Delhi Scenario of HIV/AIDS Dr. A. K. Gupta MD (Pediatrics) Additional Project Director Delhi State AIDS Control Society

Total population - 18 million, First case Estimated PLHAs (2011)- 36,000 Low prevalence state (Prevalence in Gen. population- 0.2%) Highly vulnerable state- (Migrant labour million, Truckers stationed/day-35000) Total high risk population ->1.00 Lakh HIV +VE Regd. In HIV Care At ART Centers : Eligible patients actually started on ART No. Currently Alive & on ART LFU (7%), Died (8%) or Transferred out to other states(21%) DELHI SCENARIO (March 2012)

CATEGORIZATION OF DISTRICTS IN DELHI

OTHERS PERINATAL I.D.Us BLOOD TRANSFUSION SEXUAL

HIV Trend Among Ante Natal Cases, Delhi

Declining HIV Positivity rate in ICTC of Delhi

Goal: To halt and reverse the epidemic in India over the next five years Objectives: – Prevent new infections by saturating coverage of HRG through TI and scaled up interventions in the general population. – Provide greater care, support and treatment to larger numbers of PLHIV – Strengthen the infrastructure, systems and human resources in prevention, care, support and treatment programme at district, state and national levels – Strengthen the nationwide SIMS NACP-III ( ) : Goal & Objectives

Targeted interventions STI care Condom promotion Enabling environment Blood safety Integrated Counselling and testing including PPTCT STI Care IEC and social mobilisation Mainstreaming ART HIV-TB Co- ordination Treatment of Opportunistic Infections Community Care Centres Post-Exposure Prophylaxis HIV Sentinel Surveillance Behavioural Surveillance Monitoring and evaluation Operational research DAPCU Technical Resource Groups Enhanced HR at NACO, SACS and districts Enhanced training activities Prevention High risk populations Low risk populations Care & support Monitoring and Evaluation Institutional Strengthening Care, Support & Treatment Strategic Information Management Capacity Building

Status Of Targeted Intervention (TI) Projects Sub Type (Registered) No. of TIs TargetNo. screene d for Syphilis No. found RPR reactive No. tested at ICTC No. detected HIV +ve (%) No. linked to HIV care (%) FSW (30982) (0.43)59 (60.8) MSM+TG (15624) (1.4)82 (70.7) IDUs (10124) (2.9)62(49.6) Truckers (11602) (1.6)11(73.3) Migrants (43200) (3.2)19(57.6) Total (111532) (0.7%) (1.0%) 233 (60.3%)

Integrated Counseling & Testing (I.C.T.C) (93 centres) S. NoNEW PHYSICAL TARGETSTARGET(April- DC 11) Achievement (April- DEC 11) 1TESTING OF GENERAL PATIENT (ICTC) – annual target 3,00, (91.5%) 2No. OF GEN CLIENTS DETECTED HIV +VE 7344(3.21%) 3TESTING OF ANC (PPTCT)- annual target 2, (91%) 4No. OF ANC CLIENTS DETECTED HIV +VE- annual estimate 500 cases 356 5No. ANC delivered and Mother Baby pair given NVP prophylaxis (62.9 %) 6HIV-TB CROSS REFERRALS- annual target No. OF PEOPLE WITH HIV-TB CO- INFECTION- annual estimate 1000 cases

Testing algorithm

Rationale For PPTCT Services in Delhi Annual pregnancies-2.5 lakh HIV infected pregnancies % Transmission rate * Infected newborns-175 * Risk of transmission without PMTCT intervention (WHO 2010)

Early Infant Diagnosis Launched in Dec 2010 EID Test Lab for DNA-PCR testing-1 (NCDC, New Delhi) EID sample collection sites- 19 ICTCs Whole Blood Collection for DNA-PCR sites (ART centers)- 7

Procedure for heel prick 1.Warm the area 2.Wash hands, put on gloves 3.Position baby with foot down 4.Clean area, dry 30 sec 5.Press lancet into foot, prick skin 6.Wipe away first drop 7.Allow large drop to collect 8.Touch blood drop to card 9.Fill entire circle with drop 10.Fill at least 3 circles 11.Clean foot, no bandage <5kg infants 5-10kg infants Overhead 4-5

Valid DBS specimen Overhead 4-34

Status of PMTCT ARV Prophylaxis in 234 MB pair (Feb 11-Jan12) Category (Number) HIV Positive infantMTCT rate (%) Category I- MB pair received ARV Prophylaxis (n=161) 95.6 Category IA Maternal HAART (CD4≤350) in pregnancy & Baby received SdNVP (n=42) 00 Category IB- MB pair short course AZT+3TC to mother & AZT to baby (n=19) 00 Category IC- MB pair Sd NVP (n=100)99 Category II- Only Mother received ARV prophylaxis (n-9) Category III- Only baby received ARV prophylaxis (n=26) Category IV- No. ARV prophylaxis (n=38)1128.9

Age of Initiation of ART (in months) through EID Age of First DBS test Total Time spent on PCR testing and receipt of reports Gap in receiving PCR result and initiation of ART Age of Initiation of started Delay in starting ART* Outcome after Initiation of ART stable for last 2 months stable for last 4 months OI before starting ART Stable for 4 months on ART, Lost to Follow-up after death of father Died within 1 month of initiating ART OI before starting ART stable for last 1 month stable for last 1 month OI before starting ART, stable for last 5 months. 18 month RHT positive Stable for 6 months. 18 month RHT positive stable for last 4 months stable for last 4.5 months OI before starting ART, stable for last 6 months. 18 month RHT positive OI before starting ART, stable for last 5 months. 18 month RHT positive OI before starting ART, stable for last 2 months. 18 month RHT positive

TB-HIV Collaborative Activities

TB and HIV in India Highest TB burden in the world – 1.8 million TB cases per year 3 rd highest HIV burden – 2.3 million PLHA (2007) – Prevalence 0.34% (adult population) Estimated HIV-TB co-infected: 55,000-65,000

Risk of TB in HIV Patients HIV patients are at an increased risk of: Acquiring latent TB Developing active TB once infected with M. tuberculosis Becoming re-infected with a second strain of TB Relapsing after stopping treatment Source: NACO Lifetime Risk of TB

Revised guidelines for starting ART for HIV TB co-infected patients All HIV infected TB patients need to be started on ART – with CD4 count <350 (in case of pulmonary TB) and – irrespective of CD4 count in case of extrapulmonary TB – within 2 weeks of starting ATT NACO, November 2008

Anti Retroviral Treatment

Goals of ART 1.Clinical goal To prolong life & improve quality of life 2.Virological goal Greatest possible reduction in viral load for as long as possible to halt disease progression and to prevent or delay resistance 3.Immunological goal Immune reconstitution - CD4 within normal range

WHEN TO START? - Initiation of ART in Adults and Adolescents National Guideline Revised National Guideline (April 2009) WHO Clinical Staging CD4 (cells/cu.mm) I and IITreat if CD4 Count < 350 III Treat irrespective of CD4 Count IV

National ART regimen First-line ART: First-line ART is the initial regimen prescribed for an ART naïve patient when the patient fulfils national clinical and laboratory criteria to start ART. (Current NACO treatment guidelines for first-line ART recommends two classes of drugs for initial treatment ie 2 NRTI + 1 NNRTI.) Zidovudine / Lamivudine / Nevirapine Or Stavudine / Lamivudine / Nevirapine ( Efavirenz in place of Nevarapine if coinfected with TB or side effects with NVP, Tenofovir for special situations only)

Initiating ART: Patient Education It is not curative, but prolongs life Treatment is lifelong, expensive High level of adherence is critical (>95%) Short and long term adverse events Drug interactions Safer sex still essential Do not share drugs with friends, family members Start ART when patient is ready

SUCCESSFUL HIV THERAPY REQUIRES RIGOROUS ADHERENCE >95% adherence necessary to achieve viral load <400 copies/mL in 81% of HIV patients A 10% reduction in adherence was associated with a doubling of HIV RNA level 80% adherence may be sufficient to achieve therapeutic goals in other chronic disease states (e.g., hypertension)

Cumulative Outcome of PLHAs on ART, India

ALL 9 ART CENTRES of Delhi SINCE BEGINNING (2004) TO DECEMBER 2011 S. NO INDICATORCUMULATIVE 1 REGISTRATION EVER STARTED ON ART ALIVE ON ART DEATH TRANSFERRED OUT STOPPED TREATMENT135 7 LOST TO FOLLOW UP MISS453

Special Achievements of DSACS under NACP III Financial Assistance to Poor PLHAs and Orphan children by Delhi Govt Free Investigations including CT Scan, MRI, blood and other tests of PLHAs in HIV care at ART centers of Delhi Free Blood / Blood products for PLHAs without processing fees and without replacement donations Launch of First Post Exposure Prophylaxis toll free interactive voice response helpline in the country (dial 1097 and select option 6) for prevention of HIV, HBV & HCV in Health care Workers during occupational exposure. Setting up of First Youth Friendly health Centre in Delhi in collaboration with DSHM/NRHM at Jamia Milia Islamia in August Mapping of massage parlors for the first time in the country- in New Delhi, Central, North, North- West and South Delhi districts with aim to assess the Knowledge, Behavior, Attitude and practices of the workers, clients and owners of 1050 massage parlours and categorize them by assessment of vulnerability. 18% massage parlours observed to be having risky behavior activities. Training of NRHM Grass-root level functionaries –ASHAs, ANMs etc