National AIDS Control Programme IV
India’s AIDS Control Programme is globally acclaimed as a success story. The National AIDS Control Programme (NACP), launched in 1992, is being implemented as a comprehensive programme for prevention and control of HIV/AIDS in India. Over time, the focus has shifted from raising awareness to behavior change, from a national response to a more decentralized response and to increasing involvement of NGOs and networks of PLHIV.
In 1992, the Government launched the first National AIDS Control Programme (NACPI) with an IDA Credit of USD84 million and demonstrated its commitment to combat the disease. NACP I was implemented with an objective of slowing down the spread of HIV infections so as to reduce morbidity, mortality and impact of AIDS in the country. National AIDS Control Board (NACB) was constituted and an autonomous National AIDS Control Organization (NACO) was set up to implement the project. The first phase focused on awareness generation, setting up surveillance system for monitoring HIV epidemic, measures to ensure access to safe blood and preventive services for high risk group populations.
In November 1999, the second National AIDS Control Project (NACP II) was launched with World Bank credit support of USD 191 million. The policy and strategic shift was reflected in the two key objectives of NACP II: (i) to reduce the spread of HIV infection in India, and (ii) to increase India’s capacity to respond to HIV/AIDS on a long-term basis. Key policy initiatives taken during NACP II included: adoption of National AIDS Prevention and Control Policy (2002); Scale up of Targeted Interventions for High risk groups in high prevalence states; Adoption of National Blood Policy; a strategy for Greater Involvement of People with HIV/AIDS (GIPA); launch of National Adolescent Education Programme (NAEP); introduction of counseling, testing and PPTCT programmes; Launch of National Anti-Retroviral Treatment (ART) programme; formation of anointer-ministerial group for mainstreaming; and setting up of the National Council on AIDS, chaired by the Prime Minister; and setting up of State AIDS Control Societies in all states.
In response to the evolving epidemic, the third phase of the national programme (NACPIII) was launched in July 2007 with the goal of Halting and Reversing the Epidemic by the end of project period. NACP was a scientifically well-evolved programme, grounded on a strong structure of policies, programmes, schemes, operational guidelines, rules and norms. NACP-III aimed at halting and reversing the HIV epidemic in India over its five-year period by scaling up prevention efforts among High Risk Groups (HRG) and General Population and integrating them with Care, Support & Treatment services. Thus, Prevention and Care, Support & Treatment (CST) form the two key pillars of all the AIDS control efforts in India. Strategic Information Management and Institutional Strengthening activities provide the required technical, managerial and administrative support for implementing the core activities under NACP-III at national, state and district levels.
The capacities of State AIDS Control Societies (SACS) and District AIDS Prevention and Control Units (DAPCUs) have been strengthened. Technical Support Units (TSUs) were established at National and State level to assist in the Programme monitoring and technical areas. A dedicated North-East regional Office has been established for focused attention to the North Eastern states. State Training Resource Centres (STRC) was set up to help the state level implementation units and functionaries. Strategic Information Management System (SIMS) has been established and nation-wide rollout is under way with about 15,000 reporting units across the country. The next phase of NACP will build on these achievements and it will be ensured that these gains are consolidated and sustained.
Programme Priorities and Thrust Areas
KEY PRIORITIES UNDER NACP-IV ARE
• Preventing new infections by sustaining the reach of current interventions and effectively addressing emerging epidemics.
• Prevention of Parent to Child transmission.
• Focusing on IEC strategies for behavior change in HRG, awareness among general population and demand generation for HIV services.
• Providing comprehensive care, support and treatment to eligible PLHIV.
• Reducing stigma and discrimination through Greater involvement of PLHA(GIPA).
• De-centralizing rollout of services including technical support.
• Ensuring effective use of strategic information at all levels of programme.
• Building capacities of NGO and civil society partners especially in states with emerging epidemics.
• Integrating HIV services with health systems in a phased manner
• Mainstreaming of HIV/AIDS activities with all key central/state level Ministries/departments will be given a high priority and resources of the respective departments will be leveraged. Social protection and insurance mechanisms for PLHIV will be strengthened.
Mainstreaming and partnerships are the key approaches to facilitate multi-sectoral response engaging a wide range of stakeholders. Private sector, civil society organisations, networks of people living with HIV/AIDS and government departments all have a crucial role in prevention, care, support, treatment and service delivery. Technical and financial resources of the development partners are leveraged to achieve the objectives of the programme.
Prevention Strategies
Targeted Intervention for High Risk Group
India’s HIV program has been recognized globally as a very successful public health model with specific interventions for key population of Female Sex Workers (FSW), Men who have Sex with Men (MSM), Transgender (TG)/Hijra and Injecting Drug Users (IDUs) known as the Core Group and Migrants and Truckers known as the Bridge Population. Over 3 decades of implementing Targeted Interventions through NGO/CBOs, critical insights into the operational aspects is gained. Consolidating the success gained, a focused HIV intervention has been developed to reduce HIV prevalence among the key population.
The TI program has evolved over 4 Phases of the National AIDS Control Program (NACP) and this has been achieved through national, regional and state level consultations with multiple stake holders including community members and civil society organizations.
Targeted Intervention (TI) Approach
The prevention of HIV infection among the high risk group (HRGs) is the main thrust area for the NACP and the TI program has demonstrated that it is the most effective way of controlling the epidemic among this population. The approach for providing services to this population began by conducting various mapping exercises that helped in arriving at a specific denominator for service provision. The latest mapping was conducted for TGs/Hijra in 2013. One of the primary aims of NACO and the State AIDS Control Society (SACS) is to ensure saturation of this figure through TI service components of Behaviour Change Communication, Condom Distribution for Core Group, Condom Social Marketing for Bridge Population, Outreach Services, Counseling, HIV testing, Linkages/Referrals, STI management, Needle/Syringe Program (for IDUs), Opioid Substitution Therapy (for IDUs), enabling environment for all key population and advocacy to reduce stigma and discrimination.
In order to measure the program efficiency a system of HIV Sentinel Surveillance was introduced and over the years India’s efficient response to HIV has resulted in reduction of HIV prevalence among most of the core group with the exception of IDUs and TGs/Hijra. The HIV prevalence among ANC is 0.29% and Female Sex Worker 2.20%, Men who have Sex with Men 4.30%, Injecting Drug Users 9.90%, and Transgender/Hijra population 7.20% (IBBS 2015). The bridge population consisting of Truckers and Migrants had HIV prevalence of 2.59% and 0.99% respectively. (HSS 2012-13 Technical Brief)
Female Sex Workers (FSWs)
The HIV epidemic in India is known to be a concentrated epidemic with FSWs being one of the core risk groups that are affected. FSWs have many sexual partners concurrently. Generally, full time FSWs have at least one client per day. Some FSWs have more clients than others. In addition to the number of clients their nature of work also increases their vulnerability to HIV. The higher risk of FSWs is reflected in a substantially higher prevalence of HIV among them than in the general population.
As per the IBBS conducted in 2014-15, HIV prevalence among FSWs found to be 2.2%, which is eight times more than among pregnant women attending antenatal clinics (0.29%) as per HSS 2014-15. However there has been a steady decline in the HIV prevalence among this population as a result of effective interventions over the years.
Men having Sex with Men (MSM)
Men Having Sex with Men(MSM) are another important group who are highly vulnerable to HIV and are also a strategically important group for focusing HIV prevention programmes. The term ‘men who have sex with men’ (MSM) is used to denote all men who have sex with other men as a matter of preference or practice, regardless of their sexual identity or sexual orientation and irrespective of whether they also have sex with women or not.
It is important to know that not all MSM have many sexual partners however, there are MSM sub-populations which do have high rates of partner change as well as high number of concurrent sexual partners. These sub-groups of MSM who often engage in anal sex with multiple partners are at particularly high risk. As per the IBBS conducted in 2014-15, HIV prevalence among MSMs found to be 4.30%.
Transgender/Hijra
NACO has initiated exclusive TG/Hijra intervention under NACP IV based on the recommendation from the working groups and needs from communities. A separate costing and operational guideline has been developed for uniformity in scaling up of TG/Hijra intervention in the country based on the mapping.
In order to ensure standardization of program, feedback from stakeholders and communities, the typology wise Technical Resource Groups (TRG) formed and conducted, periodically.
TIs for Bridge Populations
Individuals who have sexual partners in the high risk groups as well as other partners of lower risk(General population) are called a “bridge population”, because they form a transmission bridge from the HRGs to the general population. Quite often they are clients or partners of male and female sex workers. Truckers and Migrant workers are named as bridge population through close proximity to high risk groups and are at the risk of contracting HIV.
They are a critical group because of their ‘mobility with HIV’. Their living and working conditions, sexually active age and separation from regular partners for extended periods of time predispose them to paid sex or sex with non-regular partners. Further, inadequate access to treatment for sexually transmitted infections aggravates the risk of contracting and transmitting the virus.
TIs to Reduce the Vulnerabilities of Bridge Population
The NACO interventions are aimed at controlling the spread of HIV and STI through increasing awareness about their transmission and prevention. All interventions are aimed at promoting safe sex through use of condoms. They also facilitate easy access to condoms, treatment for STIs, counselling, testing and treatment services.
How are Interventions reached to Truckers?
These interventions involve interaction with the target community about sexually transmitted infections, HIV/AIDS and safe sex. For better recall and understanding information, education and communication materials are used in such community interactions. Peer educational activities are also undertaken for effective outreach of the messages.
So far, all interventions were carried out by NGOs at locations where truck drivers halt for sufficient duration like along highway stretches, business activity areas, check posts or port areas. Under NACP-III, a larger gamut of organisations constituting National Highway Authority of India, social marketing organisations in the promotion of condoms, NGOs and truckers’ organisations at state and district level are involved in a concerted effort for better outreach of the interventions. The ultimate aim is to harness the trucking community, associations, brokers and others in driving these interventions.
Interventions aimed at Migrants
The interventions for migrants are focused on 8.64 million temporary, short duration migrants. They are of special significance to the epidemic because of their frequent movement between source and destination areas. Therefore, to provide continuum of services to these migrants and their spouses, interventions are proposed at destination, source and transit areas. As all migrants are not at equal risk of HIV, only the high risk migrants (both male & female) are covered at the destinations through Targeted Interventions run by NGOs. Industrial houses, factory owners, construction companies and other employers engaging these migrants are also being motivated to provide HIV prevention services to these migrants. For reaching to migrants, NGOs identify volunteers among the migrants community and train them in spreading preventive messages among their fellow workers.
Link Worker Scheme
Rural HIV infection was another challenge area that needed to be addressed. Owing to poor infrastructure, weak health care systems and poor connectivity with most facilities, large number of vulnerable population, HRGs, Bridge Population and PLHIVs needed to be provided services. In order to bridge this gap Link Worker Scheme (LWS) was initiated. For more details please click here for the operational guideline of LWS.
Employer Led Model
Employer Led Model (ELM) is initiated to reach vulnerable informal workers in organized and unorganized sectors. ELM provides broad methodology and implementation strategies for reaching out to vulnerable workforce linked to industries with HIV/AIDS prevention and care programme. The ELM is feasible in industrial sectors which have certain systems and structures such as company management, association, federation, society, contractor and subcontractor mechanisms that can be leveraged for implementation of the model.For more details please click here for the operational guideline of ELM.
Harm Reduction Program
NACO has adopted the harm reduction policy as a strategy for prevention of HIV/AIDS amongst IDUs in 2002 during the second phase of the National AIDS Control Program (NACP II). Counselling, behavior change communication (BCC), Needle Syringe Exchange Program (NSEP), abscess prevention and management, STI treatment, referral and linkages, etc are the service components of the strategy. These services are being provided through the NGOs known as the IDU TI.
In the current NACP IV, the provision of female outreach worker (ORW) was added in all the IDU TIs for reaching out to the spouses of male IDUs. Female Injecting Drug User (FIDU) is also an additional typology being included in NACP IV. The key aspects of the strategy to provide services to FIDUs include:
• Comprehensive package of services including services specifically addressing needs of Female IDUs
• Female friendly service delivery mechanisms
• Gender responsive and need based services
• Community participation in programme planning and implementation
• Evidence driven response- Collection and application of strategic information for program design and improvement in quality implementation
Opioid Substitution Therapy (OST) was integrated as part of the harm reduction service component in 2008. Buprenorphine is the drug for the OST program. India has two models for delivering OST Services:
1. NGO model: NACO has been supporting OST implementation in NGO settings since 2008. In this model, OST services are offered by NGOs already implementing an IDU TI project and offering the package of harm reduction services mentioned above. The medications are dispensed to the clients on a daily basis directly under supervision by a qualified and trained nurse (DOTS). The TI staffs are trained on OST management and are required to follow standard operating procedures drafted to ensure minimum standards of care which include maintenance of records for clinical interactions, dispensing and stock keeping.
2. Collaborative Model:In 2010, NACO has piloted a collaborated model of OST delivery based on partnership between Government hospitals and NGOs implementing IDU TIs. In this model, the OST centre is located in a Government health care setting (medical college hospital, district hospital, sub-divisional hospital, CHC, etc.) and is tasked with clinical assessment, diagnosis, prescription of substitution treatment, follow-up, dispensing of the medications and stock management. Each of these OST centres is linked with nearby IDU TI(s) which facilitate the service uptake by motivating IDU clients in the project area and referring them to the centre for treatment. In addition, the linked IDU TIs also follow-up with clients who drop-out from treatment and conduct regular advocacy with local stakeholders to generate support for the OST programme.
The NGO OST centres are accredited by an external agency (National Accreditation Board of Hospitals and Healthcare Providers) once in 2 years. Only those centres which meet the minimum standards laid down by NACO and are certified by NABH are permitted to dispense medications.
OST distance learning programme for building the capacities of service providers engaged in delivery OST has also been developed. This distance learning program is targeted towards the personnel working in OST centres. The online training programme is a joint endeavour of National Drug Dependence Treatment Centre (NDDTC), All India Institute of Medical Sciences (AIIMS), New Delhi and Public Health Foundation of India (PHFI), New Delhi under the guidance of NACO.
OST with methadone syrup has been introduced for the first time in the current NACP IV. Regional Institute of Medical Science (RIMS), Imphal is the site identified for the program. NACO plans to scale up the sites gradually in other high burden IDU states. Training module for OST with methadone has been developed in collaboration with NDDTC, AIIMS.
Recognizing that partnerships with law enforcement agencies would be a value addition to the implementation of the harm reduction services, NACO held a National Consultative meeting with key stakeholders including State prison departments in 2014 under the chairmanship of Union Secretary, MOHFW. Based on the suggestions provided by the subject knowledge experts from the national consultative meeting a National strategy on HIV Prevention and Control in Prison Settings was developed. Additionally, a National Working Committee (NWC) on Prison HIV and Law Enforcement was also constituted to overlook the implementation of the program.
In order to standardise the approach to scaling up coverage among these core groups and bridge populations and maintain a high level of quality, it is important to provide detailed information on various operational issues to TI. Hence, NACO has developed detailed TIoperational guidelines and capacity building manuals for each typologies.
Services for Prevention
Awareness-raising || Management STI /RTI || Integrated Counselling and Testing Centre (ICTC) || PPTCT || PEP || Condom Promotion Programme || Access to Safe blood
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The HIV epidemic in India is concentrated among high risk groups (sex workers, men-having-sex-with-men, injecting drug users and clients of sex workers), though there is evidence of the infection spreading to the general population. About one-third of districts in the country have high HIV prevalence.
To contain the infection, NACP-III consolidates efforts in prevention, care, support and treatment of HIV/AIDS. Under the plan all HIV/AIDS linked services are integrated and scaled up to sub-district and community level. However, the services available in any area are based on the prevalence there. This is made necessary as HIV/AIDS in India presents heterogeneous epidemiology with high rate of prevalence, more than one percent in general population in some districts and low prevalence in others.
Core Services at District level
In packaging of services, care is taken for the special needs of the region and availability of complementary healthcare system. In high prevalence districts, the full spectrum of preventive, supportive and curative services are available in medical colleges or district hospitals. These hospitals provide HIV/AIDS prevention services including treatment and cure for sexually transmitted infections, psycho-social counselling and support for people infected or affected by HIV, management of opportunistic infections and anti-retroviral therapy for people living with HIV/AIDS, counselling and testing facility for prevention of parent to child transmission of HIV infection, specialised paediatric HIV care and treatment as well as referral for specialist needs such as surgery, ENT and ophthalmology etc.
CHCs give Basic Services
Community Health Centres and Primary Health Centres are integrated in the programme and facilitate prevention through promotion of condoms, counselling and testing for HIV (ICT Centres), prevention of parent to child transmission (PPTCT), treatment and cure for sexually transmitted diseases and management of opportunistic infections.
CBOs for better Service Outreach
Hospitals providing HIV services are linked to NGOs/CBOs which play a significant role in providing peer support services and home-based care for people living with HIV/AIDS. CBOs also facilitate follow-up with children born to HIV positive women, support at the community level and outreach to services at the district level.