National Tuberculosis Elimination Programme (NTEP)

Background and Evolution

Vision and Target

• 80% reduction in TB incidence
• 90% reduction in TB mortality
• Zero TB patients or their households facing catastrophic costs due to TB

National Strategic Plan (NSP) 2017-2025

1. DETECT

• Active Case Finding (ACF): TB Mukt Bharat campaign for public awareness and early case finding
• Community and institutional screening, especially in vulnerable populations
• Engagement of private sector providers for case notification
• Use of high-sensitivity molecular diagnostic tools (NAAT/CBNAAT/TrueNat)

2. TREAT

• Prompt treatment with quality-assured first-line and second-line drug regimens
• Decentralized, patient-centric care
• Comprehensive care for drug-resistant TB (DR-TB), including the new BPaLM regimen (Bedaquiline, Pretomanid, Linezolid, Moxifloxacin) - a shorter, safer, and highly effective regimen for DR-TB patients
• Addressing co-morbidities: malnutrition, diabetes, HIV, and substance abuse
• Differentiated TB care model for early assessment and appropriate referral

3. PREVENT

• Contact tracing among household contacts of TB patients
• TB Preventive Treatment (TPT) for children, PLHIV (people living with HIV), and other high-risk groups
• Airborne infection control measures in health facilities
• Scale-up of TPT: approximately 15 lakh beneficiaries received TPT including shorter regimens

4. BUILD

• Multi-sectoral response to address social determinants of TB (poverty, malnutrition, overcrowding)
• Strengthening health system infrastructure
• Capacity building of healthcare workers at all levels
• Inter-ministerial convergence (Railways, ESI, Mines, Steel, Coal ministries)

Key Programmes and Schemes

Nikshay - Digital Backbone

Nikshay Poshan Yojana (NPY)

Pradhan Mantri TB Mukt Bharat Abhiyaan (PM-TBMBA)

• Provide additional nutritional, diagnostic, and vocational support to TB patients beyond what the government provides
• Augment community involvement
• Leverage Corporate Social Responsibility (CSR)

Ni-kshay Mitra Initiative

• Food baskets (nutritional kits)
• Psychosocial support
• Vocational support for post-recovery rehabilitation

100-Day TB Mukt Bharat Abhiyaan

Diagnostic Infrastructure

• 1.89 crore sputum smear tests
• 68.3 lakh NAAT (Nucleic Acid Amplification Tests)

Technology and Innovation

• AI-powered cough screening: AI algorithms analyze cough sounds to detect TB
• Radiology AI: AI reads chest X-rays for TB screening at scale
• Predictive analytics: Identifies high-risk populations for targeted interventions
• TB Mukt Bharat Mobile App: Patients can track Nikshay Poshan Kit delivery, report issues, and connect with Ni-kshay Mitras and health staff

Achievements (Key Metrics)

Challenges

1. Drug-resistant TB: A 32% increase in DR-TB cases puts pressure on second-line drug supplies and specialized care facilities
2. Private sector gap: One-third of notifications come from the private sector, but unnotified cases remain a significant challenge
3. Social determinants: Poverty, malnutrition, and overcrowded living conditions continue to fuel transmission
4. Health inequalities: Marginalized communities (tribal, migrant, urban slum populations) have lower access to services
5. Catastrophic expenditure: Despite support schemes, many TB patients still face financial hardship
6. Delays in DBT payments: Parliamentary records indicate delays in Nikshay Poshan Yojana payments reaching patients in several states

Administrative Structure

• National level: CTD, Ministry of Health
• State level: State TB Cells
• District level: District TB Centres (DTCs)
• Sub-district level: Tuberculosis Units (TUs) and Designated Microscopy Centres (DMCs)

Global Context

National AIDS Control Organisation (NACO)

What is NACO?

Historical Milestones

NACP Phases - Evolution of the Programme

NACP Phase I (1992-1999)

• Aimed at slowing down the spread of HIV infection
• Focused on surveillance, blood safety, and awareness generation
• Built foundational infrastructure: NACO, SACS, blood banks

NACP Phase II (1999-2006)

• Focus shifted to behaviour change communication (BCC)
• Increased decentralization of programme implementation
• Expanded NGO and civil society involvement
• Launched targeted interventions for high-risk groups (sex workers, MSM, IDUs)

NACP Phase III (2007-2012)

• Goal: Halt and reverse the HIV epidemic in India
• Scaled up targeted interventions, ART services, PPTCT
• Introduced Prevention of Parent to Child Transmission (PPTCT) as a major priority
• Expanded to all districts; classified districts into categories A, B, C, D based on epidemiological criteria

NACP Phase IV (2012-2017)

• Goal: Consolidate gains and accelerate reversal of the epidemic
• Targeted a 50% reduction in new infections from the 2007 baseline
• Provided comprehensive care and support to all PLHIV
• Introduced HIV-TB collaboration and provider-initiated testing
• Coverage of core high-risk groups (FSW, MSM, PWID) at 80%, 68%, 75% respectively by 2014-15

NACP Phase V (2021-2026)

1. Reduce annual new HIV infections by 80% from the 2010 baseline by 2025-26
2. Reduce AIDS-related mortalities by 80% from the 2010 baseline
3. Eliminate vertical transmission (mother-to-child) of HIV and syphilis by 2025-26
4. Achieve the 95-95-95 targets (see below)
5. Eradicate HIV/AIDS-related stigma and discrimination

The 95-95-95 Targets

• 78% of PLHIV aware of their status
• 83% of diagnosed PLHIV on ART
• 85% of those on ART with viral suppression

Organisational Structure

• National Level: NACO (Additional Secretary & Director General; Joint Secretary)
  • Divisions: Targeted Intervention & LWS, Basic Services (ICTC, PPTCT, HIV-TB), STI/RTI Management, Blood Safety, Lab Services, Care/Support/Treatment, IEC, Strategic Information, Admin & Procurement, Finance
• State Level: 35 State AIDS Prevention and Control Societies (SACS)
• District Level: District AIDS Prevention and Control Units (DAPCUs)
• Facility Level: ART Centres, ICTCs, Link ART Centres, PPTCT facilities

Key Programme Components

1. Prevention - Targeted Interventions (TI)

• Female Sex Workers (FSWs)
• Men who have Sex with Men (MSM)
• People who Inject Drugs (PWID)
• Transgender persons
• Bridge populations: Long-distance truckers (LDT), single male migrants (SMM)

2. HIV Testing - Integrated Counselling and Testing Centres (ICTC)

• Fixed facility ICTCs - at hospitals and health facilities
• Mobile ICTCs - for outreach to remote/unreached populations

3. Prevention of Parent-to-Child Transmission (PPTCT)

• All pregnant women are tested for HIV at antenatal care
• HIV-positive pregnant women are started on lifelong ART (Option B+)
• Goal of NACP V: Eliminate vertical transmission (rate under 5%) by 2025-26
• As of 2023-24, states like Maharashtra, Delhi, and Andhra Pradesh have achieved ARV coverage of 90-95%+ among HIV-positive mothers

4. Anti-Retroviral Treatment (ART)

• Free ART is provided to all eligible PLHIV through a network of ART centres and Link ART Centres (LACs)
• 14.94 lakh PLHIV were receiving ART as of 2020-21 (including 1.06 lakh in the private sector)
• Viral load testing has expanded: 8.9 lakh tests in 2020-21 (up from 2.13 lakh in 2018-19)

5. Blood Safety

• Mandatory HIV testing of all donated blood
• Promotion of voluntary blood donation
• Regulation and quality assurance of blood banks under the National Blood Policy (2002)

6. HIV-TB Collaboration

• Intensified TB case finding among PLHIV
• Isoniazid Preventive Therapy (IPT) for PLHIV without active TB
• TB Infection Control in HIV care settings

7. STI/RTI Management

• Free diagnosis and treatment of sexually transmitted infections (STIs) and reproductive tract infections (RTIs) at STI clinics nationwide
• Syndromic case management approach
• Integration with TI projects for high-risk groups

HIV Surveillance System

• Category A: >1% ANC prevalence (high priority)
• Category B: <1% ANC but >5% HRG prevalence
• Category C & D: Lower prevalence states

Key Achievements

Challenges

1. First 95 gap: Only 78% of PLHIV know their status - a significant gap remains in HIV testing coverage
2. Key population stigma: Stigma and discrimination continue to prevent HRGs from accessing services
3. IDU/PWID interventions: Drug injection-driven HIV in the northeastern states remains difficult to address
4. Private sector engagement: Many PLHIV seek care in the private sector and remain unnotified
5. Paediatric HIV: Eliminating vertical transmission requires sustained ARV coverage, which remains below 75% in several northeastern states and UTs
6. Funding dependency: A significant portion of the budget still relies on external donors (Global Fund, World Bank), raising sustainability concerns
7. Viral suppression monitoring: Expanding viral load testing infrastructure beyond urban centres remains challenging

NACO and Global Alignment

• UNAIDS Global AIDS Strategy (2021-2026) - "End Inequalities, End AIDS"
• WHO Global Health Sector Strategies (2022-2030)
• Sustainable Development Goal 3.3 - End AIDS as a public health threat by 2030
• 95-95-95 UNAIDS targets by 2025