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Reversal of the Epidemic The Route Looking Forward Today’s Agenda 2

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

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 Declining AIDS- related deaths Significant increase in baseline CD4 count at detection 4 Source: HIV Estimations, 2010

The Road Map NACP I ( ) Initial Interventions NACP II ( ) -Decentralisation to states - Limited coverage of services NACP III ( ) Massive scale up with quality assurance mechanisms 56% reduction in new infections achieved NACP IV (2013+) Consolidate gains Focus on MARPS Quality assurance 5

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

Ambitious Targets, Impressive Achievements 7

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10 Ambitious Targets, Impressive Achievements 10,515

11 Ambitious Targets, Impressive Achievements

12 Ambitious Targets, Impressive Achievements

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

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 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 Source: 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 Further decline in HIV prevalence among different risk groups ANC IDU FSW MSM

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

HIV Epidemics among MSM States with higher vulnerability 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 Source: NACO HIV Sentinel Surveillance – Provisional Findings; NACO Mapping of HRG ;

HIV Epidemics among IDU States with higher vulnerability 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 Source: NACO HIV Sentinel Surveillance – Provisional Findings; NACO Mapping of HRG ;

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

Emerging Vulnerabilities  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  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: NACO HIV Sentinel Surveillance – Provisional Findings TRUCKERSTRANS-GENDERS (TGs)

Targeted Interventions Proven Cost-Effective CharacteristicValue Cumulative Costs of implementing FSW TI ( ) USD 1991 Million Cumulative HIV infections averted by FSW TIs ( ) 2.7 Million Cost per HIV infection averted USD Cost per DALY avertedUSD 10.9  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  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: /sti , Prinja et al 20

Reversal of the Epidemic The Route Looking Forward Today’s Agenda 21

Guiding Principles 22 COMMUNITY and high risk groups at centre PREVENTION focused Increased access to TREATMENT, care and support Expanded service delivery with AMBITIOUS TARGETS

The Route Consultative process Management focus Listening to data – Real time 23

Consultative process for planning and implementation A community- centric approach Communities of MARPS and PLHIV Technical experts and resource groups Civil Society Development Partners Other government departments 24

The Route Consultative process Management focus Listening to data – Real time 25

Leveraging Expertise Guidelines, policy & planning Fund release, administration, programme implementation Managing in- sourced units, coordinating technical inputs Technical inputs into guideline and tool development Supportive supervision - - ‘feel on the street’ quality assurance In-sourced support Government programme delivered Core capabilities of government Build on core health systems capabilities Supplement with technical staff on contract Partner with SACS Contracts with management agencies Leveraging external skills through: Technical Resource Groups Technical Support Units Academic partnerships 26 Resulting in large improvements in service delivery… Eg: TI Management Focus…

Standardization for scale Some Examples… 27 Operational & Technical Guidelines Uniform Training Modules Structured Monitoring Mechanisms Unit Costing for Interventions Management Focus…

PHASE-1 (2007) Focus on outreach No services PHASE-2 (2010) Addition of services (Counseling & testing) Convergence with the health system External Evaluation PHASE-3 (2012) Focus on Knowledge of HIV Services & Vulnerabilities – Youth & Migration Convergence and outreach strengthened; Greater focus on mid-media, folk arts, bus campaigns etc. Day-to-day monitoring, Pre-Post & Concurrent Evaluation Flexible Modeling-Greater Impact Eg. Red Ribbon Express 28

The Route Consultative process Management focus Listening to data – Real time 29

Evidence-driven recasting of Migrant Strategy Higher HIV Prevalence among Pregnant Women with a Migrant Spouse Migrants over-represented (80%) among HIV+ men (Ganjam) …resulting in re-scoping and reshaping of Migrant Strategy under NACP-III Adding transit and source interventio ns to migrant package Tracking migrant routes for better focus Reverse mapping to identify sources and address spouses of migrants 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 :S6; NACO HIV Sentinel Surveillance Linkages between source & destination 30

Roll out of OST Programme Setting up of Link ART Centres 31 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 * Projected as per scale-up plan OR to study Factors affecting ART Adherence Evidence Led…

Reversal of the Epidemic The Route Looking Forward Today’s Agenda 32

Challenges and the way forward Higher domestic funding Balancing prevention and treatment Convergence with health system Progressive policy initiatives Maintaining political will 33

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

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

3. Convergence for Higher Impact Source: NACO-CMIS ICTC, PPTCT, STI, Blood Safety, Condom MARPS, ART Social Protection IEC CHALLENGES  Competing priorities at state level  Scaling up integration initiatives  Ensuring availability of trained counselors / staff  Stigma in health care settings CHALLENGES  Competing priorities at state level  Scaling up integration initiatives  Ensuring availability of trained counselors / staff  Stigma in health care settings Launch of PMTCT integration – mid-2008 Complete integration Partial integration Coordination Value addition / linkages

4. Taking the lead…Policy Initiatives Mainstreaming harm reduction policy for IDUs Decriminalizing homosexuality Roll out of more efficacious regimen (Option-B) for PPTCT Scale up of free Second Line ART 37

“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, Sustained political will 38

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

Thank You! and we march on… 40

Resulting in large improvements in TI service delivery levels Growth Core groups attending STI clinics 2.3 mn2.7 mn 16% Core groups tested for HIV 0.8 mn1.1 mn 35% Condoms distributed to core groups 282 mn298 mn 6% Needle/syringe distribution to IDUs 44.5 mn56.4 mn 27% 41