1. Guided by –
Dr. Y. D. Badgaiyan
Prof. and Head
Deptt. of Community Medicine,
CIMS, Bilaspur (C.G.)
Status & Management of
HIV/AIDS in India

2. Background
 The Government of India estimates that about
2.40 million Indians are living with HIV (1.93 ‐3.04
million) with an adult prevalence of 0.31% .
 Children (<15 yrs) account for 3.5% of all
infections, while 83% are the in age group 15-49
years.

3.  Of all HIV infections, 39% (930,000) are among
women.
 India’s highly heterogeneous epidemic is largely
concentrated in only a few states — in the
industrialized south and west, and in the
north‐east.

4.  The four high prevalence states of South India
(Andhra Pradesh – 500,000, Maharashtra –
420,000, Karnataka – 250,000, Tamil Nadu –
150,000) account for 55% of all HIV infections in
the country.
 West Bengal, Gujarat, Bihar and Uttar Pradesh
are estimated to have more than 100,000 PLHA
each and together account for another 22% of
HIV infections in India.

5. Status of HIV epidemic in India

6.  High prevalent States - States where HIV
prevalence in antenatal women is 1% or more.
 Moderate prevalent States - States where the
HIV prevalence in antenatal women is less than
1% and prevalence in STD and other high risk
groups is 5% or more.
 Low prevalent States- States where the HIV
prevalence in antenatal women is less than 1%
and HIV prevalence among STD and other high-
risk group is less than 5%.

7. District-wise Scenario of HIV/AIDS
Catego
ry
NACP-III Definition
A > 1% ANC prevalence in any of the sites in
the last 3 years
B < 1% ANC prevalence in all the sites during
last 3 years with > 5% prevalence in any
HRG site (STD/FSW/MSM/IDU)
C < 1% ANC prevalence in all sites during last
3 years with < 5% in all STD clinic
attendees or any HRG, with known hot
spots
D < 1% ANC prevalence in all sites during last
3 years with < 5% in all STD clinic
attendees or any HRG OR no or poor HIV
data with no known hot spots
Category NACP-III
A 156
B 39
C 296
D 118
New
Districts
30
Total 609

8.  The Indian epidemic is concentrated among
vulnerable populations at high risk for HIV.
 The concentrated epidemics are driven by
unsafe sex between sex workers and their
clients and by injection drug user.

9.  Several of the most at risk groups have high and
still rising HIV prevalence rates.
 According to India’s National AIDS Control
Organization (NACO), the bulk of HIV infections
in India occur during unprotected heterosexual
intercourse.

10.  Consequently, and as the epidemic has
matured, women account for a growing
proportion of people living with HIV, especially in
rural areas.
 However, although overall prevalence remains
low, even relatively minor increases in HIV
infection rates in a country of more than one
billion people translate into large numbers of
people becoming infected.

11. All the high prevalence states
show a clear declining trend
in adult HIV prevalence.

12. India
22.5 21.9 21.4 21.1 20.9
0.33
0.31 0.30
0.28 0.27
0.00
0.05
0.10
0.15
0.20
0.25
0.30
0.35
0.0
5.0
10.0
15.0
20.0
25.0
2007 2008 2009 2010 2011
AdultHIVPrevalence(%)
NumberofPLHIV(Lakhs)
Estimated Adult HIV Prevalence & Number of
PLHIV, India, 2007-11
Number of PLHA (Lakhs) Adult HIV Prevalence (%)
Female: 39% of PLHIV; Children: 7% of PLHIV
Source: Technical Report India HIV Estimates 2012, NACO & NIMS

13.  However, low prevalence states of
Chandigarh, Orissa, Kerala, Jharkh
and, Uttarakhand, Jammu &
Kashmir, Arunachal Pradesh and
Meghalaya show rising trends in
adult HIV prevalence in the last four
years.

14. However, Regional Variations Exist…
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
03-05 04-06 05-07 06-08 07-10
ANC HIV Prevalence (%)
Distribution of Estimated
New HIV Infections (2011)
HP-South-4
HP-NE-3
India
LP-North-7
LP-North-6
Declining trends in high prev. states of
South & North East, but still at higher levels;
Stable to rising trends in low prev. states of
Central & North India
Source: HSS 2010-11 & HIV Estimations 2012
Note: 3-yr moving averages based on consistent sites; India – 385; HP-South-4 (AP,TN,KR,MH) – 233, HP-
NE-3 (MN,NG,MZ) – 31, LP-North-6 (BI,DL,HP,PJ,RJ,UP) – 45, LP-North-7 (AS,CH,GJ,HR,JH,OR, UK) – 33

15.  Most encouraging, the decline is also evident in
HIV prevalence among the young population
(15-24 yrs) at national level, both among men and
women.
 Stable to declining trends in HIV prevalence
among the young population (15-24 yrs) are also
noted in most of the states.
 However, rising trends are noted in some states
including
Orissa, Assam, Chandigarh, Kerala, Jharkhand
and Meghalaya.

16. Declining trends, but higher levels…
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
0
2
4
6
8
10
12
03-05 04-06 05-07 06-08 07-10
ANCHIVPrevalence(%)
HRGHIVPrevalence(%)
ANC
MSM
FSW
IDU
Declining trends among general
population, FSW & MSM;
Stable trends among IDU
Note: 3-yr moving averages based on consistent sites; ANC–385 sites, FSW–89 sites, MSM–22 sites, IDU–38 sites
Source: HIV Sentinel Surveillance 2010-11 – A Technical Brief, NACO
Need to sustain efforts in High
Prevalence areas to consolidate gains

17. Risk Factors
 Several factors put India in danger of
experiencing rapid spread of HIV .
 These risk factors include:
1. Unsafe sex.
2. MSM (Men having Sex with Men).
3. IDU (Injection Drug User).
4. Migration & Mobility.
5. Low status of women.
6. Widespread stigma.

18. www.ias2013.org Kuala Lumpur, Malaysia , 30 June - 3 July 2013
Routes of HIV Transmission, 2012-13

19. 1.
Unsafe Sex and Low Condom Use
 In India, sexual transmission is responsible for
88.2 percent of reported HIV cases and HIV
prevalence is high among sex workers (both male
and female) and their clients.
 A large proportion of women with HIV appears to
have acquired the virus from their regular
partner.

20. 2. Men Who Have Sex with Men
(MSM)
 Relatively little is known about the role of sex
between men in India’s HIV epidemic,
 but the few studies that have examined this
subject have found that a significant proportion of
men in India do have sex with other men.

21.  As per recent data Chhattisgarh (15
%), Nagaland (13.58%) and Maharashtra (13%)
have the highest HIV prevalence among MSM.
 Poor knowledge of HIV has been found in groups
of MSM.
 The extent and effectiveness of India’s efforts to
increase safe sex practices between MSM (and
their other sex partners) will play a significant role
in determining the scale and development of
India’s HIV epidemic.

22. 3. Injecting Drug Use (IDU)
 Injecting drugs with contaminated injecting
equipment is the main risk factor for HIV infection
in the north‐east.
 Current interventions targeting IDU tend to be
inconsistent, and too small and infrequent to yield
demonstrable results.
 Comprehensive harm reduction
programs, including clean needle and syringe
exchange is an urgent need.

23. 4. Migration and Mobility:
 Migration for work, takes people away from the
social environment of their families and
community.
 This can lead to an increased likelihood to
engage in risky behavior.
 Concerted efforts are needed to address the
vulnerabilities of the large migrant population.

24. 5. Low Status of Women:
 Infection rates have been on the increase among
women and their infants in some states as the
epidemic spreads through bridging population
groups.
 As in many other countries, unequal power
relations and the low status of women, weakens
the ability of women to protect themselves and
negotiate safer sex both within and outside of
marriage, thereby increasing their vulnerability.

25. 6. Widespread Stigma:
 Stigma towards people living with HIV is
widespread.
 The misconception about AIDS perpetuates
existing discrimination.

26.  The most affected groups, often
marginalized, have little or no access to legal
protection of their basic human rights.
 Addressing the issue of human rights violations
and creating an enabling environment that
increases knowledge and encourages behavior
change are thus extremely important to the fight
against AIDS.

27. National Response to HIV in
India

28. HIV/AIDS – India’s Response
• 1986: 1st case of HIV detected in Chennai.
• 1990: HIV/AIDS Cell set up in MoHFW.
• 1992: NACP-I launched.
• 1992: National AIDS Control Organisation (NACO)
established within MoHFW.
• 1999-2006: NACP-II launched.
• 2007-2012: NACP-III launched.
• NACP IV (2012-2017) on the anvil with projected outlay of
more than US$ 2 billion

29.  four-pronged strategy –
1. Prevention of infections through saturation of
coverage of high-risk groups with targeted
interventions (TIs) and scaled up interventions in
the general population.
2. Provision of greater care, support and treatment
to larger number of people living with HIV/AIDS
(PLHA).
NACP STRATEGIES

30. 3.Strengthening the infrastructure, systems and
human resources in prevention, care, support and
treatment programs at district, state and national
levels and
4. Strengthening the nationwide Strategic Information
Management System (SIMS).

31.  To meet the above objectives, various
interventions were initiated with clearly defined -
- technical and operational guidelines and
- monitoring indicators.
NACP Program Implementation

32.  The National AIDS Control Organisation
(NACO) under Ministry of Health and Family
Welfare is the overall body for framing
policy, guidelines and strategies for program
implementation.
 It also releases funds to various states and
reviews the progress under various components
of the program.

33.  State AIDS Control Societies (SACS) have
been constituted throughout the country with the
responsibility of program implementation.
 In high HIV prevalent districts, District AIDS
Prevention Control Unit (DAPCU) has been set
up for direct supervision at the ground level.

34. 1. Targeted interventions.
2. Management of STI.
3. Condom promotion.
4. Blood safety.
5. Integrated counseling and testing services.
6. Care, support and treatment.
7. Information, education, communication and
mainstreaming.
8. Strategic information management system.
Program Components

35.  HIV epidemic in India is mainly concentrated in
high-risk population like
- female sex workers (FSW),
- men having sex with men (MSM),
- injecting drug users (IDU) and
- clients of sex workers.
1. Targeted intervention

36.  Given their special vulnerabilities, prevention
strategies include five elements-
- behaviour change,
- treatment for sexually transmitted infections (STI),
- monitoring access to and utilization of condoms,
- ownership building and
- creating an enabling environment.

37.  STI and Reproductive Tract Infections (RTI) are
key determinants of HIV transmission.
 An estimated 6% of adult population suffers from
STI/RTI annually, accounting for about 30 million
episodes per year.
 Presence of STI increases the risk of acquisition
and transmission of HIV infection five to ten
times.
2. Management of STI

38.  Control of STI provides a window of opportunity
for prevention of new HIV infection and is the
most cost-effective means for preventing HIV
transmission.
 Provision of standardized package of STI/RTI
services through syndromic case management by
public health facilities and preferred private
practitioners is the cornerstone of the program.

39.  Condom promotion strategy aims to integrate the
use for family planning as well as prevention of
HIV and STI using various channels of supply, i.e.
free, through social marketing and commercial
outlets.
 In addition, various innovative approaches have
been introduced including Condom Vending
Machines (CVMs) at strategic sites, female
condoms particularly for FSW and special
condoms for MSM population.
3. Condom promotion

40.  Blood Safety program under NACP-III aims to
ensure provision of safe and quality blood to the
far-flung remote areas of the country in the
shortest possible time through a well-coordinated
National Blood Transfusion Service.
4.Blood safety

41.  Counseling and HIV testing services are being
provided through 5223 Integrated Counselling
and Testing Centres (ICTC) mainly located in
government hospitals.
 These services are also being expanded in
PHC/CHC in the rural areas, private sector
facilities and mobile clinics.
5.Integrated counseling and testing
services

42.  The main functions of an ICTC include HIV
diagnostic tests, counseling and promoting
behavioral change and referral for care and
treatment services.
 The ICTC services are accessed by voluntary
clients (who visit the ICTC on their own), provider
initiated client testing including patients with
signs/symptoms of HIV infection, patients with
STI/RTI/TB and pregnant women visiting
antenatal clinics.

43.  The care, support and treatment needs of HIV
positive people vary with the stage of the
infection.
 The HIV infected person remains asymptomatic
for 6-8 years.
6. Care, support and treatment

44.  As immunity falls over time, the person becomes
susceptible to various Opportunistic Infections
(OIs).
 At this stage, medical treatment and psychosocial
support are needed.
 ART and prompt diagnosis and treatment of OIs
improve the survival and quality of life.

45.  Information, Education and Communication (IEC)
cuts across all program components.
 There has been a strategic shift in IEC strategy
, with the focus moving on to behavior change
communication from just awareness creation.
7. Information, education, communication and
mainstreaming

46.  India's response to HIV epidemic is governed by the
strategic information derived from HIV Sentinel
Surveillance, routine program monitoring, operational
research and evaluation studies.
 A nationwide web-enabled Strategic Information
Management System (SIMS) has been set up to
empower program management at various levels with
the information required for planning, management
and monitoring purposes.
 This system also helps in evidence-based policy
formulation and program planning.
8. Strategic information management system

47. Diagnosis & Management of HIV/AIDS in India

48. Clinical Diagnosis
 WHO case definition for AIDS surveillance- 2
major signs in combination with 1 minor sign.
 MAJOR SIGNS
1.Weight loss> 10% body wt.
2. Chronic Diarrhaea for> 1 month.
3. Prolonged fever for > 1 month

49.  MINOR SIGNS
 1. persistent cough for > 1 month.
 2. generalized pruritic dermatitis.
 3. history of herpes zoster.
 4. oropharyngeal candidiasis.
 5. chronic herpes simplex infection.
 6. genaralized lymphadenopathy.

50. Laboratory Diagnosis
 A person whose blood contain HIV – antibodies is
said to be HIV positive.
 The screening test to detect HIV antibody uses
normally is ELISA test.
 Confirmatory test is WESTERN- BLOT , which is
highly specific.

51. Topic
Old
Guidelines
New Guidelines
HIV Testing
Provider-
initiated
testing and
counselling
Community-based HIV
testing and counselling
with linkage to
prevention, care and
treatment services is
recommended, in
addition to old
guidelines.
Couples Voluntary HIV testing and counselling
HIV Testing & counselling

52. Who to test When to test
Pregnant women
and
male partners
At first antenatal care visit
Re-test in third trimester or peripartum
Offer partner testing
Infants and
children <18
months old
At 4–6 weeks for all whose mothers are HIV
Positive or status uncertain;
Final status after 18 months and/or when
breastfeeding ends
Children
Establish HIV status for all health contacts
Tell their HIV status & parents or caregiver’s
status
Adolescents
Integrate into all health care encounters.
Annually if sexually active; with new sexual
partners

53. Control of AIDS
 Four basic approaches to control AIDS-
1. Prevention.
2. Antiretroviral treatment,
3. Specific prophylaxis.
4. Primary Health Care.

54. PREVENTION
 1. Health Education
- Safe sex
- Avoid pregnancy by infected female.
- Mass media education
 2. Prevention of Blood borne HIV
transmission.
- Stict sterlization practices.
- Testing of blood before transfusion.

55. 2. Antiretroviral Treatment

56. Why to Initiate early ART ?
 Reduces risk of progression to AIDS and/or death, TB, non-
AIDS-defining illness & increased the likelihood of immune
recovery.
 Reduces sexual transmission in HIV-serodiscordant couples,
 More convenient and less toxic regimens widely available,
 Costs and epidemiological benefits
 The increased cost of earlier ART would be partly offset by
subsequent reduced costs (such as decreased hospitalization
and increased productivity) and preventing new HIV infections.

57. GUIDELINES TO START ART
 Start ART in all individuals with a CD4 < 500
 Priority to severe or advanced HIV disease and CD4 <
350 .
 ART at any CD4 count in PLHIV
 Active TB disease ,
 HBV co-infection with severe chronic liver disease,
 HIV-positive partners in sero-discordant couples,
 Pregnant and breastfeeding women and
 Children younger than five years of age

58. When to start ART in people living with
HIV
Adults and
adolescen
ts
(≥10 years)
Initiate ART if CD4 cell count ≤500 cells/mm3
• As a priority,
 Severe/advanced HIV (WHO clinical stage 3
or 4)
or
 CD4 count ≤350 cells/mm3
Regardless of WHO clinical stage and CD4
• Active TB disease
• HBV coinfection with severe chronic liver
disease
• Pregnant and breastfeeding women with HIV
• HIV-positive individual in a serodiscordant
partnership (to reduce HIV transmission
risk)
Infants <1 In all , Regardless of WHO clinical stage and CD4
NE
W
NE
W
NE
W
NE
W

59. Children
≥5 yrs to
<10 yrs old
CD4 ≤500 cells/mm3
• As a priority,
 All WHO clinical stage 3 or 4 or
 CD4 count ≤350
Initiate ART regardless of CD4 cell count
• WHO clinical stage 3 or 4
• Active TB disease
Children
1–5 yrs old
ART in all regardless of WHO clinical stage
and CD4
• As a priority,
 All HIV-infected children 1–2 yrs old or
 WHO clinical stage 3 or 4 or
 CD4 count ≤750 or <25%, whichever is
lower
Any child < 18 months with presumptive
clinical diagnosis of HIV infection.
NE
W
NE
W

60. What ART to start ?
First-line ART
regimens for
adults
First-line ART = two (NRTIs) + (NNRTI).
• TDF + 3TC (or FTC) + EFV (fixed-dose
combination)
If TDF + 3TC (or FTC) + EFV is
contraindicated/not available, options are…
• AZT + 3TC + EFV
• AZT + 3TC + NVP
• TDF + 3TC (or FTC) + NVP
Countries should discontinue d4T use in first-line
regimens because of its well-recognized
metabolic toxicities.
NE
W
Once-daily regimens comprising a non- thymidine NRTI
backbone (TDF + FTC or TDF + 3TC) and one NNRTI (EFV)
as the preferred choices in adults, adolescents and
children >3 yrs.

61. First-line ART
Preferred
first-line regimens
Alternative
first-line Regimens
Adults
(including pregnant
and
breastfeeding women
and adults with TB and
HBV coinfection) TDF + 3TC (or FTC) +
EFV
AZT + 3TC + EFV
AZT + 3TC + NVP
TDF + 3TC (or FTC) +
NVP
Adolescents
(10 to 19 years) ≥35 kg
AZT + 3TC + EFV
AZT + 3TC + NVP
TDF + 3TC (or FTC) +
NVP
ABC + 3TC + EFV (or
NVP)
Children 3 - 10 years
and adolescents <35
kg
ABC + 3TC + EFV
ABC + 3TC + NVP
AZT + 3TC + EFV
AZT + 3TC + NVP
TDF + 3TC (or FTC) +
EFV
TDF + 3TC (or FTC) +
NVP
NE
W

62. Monitoring of Efficacy of ART
1. Clinical improvement
- Weight gain.
- Decrease severity of HIV related disease.
2. Increase in Total Lymphocyte count.
3. Improvement in biological markers of HIV.
- CD 4 + T – Lymphocyte count.
- Plasma HIV – RNA levels.

63. CONCLUSION

64.  National response to HIV/AIDS during the first
three years of the NACP-III has been
commendable in terms of infrastructure and
system development, coverage of targeted
population and monitoring systems.
 However, there are still challenges to achieve the
goal of the reversal of the epidemic.
 Key areas which require special attention are TIs
for MSM, IDU and migrants and services to HIV
positive pregnant women and infants.
Conclusion