outlay of US$ 84 m • 1992: National AIDS Control Organisation (NACO) established within MoHFW • 1999-2006: NACP-II Budgetary outlay of US$ 191.9m • 2007-2012: NACP-III Budgetary outlay of US$ 1.3 billion • NACP IV (2012-2017) on the anvil with projected outlay of more than US$ 2 billion

12. NACP Strategies Prevention is the main stay Care, Support and Treatment High risk populations Low risk populations People living with HIV/AIDS • Targeted Interventions for High Risk Groups (FSW, MSM, IDU, Truckers & Migrants) • Link Worker Scheme for rural population • Prevention & Control of Sexually Transmitted Infections • IEC, Social Mobilization & Mainstreaming • Condom promotion • Blood safety • Counselling & Testing Services (ICTC, PPTCT, HIV/TB) • First line & second line ART • Care &Support Centres • HIV-TB Coordination • Focus on PPTCT • Treatment of Opportunistic Infections Strategic Information Management Institutional Strengthening

13. Evidence of Programme Impact 57% Reduction in New Infections (2000-11) with Scale-up of Prevention Strategies 29% Reduction in AIDS-related Deaths (2007-11) with Scale-up of Anti-Retroviral Treatment Source: Technical Report India HIV Estimates 2012, NACO & NIMS

14. Key Approaches towards Improving Access to testing and Treatment Services

15. How we scaled up… PREVENTION focused COMMUNITY and high risk groups at centre QUALITY assurance through institutional mechanisms Increased ACCESS to testing, care and treatment SCALE – expanded service delivery

16. Significant Expansion of Service Delivery Source: NACO-CMIS

17. Counseling & testing Services • 1997: VCT services started in the country • 2006: Integration of VCT and PPTCT as ICTC • Special focus on key population and MARPs • 10515 ICTCs have been set up, nearly half are facility integrated • HIV testing offered to all ANC , TB patients and STI patients • Still around 40% do not know their status • 2012-2017: NACP IV strategies for scale up at least to CHC level across the country and 24X7 PHCs in high prevalence districts

18. Scale up of HIV Testing Facilities (ICTCs) 5018 facility integrated ICTCs in the Government facilities & 964 ICTCs under Public Private Partnership model currently functional, besides 4533 Stand alone ICTCs

19. Significant Expansion of PPTCT but still far away Source: NACO-CMIS

21. Trend in HIV testing of TB patients

22. Care, Support & Treatment Programme in India • The ART programme in India was launched on 1st April 2004 at 8 institutions in 6 high prevalence states & Delhi • Rapidly scaled up to network of 1100 ART centers and Link ART centers • All PLHIV including children registered in HIV care are provided free diagnostic & treatment services • Nearly 1.5 million PLHIV registered in HIV care • 0.65 million are currently on ART • Concept of Link ART centers evolved in 2008 for decentralization of services so as to facilitate easy access to services • All ART centers linked to Care & Support Centers run by Positive networks and NGOs

23. Anti-retroviral Treatment (ART): Policy Package • Free Diagnostic services (CD4 count and other baseline tests) --CD 4 count twice a year or earlier if required, Viral load –targeted approach • Standardized Free ART: • First line ARV drugs • Alternate first line ARV drugs • Second line ARV drugs • Free diagnosis & Treatment of Opportunistic Infections • Linkage to various social protection schemes of Govt. • Robust mechanism for Retention in Care

24. Accessibility to ART services • Three tier model of ART services evolved-CoE , ART centers, Link ART centers • Need based and evidence based scale up to address concentrated epidemic in a geographically large & diverse country • District-wise ICTC data for sero-positives detected is analysed and geographic locations and catchment areas are mapped to select the sites for setting up ART Centres • Existing health care systems strengthened by providing additional technical, human, infrastructure support and additional laboratory investigation like CD4 tests under NACP

25. Scale up of Treatment • High level political commitment. • 9 fold increase in ART provision in last 5 years • 58% coverage of those in need as per spectrum model • 85% coverage of those in need among those detected • ART services available in 609/671 (90%) districts of country • Strong partnership with PLHIV network and civil society • 220 networks of PLHIV functional • Plan to increase no. of ART facilities to nearly 2100 and provide ART to 1 million PLHIV in public sector over next 5 years

29. linkage to CPT and ART - Trend

30. Key Approaches towards Improving Access to Treatment

31. Guidelines on initiation of ART in adult and adolescents

32. Guidelines on initiation of ART in Pregnant women for Prevention of Mother to Child transmission • To prevent transmission of infection from positive mothers to newborns, it has been decided to use multidrug ARV regimen and provide ART/ARV prophylaxis to all positive pregnant women irrespective of CD count. (Option B)

33. First line ART Regimens ( July 2012) NRTI Backbone NNRTI ZIDOVUDINE NEVIRAPINE OR + LAMIVUDINE + OR Tenofovir EFAVIRENZ

34. Key Approaches towards Improving Access to Treatment

35. Monitoringand supervision • Significant increase in number of facilities providing ART and the decentralization necessitated the need for a strong monitoring & supervisory structure . • Realizing the need for Uniformity and Quality of care , NACO appointed Regional Coordinators (RC) for Care, Support & Treatment services in different parts of country . They are mandated to travel for at least 12-15 days a month to the ART centers and LAC in their region • The RC’s (and SACS officials) visit allotted ART Centres at least once in two months and send regular weekly and monthly reports to NACO. They also mentor the sites on technical issues during the visit and through e- communication. • Special focus is given on centers which have high LFU/ death rate etc or are facing some operational problems .

36. Key Approaches towards Improving Access to Treatment

37. Risk factors and barriers for linkage and retention

38. Enhancing patient retention in HIV Care- How? • Addressing Operational/systemic factors • Standard Operating Procedures for patient follow up • Standardized reporting & recording mechanism • Operational research commissioned to identify the factors • Data collected through M & E, research & field experience is used for: • updating standard operating procedures for the facilities • monitoring quality of care including CD4 test for all, early ART initiation, ART for all those eligible, LFU/Missed rates • for policy making , planning scale up and launching new initiatives to address the gaps for better outcomes • Structured training curriculums for all staff on issues related to HIV, SoPs & M & E systems

39. ….Enhancing patient retention in HIV Care- Facilitators • Addressing Patient related factors • Care coordinator appointed at all ART centers to make services more patient friendly and reduce stigma • Scale up and decentralization of ART services done so as to improve accessibility to services. • 50% concession in rail fare and free bus travel in many states • CCC and DLN outreach workers involved in patient tracking and monthly meeting held between CCC & ART centre for exchange of lists and information • Laisoning with other ministries & departments so that PLHIV can take benefits of existing social protection schemes

40. Key Approaches towards Improving Access to Treatment

41. NACP IV (2012-2017)strategies • Evidence based approach – focus on key districts • Scale up to CHC level across the country • Focus on HRGs, Bridge population, TB and STI patients • Universal coverage for ANC population • Meaningful involvement of private sector

42. NACP-IV – Targets (ICTC)

43. NACP IV-Way forward in Treatment NACP IV will provide “Universal access to comprehensive, equitable, stigma-free, quality care, support and treatment services to all PLHIV using an integrated approach”.

44. Next Five Years………

45. Need for further decentralization and expansion of ART services but up to what level ?? Sustainability Universal access will lead 2 fold increase in PLHA on ART Increasing need for 2nd line as ART programme matures 2nd line failure? What further ? Increased costs of ARV in view of introduction of newer drugs Quantifying the quality of care at ART centers- quarterly indicators to judge the quality of care at ART centers- leading to accreditation of ART centres Challenges Ahead

46. Most Important challenge with 99.73 % population uninfected Treatment Prevention

47. Sustainability - A critical agenda • In NACP III, donor funding accounted for 86% and domestic funding only 14% in total AIDS spending • This will reverse in NACP IV now • Incremental rise in treatment costs with increased testing and coverage– What would be impact of interventions like TIs, which may not be quantifiable but have been instrumental in reducing new infections.

48. Need for further decentralization and expansion of ART services but up to what level ?? Quality issues Additional Numbers on ART, CD 4 cut off 500—12 to 20% VL in first Line ART, feasibility, costs Need for third line drugs Newer drugs—patented, rising costs Additional consideration with New Guidelines on ART (2013)

49. Data from2 Indian sites in HPTN 052 did not show any difference in two arms, sample size small Need for OR studies to see feasibility of TsAP in terms of acceptability, increased burden at centers and cost Addressing challenges of long term adherence in PLHIV who are asymptomatic and do not require ART for their own health, toxicity?? Drug Resistance TsAP for whom ? Sero-discordant couples No data about TsAP among IDU , none in HPTN 052 study Only 37 HIV discordant MSM couples in the study No information on peno-anal sex among heterosexuals Whom to Focus in concentrated epidemic settings- Sero discordant or Key Populations—evidence? Treatment as Prevention

50. HRGs found HIV Positive and Linked to ART during 2012-13 (till Dec, 2012) – NACO CMIS Good linkages of key population to testing and care but retention remains an issue.