NACP (EVERYTHING should be included in NACP like surakshaa clinic strategic plan for hiv sti 2017-2024 strictly from the park textbook spm...no Missing and messing up

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NATIONAL AIDS CONTROL PROGRAMME (NACP)

Source: Park's Textbook of Preventive and Social Medicine

LAUNCH & AIM

The National AIDS Control Programme was launched in India in 1987. The Ministry of Health and Family Welfare set up the National AIDS Control Organization (NACO) as a separate wing to implement and monitor the programme.

Aim of the programme:

Prevent further transmission of HIV
Decrease morbidity and mortality associated with HIV infection
Minimize the socio-economic impact resulting from HIV infection

MILESTONES OF THE PROGRAMME

Year	Milestone
1986	First case of HIV detected; AIDS Task Force set up by ICMR; National AIDS Committee established under Ministry of Health
1990	Medium Term Plan launched for four states and four metros
1992	NACP-I launched to slow down the spread of HIV infection; National AIDS Control Board constituted; NACO set up
1999	NACP-II begins - focusing on behaviour change, increased decentralization and NGO involvement; State AIDS Control Societies established
2002	National AIDS Control Policy adopted; National Blood Policy adopted
2004	Anti-retroviral treatment initiated
2006	National Council on AIDS constituted under chairmanship of the Prime Minister; National Policy on Paediatric ART formulated
2007	NACP-III launched for 5 years (2007-2012)
2014	NACP-IV launched for 5 years (2012-2017)
2017	National Strategic Plan for HIV/AIDS and STIs 2017-2024

NATIONAL STRATEGY - COMPONENTS

The national strategy has the following components:

Establishment of surveillance centres to cover the whole country
Identification of high-risk group and their screening
Issuing specific guidelines for management of detected cases and follow-up
Formulating guidelines for blood banks, blood product manufacturers, blood donors and dialysis units
Information, education, and communication activities by involving mass media
Research for reduction of personal and social impact of the disease
Control of sexually transmitted diseases
Condom programme

NACP-IV (2012-2017)

Primary Goal: To halt and reverse the epidemic in India over 5 years by integrating programmes for prevention, care, support and treatment.

1. Prevention Services

Targeted interventions for high-risk groups: Female Sex Workers (FSW), Men who have Sex with Men (MSM), Transgenders/hijras, Injecting Drug Users (IDU)
Bridge population: Truckers and migrants
Needle-syringe exchange programme and opioid substitution therapy for IDUs
Prevention interventions for migrant population at source, transit and destination
Link worker scheme for HRGs and vulnerable population in rural areas
Prevention and control of STIs/RTIs
Blood safety
HIV counselling and testing services
Prevention of Parent to Child Transmission (PPTCT)
Condom promotion
Information, education and communication (IEC) and Behaviour Change Communication (BCC)
Social mobilization, youth interventions and Adolescence Education Programme
Mainstreaming HIV/AIDS response
Work place interventions

2. Care, Support and Treatment Services

Laboratory services for CD4 testing and other investigations
Free first-line and second-line ART through ART centres and Link ART Centres (LACs), Centres of Excellence (CoE) and ART Plus centres
Paediatric ART for children
Early infant diagnosis for HIV exposed infants and children below 18 months
Nutritional and psycho-social support through Care and Support Centres (CSC)
HIV/TB coordination (cross-referral, detection and treatment of co-infections)
Treatment of opportunistic infections
Drop-in centres for PLHIV networks

ORGANIZATIONAL STRUCTURE (NACO)

NACO is established as a division under the Ministry of Health and Family Welfare, headed by the Additional Secretary, Ministry of Health and Director General, NACO.

Technical divisions (headed by Deputy DG/DGHS):

Division
Targeted Intervention and LWS
Basic Services (ICTC, PPTCT & HIV/TB)
STI/RTI Management
Blood Safety
Lab Services
Care, Support and Treatment
Information, Education & Communication
Strategic Information (Monitoring, Evaluation, Surveillance, Research & Data Analysis)
Admin & Procurement
Finance

COUNTRY SCENARIO - CLASSIFICATION OF STATES

Based on sentinel surveillance data, HIV prevalence is classified into three groups:

Group I - High Prevalence States: Maharashtra, Tamil Nadu, Karnataka, Andhra Pradesh, Manipur and Nagaland - HIV infection has crossed 5% in high-risk group and 1% or more in antenatal women.

Group II - Moderate Prevalence States: Gujarat, Goa and Puducherry - HIV infection has crossed 5% or more among high risk groups but below 1% in antenatal women.

Group III - Low Prevalence States: Remaining states where HIV infection in any high risk group is still less than 5% and less than 1% among antenatal women.

CATEGORIES OF DISTRICTS

Category	Criteria
A (156 districts)	More than 1% ANC/PTCT prevalence in district at any time in any site in last 3 years
B (39 districts)	Less than 1% ANC/PTCT prevalence + more than 5% prevalence in any HRG (STD/CSW/MSM/IDU)
C (296 districts)	Less than 1% ANC prevalence with less than 5% in all STD clinic attendees, but with known hot spots (migrants, truckers, factory workers, tourists)
D (118 districts)	Less than 1% ANC prevalence with less than 5% in all STD clinic attendees OR poor HIV data with no known hot spots

HIV SURVEILLANCE

Types of surveillance:

(a) HIV Sentinel Surveillance
(b) HIV Sero-Surveillance
(c) AIDS Case Surveillance
(d) STD Surveillance
(e) Behavioural Surveillance
(f) Integration with surveillance of other diseases (e.g., tuberculosis)

HIV Sentinel Surveillance

Objectives:

To provide reliable HIV estimates and HIV trend information to policy makers
To understand the trends of HIV epidemic among general population and high-risk groups in different states
To understand the geographical spread of HIV infection and identify emerging pockets
To provide information for prioritization of programme resources and evaluation of programme impact
To estimate HIV prevalence and HIV burden in the country

Method: Annual cross-sectional survey of risk groups, in the same place over few years, by unlinked anonymous serological testing (two ERS).

HIV sentinel surveillance started from 1994 in 55 sentinel sites; increased to 180 in 1998.

Number of HIV Sentinel Surveillance Sites (2016-2017)

Site Type	Number
ANC	829
IDU	87
MSM	89
FSW	245
Migrant	27
TG	18
Truckers	28
Total	1,323

HIV Sentinel Surveillance Round 2016-2017 - Strategy

Parameter	High Risk Groups (IDU/MSM/FSW/TG)	Bridge Population (SMM/LDT)	General Population (Pregnant women at ANC)
Sentinel site	TI projects	STD clinic, TI projects	Antenatal clinic
Sample size	250	250	400
Duration	3 months	3 months	3 months
Frequency	Once in 2 years	Once in 2 years	Once in 2 years
Sampling method	Consecutive/random	Consecutive	Consecutive
Age group	15-49 years	15-49 years	15-49 years
Testing strategy	Unlinked anonymous	Unlinked anonymous	Unlinked anonymous

COUNSELLING AND HIV TESTING SERVICES

Provided by the Basic Service Division of the Department of AIDS Control. Goal: To identify as many people living with HIV, as early as possible, and link them to prevention, care and treatment services (started in 1997; boosted by ART services from 2004).

Three components:

Integrated Counselling and Testing Centres (ICTC)
Prevention of Parent-to-Child Transmission of HIV (PPTCT)
HIV/Tuberculosis collaborative activities

Types of HIV Counselling and Testing Facilities

1. Integrated Counselling and Testing Centres (ICTC)

Testing is either client-initiated (own free will) or provider-initiated (on medical advice)
Functions: Early detection of HIV; provision of basic information on modes of transmission and prevention; linking PLHIV to other services
Two types: Fixed facility ICTC and Mobile ICTC

Fixed Facility ICTCs:

(a) Standalone ICTC (SA-ICTC): High client load, full-time counsellor and lab technician; located in medical colleges, district hospitals, sub-district hospitals, CHCs
(b) Facility-Integrated ICTC (F-ICTC): Set up below block levels at 24x7 PHC; staff trained in HIV counselling and testing; also PPP-ICTCs in private facilities

Mobile ICTC: A van with general examination room, counselling room, and sample collection/processing space; serves hard-to-reach areas with flexible working hours; also provides STI/RTI management, antenatal services, immunization etc.

2. Community-Based HIV Screening

Conducted by frontline health workers (ANMs) at sub-centre level, to offer HIV testing to every pregnant woman.

PREVENTION OF PARENT-TO-CHILD TRANSMISSION (PPTCT)

Started in 2002 in India using SD-NVP (single-dose Nevirapine) prophylaxis
Currently more than 15,000 ICTCs offer PPTCT services
Aim: Universal coverage - HIV testing to every pregnant woman to detect all HIV positive pregnant women and eliminate mother-to-child transmission

Transition of regimen:

2002: SD-NVP strategy
September 2012: Transitioned to multi-drug ARV prophylaxis ("Option B", WHO 2010) - piloted in Andhra Pradesh, Karnataka, Tamil Nadu
December 2013: India adopted lifelong ART (triple drug regimen) for all HIV positive pregnant and breast-feeding women, regardless of CD4 count or WHO clinical stage

Essential Package of PPTCT Services

Routine offer of HIV counselling and testing to all pregnant women enrolled into ANC with an "opt out" option
Ensuring involvement of spouse and family members; move from ANC-centric to Family-Centric approach
Provision of life-long ART (TDF+...)
(Nutritional support)
(Psychosocial support for HIV infected pregnant women)
Provision of nutrition, counselling and psychosocial support
Provision of counselling and support for exclusive breastfeeding within 1 hour of delivery, continued for 6 months
Provision of ARV prophylaxis to infants from birth up to a minimum of 6 months
Integrating follow-up of HIV-exposed infants into routine healthcare services including immunization
Ensuring initiation of Co-trimoxazole Prophylactic Therapy (CPT) and Early Infant Diagnosis (EID) using HIV-DNA PCR at 6 weeks of age onwards
Strengthening community follow-up and outreach through local community networks

HIV TESTING OF TB PATIENTS

Joint implementation by NACP and RNTCP since 2007-08
Case fatality rate among HIV-infected TB cases: 13-14% (vs. <4% in HIV-negative TB cases)
HIV testing in presumptive TB cases rolled out in October 2012 starting in Karnataka, then Maharashtra, Andhra Pradesh, Tamil Nadu
Target: Extend to high HIV prevalence A and B category districts; recommended for 25-54 years age group

Four-Pronged Strategy for HIV-TB coordination (to reduce mortality):

PITC - Provider Initiated HIV Testing and Counselling
ICF - Intensified Case Finding
LAC - Link ART Centres
TI - Targeted Intervention

CARE, SUPPORT AND TREATMENT (CST)

Policy package includes:

Free universal access to lifelong standardized ART
Free laboratory diagnostic and monitoring services (baseline tests, CD4 testing, targeted viral load)
Facilitating long-term retention in care
Prevention, diagnosis and management of opportunistic infections
Linkage to care and support services and social protection schemes

90-90-90 Fast Track Targets (to end AIDS as public health threat by 2030):

90% of PLHIV know their status
90% of those who know their status are on treatment
90% of those on treatment achieve viral suppression

"Test and Treat" policy rolled out as a significant step towards achieving these targets.

ART Network (as of September 2019)

548 ART centres
1,236 Link ART Centres (LAC)
17 Centres of Excellence (CoE)
7 Paediatric Centres of Excellence
93 ART Plus centres
310 Care and Support Centres

Services Provided at ART Centres

First-line ART: Free of cost to all eligible PLHIV; assessment by clinical examination and CD4 count; till August 2017, 11.33 lakh PLHIV were on first-line ART
Alternative first-line ART: For those with acute/chronic toxicity/intolerance; provided at CoE and ART-Plus centres
Second-line ART: For treatment failure cases; average switch rate from first to second-line is 2-3% per year
Paediatric ART: Available at all CoE and ART-Plus centres
Early Infant Diagnosis (EID): Confirmed HIV in children; all confirmed linked to ART services

Follow-up and Monitoring

Monthly follow-up
Clinical evaluation + weight measurement + opportunistic infection screening on every visit
CD4 testing every 6 months
Patients encouraged to visit Care and Support Centres for psycho-social support

Management of Opportunistic Infections

(a) HIV-TB: All ART centre patients screened verbally for 4-symptom complex; positive - referred for TB testing; co-infected - initiated on Anti-TB treatment then ART; TB ruled out - Isoniazid prophylaxis

(b) HIV-Hepatitis B and C: Hepatitis B treatment is part of ART programme (TDF + 3TC/FTC suppresses both HIV and HBV); Hepatitis C treated with DAAs (sofosbuvir, grazoprevir, glecaprevir)

(c) HIV-Kala-azar: Endemic in some districts of UP, Bihar, Jharkhand; PLHIVs with suggestive symptoms screened and referred for treatment

(d) Other Opportunistic Infections: Prophylaxis (e.g., Co-trimoxazole for those with low CD4 count)

TARGETED INTERVENTIONS (TI) FOR HIGH RISK GROUPS

Objective: To improve health-seeking behaviour of HRGs and reduce risk of STIs and HIV infections.

High risk groups: FSW, MSM, Transgenders/Hijras, IDUs; Bridge populations: Truckers, migrants.

Package of services under TI includes:

Outreach and peer education
Condom promotion through social marketing
Behaviour change communication
Creating an enabling environment with community involvement
Linkages to ICTC and care/support/treatment services
Community organization and ownership building

Specific interventions for IDUs:

Distribution of clean needles and syringes
Abscess prevention and management
Opioid substitution therapy
Linkage with detoxification/rehabilitation services

Specific interventions for MSM/TGs:

Provision of lubricants
Provision of project-based STI clinics

LINK WORKER SCHEME

A community-based outreach strategy to address HIV prevention and care needs of HRGs and vulnerable population in rural areas.

Specific objectives:

Reach out with information and knowledge on prevention and risk reduction of HIV and STI
Condom promotion and distribution
Referral and follow-up linkages for various services
Counselling, testing and treatment of STI and opportunistic infections
Creating enabling environment for PLHIV and reducing stigma

Coverage: Implemented in 18 states covering 163 highly vulnerable districts.

BLOOD TRANSFUSION SERVICES

Division of Blood Safety renamed as Division of Blood Transfusion Services (to broaden the horizon)
Blood Transfusion Councils set up at national and state levels
Professional blood donation prohibited since 1st January 1998
Only licensed blood banks are permitted; voluntary blood donation is encouraged
Testing of every unit of blood is mandatory for: HIV, Hepatitis B, Hepatitis C, Malaria, and Syphilis
NACO supports a network of 1,131 blood banks including:
- 590 Blood Component Separation Units (BCSU)
- 34 Model Blood Banks
- 108 major blood banks
- 591 district level blood banks

CONDOM PROMOTION

Districts classified into four categories:

(a) HPHF - High prevalence of HIV and High Fertility
(b) HPLF - High prevalence of HIV and Low Fertility
(c) LPLF - Low prevalence of HIV and Low Fertility
(d) LPHF - Low prevalence of HIV and High Fertility

During 2014, condom social marketing covered 395 districts across 11 states.

STD CONTROL PROGRAMME

STD control is linked to HIV/AIDS control as behaviour resulting in transmission of STD and HIV is the same. HIV is transmitted more easily in the presence of another STD. Hence, early diagnosis and treatment of STD is a major strategy to control HIV.

Approach adopted: (a) Management of STDs through syndromic approach (based on specific symptoms and signs, not dependent on laboratory investigations)

(b) Integration of STI/RTI services at all levels of health care:

STD clinics at district/block/FRU level as referral centres
Strengthening STD clinics at all district hospitals, medical colleges
Mass orientation-training for medical and paramedical workers in syndromic approach
All STD clinics to provide counselling and condoms to STD patients
NGO services to be utilized for counselling

"SURAKSHA CLINIC"

NACO has branded the STI/RTI services as "Suraksha Clinic" and has developed a communication strategy for generating demand for these services.

Pre-packed STI/RTI Colour-Coded Kits

Provided free to all designated STI/RTI clinics, procured centrally and supplied to all State AIDS Control Societies:

Kit Number	Colour	Indication
Kit 1	Grey	Urethral discharge, ano-rectal discharge and cervicitis
Kit 2	Green	Vaginitis
Kit 3	White	Genital ulcers
Kit 4	Blue	Genital ulcers
Kit 5	Red	Genital ulcers
Kit 6	Yellow	Lower abdominal pain
Kit 7	Black	Inguinal bubo

NATIONAL STRATEGIC PLAN FOR HIV/AIDS AND STI 2017-2024

Vision: An AIDS free India

Mission: To attain universal coverage of HIV prevention, testing, treatment to care continuum that is effective, inclusive, equitable and adapted to population and local needs.

Goal: To achieve:

Zero new infection
Zero AIDS-related deaths
Zero AIDS-related stigma and discrimination

Strategic Framework

Based on a results-based framework reflecting fast-track targets and the "ending of AIDS" commitment. Three epidemiological contexts addressed:

(i) Mature epidemic states/UTs - High HIV incidence and prevalence in key, bridge and at-risk populations, sometimes in general population

(ii) Emerging epidemic states/UTs - Relatively new and rising rates of infection among key, bridge and at-risk populations

(iii) Low/stable epidemic states/UTs - Need to focus on potential risks and maintain low infection rates

Six Objectives of NSP 2017-2024

Objective	Target
Objective 1	Reduce 80% new infections by 2024 (baseline: 2010)
Objective 2	Ensure 95% of estimated PLHIV know their status by 2024
Objective 3	Ensure 95% PLHIV have ART initiation and retention by 2024 for sustained viral suppression
Objective 4	Eliminate mother-to-child transmission of HIV and syphilis by 2020
Objective 5	Eliminate HIV/AIDS related stigma and discrimination by 2020
Objective 6	Facilitate sustainable NACP service delivery by 2024

Expected Results by 2024

Estimated new infections will reduce from 102,226 (2010) to <21,000 per year
2.14 million PLHIV of the total estimated (2.25 million) would know their status
2.03 million PLHIV would be put on ART
1.93 million PLHIV would be retained on treatment with HIV VL <1000 copies/ml
<50 cases of new paediatric HIV infections per 100,000 live births; mother-to-child transmission rate <5% by 2020
<50 cases of congenital syphilis per 100,000 live births
HIV/AIDS perceived as a chronic, manageable disease with no stigma or discrimination
Key NACP components to continue through 100% domestic funding

INFORMATION, EDUCATION AND COMMUNICATION (IEC)

Communication in NACP-IV is directed at:

(a) Increase knowledge among general population (especially youth and women) on safe sexual behaviour
(b) Sustain behaviour change in high risk groups and bridge populations
(c) Generate demand for care, support and treatment services
(d) Make appropriate changes in societal norms to reduce stigma and discrimination

Adolescence Education Programme

Runs in secondary and senior secondary schools to build life skills
16-hour sessions scheduled during academic terms of Class IX and XI
Being implemented in 23 states; by March 2014, 49,000 schools covered

Red Ribbon Clubs (RRC)

Formed in colleges to encourage peer-to-peer messaging on HIV prevention
Provides a safe space for young people to seek clarifications on HIV/AIDS myths
Also promotes voluntary blood donation among youth

Source: Park's Textbook of Preventive and Social Medicine, Chapter 7 (p. 489-496)

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