Department of AIDS Control - Strategic Plan Document

Strategic Plan Document for Next Five Years

The Department of AIDS Control Ministry of Health & Family Welfare Government of India Department of AIDS Control - Strategic Plan Document

Department of AIDS Control adopts a robust evidence-based approach for development of strategy and implementation plan for prevention and control of HIV/AIDS in the country. National AIDS Control Programme (NACP) Phase-III (2007-12) was developed over a period of 2 years through dedicated Working Groups on each technical area, several consultations with stakeholders, reviews, special studies and consolidating evidence on the issues to be addressed as well as the interventions to be put in place.

Being in the last year of NACP-III, NACO has already initiated a similar robust exercise for consolidating the evidence on achievements made till now, effectiveness of current strategies, need for strengthening ongoing interventions and identifying the important programme gaps where the next phase of NACP should focus upon. This exercise shall also examine the need for new strategies, new models of implementation as well as innovative approaches to achieve prevention and control of HIV/AIDS in India through universal access to prevention and care, treatment services.

Since the exact strategy and implementation plan for next five years is in the process of development, this document outlines the broad strategy and plan adopted during NACP-III, strategies rolled out recently and the issues that are important for the next plan.

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Department of AIDS Control - Strategic Plan Document

SECTION 1:

Vision, Mission, Objectives and Functions

Vision: The Department of AIDS Control envisions preventing and reducing HIV burden in India.

Mission: The mission is to reduce HIV prevalence in population groups at risk of HIV/AIDS by an integrated prevention, care and support programme.

Objective: The National AIDS Control Programme Phase-III (NACP-III) has the goal of halting and reversing the HIV epidemic in India over the five years (2007-12) by integrating programmes for prevention, care and support and treatment. This will be achieved through a four-pronged strategy:

Prevention of infections through saturation of coverage of high-risk groups with targeted interventions (TIs) and scaled up interventions in the general population; Provision of greater care, support and treatment to larger number of people living with HIV/AIDS (PLHA); Strengthening the infrastructure, systems and human resources in prevention, care, support and treatment programmes at district, state and national levels; and Strengthening the nationwide Strategic Information Management System.

Functions:

Targeted Interventions Link Worker Scheme Management of Sexually Transmitted Infection / Reproductive Tract Infection Promotion of Condom use Blood Safety including promotion of Voluntary Blood Donation Integrated Counseling and Testing, and Prevention of Parent to Child Transmission services Information Education and Communication, and Social Mobilisation including mainstreaming Care, Support and Treatment including Antiretroviral therapy (ART) services and Treatment of Opportunistic Infections, HIV-TB Cross Referral and Community Care services for PLHA. Strategic Information Management including Monitoring & Evaluation, Surveillance and Research

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SECTION 2:

Assessment of the situation

An estimated 23.9 lakh Indians are infected with HIV with an estimated adult HIV prevalence of 0.31% in an epidemic that is concentrated in high-risk populations, such as sex workers, men who have sex with men, transgender, injecting drug users, and clients of sex workers. Since the first HIV case was identified in India in 1986, the Government of India has worked to contain and prevent the spread of HIV and to provide care, support, and treatment for those already infected. In 1992, the National AIDS Control Organisation (NACO) was created by the Government of India, to prevent and contain the HIV epidemic through the three successive phases of National AIDS Control Programme (NACP-I, II and III).

Overview of the HIV epidemic in India

HIV epidemic in India is concentrated in nature. The HIV prevalence among the High Risk Groups i.e. Female Sex Workers, Injecting Drug Users, Men who have Sex with Men and Transgender is about 20 times higher than the general population. Based on HIV Sentinel Surveillance 2008-09, it is estimated that 23.9 lakh people are infected with HIV in India, of which, 39% are female and 3.5% are children. The estimates highlight an overall reduction in adult HIV prevalence and HIV incidence (new infections) in India. Adult HIV prevalence at national level has declined from 0.41% in 2000 to 0.31% in 2009. The estimated number of new annual HIV infections has declined by more than 50% over the past decade from 2.7 lakh new infections in 2000 to 1.2 lakh in 2009. The epidemic is concentrated with high prevalence among the High Risk Groups (HRGs) – Injecting Drug Users (IDUs) (9.2%), Men who have sex with men (MSM) (7.3%), Females Sex Workers (FSW) (4.9%) and Sexually Transmitted Infection clinic attendees (2.5%). Compared to this the prevalence among Antenatal Clinic attendees (pregnant women- proxy for general population) is much lower (0.49%).

11th five year plan document on health prepared by Planning Commission of India suggest that during the Eleventh Five Year Plan, the NACP goal is to halt and reverse the epidemic in India over the next five years by integrating programmes for prevention, care, support, and treatment and also addressing the human rights issues specific to people living with HIV/AIDS (PLHA). The specific objectives are to reduce new infections by 60% in high prevalence States so as to obtain reversal of the epidemic and by 40% in the vulnerable States so as to stabilize the epidemic this objective is in consonance with the objective NACP-III

Based on Programme data, unprotected sex (87.1% heterosexual and 1.5% homosexual) is the major route of HIV transmission, followed by transmission from Parent to Child which is 5.4% and use of infected blood and blood products is 1.1%. While Injecting Drug Use is the predominant route of transmission in north eastern states, it accounts for 1.7% of HIV infections.

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Fig1: Routes of HIV Transmission 2009-10:

HIV Incidence

HIV Sentinel Surveillance 2008-09 revealed that the number of new annual HIV infections has declined by more than 50% during the last decade. This is one of the most important evidence on the impact of the various interventions under National AIDS Control Programme and scaled-up prevention strategies. It is estimated that India had approximately 1.2 lakh new HIV infections in 2009, as against 2.7 lakh in 2000. While this trend is evident in most states, some low prevalence states have shown a slight increase in the number of new infections over the past two years that underscores the need for the programme to focus more on these states with low prevalence, but high vulnerability. Of the 1.2 lakh estimated new infections in 2009, the six high prevalence states account for only 39% of the cases, while the states of Orissa, Bihar, West Bengal, Uttar Pradesh, Rajasthan, Madhya Pradesh and Gujarat account for 41% of new infections.

HIV prevalence

There was a gradual scale up of the HIV Sentinel Survey (HSS) by an increase in the number of sites from 176 in 1998 to 1215 in HSS 2008/09 across the country. Technical changes were made to the recruitment strategy and the sample collection method for testing at HRG sites. Operational changes were also made by establishing an effective and structured training programme and institutionalizing a strong monitoring and supervision system.

While an overall decline in HIV prevalence among antenatal care clinic (ANC) attendees is noted especially in high prevalence states; however, there is an increase in some low and moderate prevalence states. While there is a decline in the epidemic among FSW in south Indian states, rising trends are evident in the North East where the epidemic is increasingly driven both by IDU and sexual transmission.

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Fig2: Declining Trends among FSW Stable to Rising Trends among IDU & MSM

Source: HIV Sentinel Surveillance, 2003-09

A steady decline in HIV prevalence amongst FSW has been noted, resulting it may be argued, from focused government and stakeholder interventions. HIV prevalence among MSM is stable. A varied trend in prevalence has emerged among IDU however. The estimated adult HIV prevalence in India was 0.32% (0.26% – 0.41%) in 2008 and 0.31% (0.25% – 0.39%) in 2009(Source: HSS 2008-09), the adult prevalence is 0.26% among women and 0.38% among men in 2008, and 0.25% among women and 0.36% among men in 2009. Among the states, Manipur has shown the highest estimated adult HIV prevalence of 1.40%, followed by Andhra Pradesh (0.90%), Mizoram (0.81%), Nagaland (0.78%), Karnataka (0.63%) and Maharashtra (0.55%). Besides these states, Goa, Chandigarh, Gujarat, Punjab and Tamil Nadu have shown estimated adult HIV prevalence greater than national prevalence (0.31%), while Delhi, Orissa, West Bengal, Chhattisgarh & Puducherry have shown estimated adult HIV prevalence of 0.28-0.30%. All other states/UTs have lower levels of HIV.

Trends of Adult HIV Prevalence

The adult HIV prevalence at national level has continued its steady decline from estimated level of 0.41% in 2000 through 0.36% in 2006 to 0.31% in 2009. All the high prevalence states show a clear declining trend in adult HIV prevalence. HIV has declined notably in Tamil Nadu to reach 0.33% in 2009. However, the low prevalence states of Chandigarh, Orissa, Kerala, Jharkhand, Uttarakhand, Jammu & Kashmir, Arunachal Pradesh and Meghalaya show rising trends in adult HIV prevalence in the last four years. A clear 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 6 | P a g e

Department of AIDS Control - Strategic Plan Document 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.

Fig3: Decline in No. of PLHA as a result of greater decline in new infections, despite increased survival of PLHA due to ART

Source: HIV Estimations, 2008-09

People Living with HIV/AIDS (PLHA) The total number of people living with HIV/AIDS (PLHA) in India is estimated at 24 lakh (19.3 – 30.4) in 2009. Children (<15 yrs) account for 3.5% of all infections, while 83% are the in age group 15-49 years. Of all HIV infections, 39% (9.3 lakh) are among women. The four high prevalence states of South India (Andhra Pradesh – 5 lakh, Maharashtra – 4.2 lakh, Karnataka – 2.5 lakh, Tamil Nadu – 1.5 lakh) account for 55% of all HIV infections in the country. West Bengal, Gujarat, Bihar and Uttar Pradesh are estimated to have more than 1 lakh PLHA each and together account for another 22% of HIV infections in India. The states of Punjab, Orissa, Rajasthan & Madhya Pradesh have 50,000 – 1 lakh HIV infections each and together account for another 12% of HIV infections. These states, in spite of low HIV prevalence, have large number of PLHA due to the large population size. (See Annex-I)

AIDS deaths

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Using globally accepted methodologies and updated evidence on survival to HIV with and without treatment, it is estimated that about 1.72 lakh people died of AIDS related causes in 2009 in India. Wider access to ART has resulted in a decline of the number of people dying due to AIDS related causes. The trend of annual AIDS deaths is showing a steady decline since the roll out of free ART programme in India in 2004.

11th five year plan document on health outline strategy for achieving the objectives for AIDS Control: Preventing new infections in high risk groups and general population through: Saturation of coverage of high risk groups with targeted interventions. Scaled up interventions in the general population. Increasing the proportion of PLWHA who receive care, support, and treatment. Strengthening the infrastructure, system, and human resource in prevention, care, support, and treatment programmes at the district and national levels. Enacting and enforcing national legislation prohibiting discrimination against PLWHA and their families in health facilities, schools, places of employment, and other institutions. Including mechanisms for victims and their guardians to lodge complaints and receive quick redressal. Ensuring that women and children living with HIV/ AIDS receive medical care, including antiretroviral (ARV) treatment and use all possible means to remove barriers to their receiving care. Strengthening a nation-wide strategic information management system. Advancing R&D of vaccines suitable for the strains of HIV prevalent in India.

This is also in consonance with NACP-III strategy which NACO is implementing

Financial Allocations and Expenditure

The total outlay for NACP III is INR 115,850 million which includes support from the World Bank, DFID and Government of India contributions (Pool fund), GFATM, and contributions from bilateral agencies and private initiatives such as Bill and Melinda Gates Foundation. The main sources of funds for NACP III are below: • Direct Budgetary Support: — including funds allocated under NRHM — for meeting expenditures for Establishment, Blood Safety, Condom Promotion and STD. • External Aid Component (EAC) that includes GFATM grants (Rounds 2, 3, 4, 6, 7), pooled funds (comprising funds from the World Bank, DFID and Government of India), USAID, Bilateral and UNDP. • Extra Budgetary Resources that includes monies from various Development Partners and GFATM grants to NGO (Population Foundation of India, India AIDS Alliance, Tata Institute of Social Science and Indian Nursing Council).

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Table1: Resource Envelope for NACP III

Source Investment Plan Percent % USD million INR million Direct Budgetary Support 636 28,610 25 External AID Component 892 40,160 35 Funding Gap 255 11,460 10 Extra Budgetary Resources 792 35,620 30 Total 2,574 115,850 100 Source: Indrani Gupta, Mayur Trivedi. Analysis of Resource Envelope for NACP III. Institute of Economic Growth. Delhi, 2010.

Figure4: Resource envelope of NACP III by objectives

Special efforts are taken for building in systems — both at NACO and SACS level — towards effective management and mobilisation of funds and resources. Monitoring resource utilisation at SACS and even at NGO and peripheral units is through a dedicated computerized financial management system. The central achievements in the financial systems are: • Improvement in staffing, capacity building. • Timely issuance of sanctions and its upload on websites for use by states for their respective Annual Action Plans. • Instant releases through E-transfer. • Monitoring of financial data by concurrent entries through the computerized financial management system. • Multi-donor facilities established in the computerized financial management system.

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Table2: Status of allocation and expenditures in the past 4 years: Amount in Rs. crores Year Revised Estimate Expenditure Incurred % Budget Utilization 2007-08 953.89 917.59 96.19 2008-09 1123.36 1037 92.31 2009-10 980.15 959.82 97.93 2010-11 1400.22 1029.92* 74 Total 4461.35 3698.19 82.89 * As on 04th Feb 2011

NACP-III strategy which NACO has been implementing has shown the result as described above (See Annex- II & III)

NACP-III Achievements

A number of significant achievements have been gained under NACP-III. These include:

Targeted Interventions (TI) implemented through non-gvernment organizations (NGOs) and community-based organizations (CBOs) provide behavior change communication, condom promotion, STI care and referrals for HIV testing and Anti- Retroviral Treatment. TIs have been scaled up to 1,385 projects to increase the coverage of Female Sex Workers to 78%, Injecting Drug Users to 76%, Men having sex with Men to 69% and bridge population including Migrants (32%) and Truckers (33%). There are 224 additional TI projects supported by partner organizations. Over 30 crore condoms were distributed, over 12 lakh High Risk Group individuals were referred and tested at ICTC and 1 million STI episodes were treated in 2009-10 through TI projects.

Table3: Targeted Interventions coverage and risk group estimates Typology NACP-III Mapping Current Coverage in No. of TI Estimates Estimates TIs TIs Coverage (Figures in lakhs) FSW 12.63 8.68 6.78 454 78% MSM 3.51 4.12 2.85 145 69% IDU 1.86 1.77 1.36 263 76% Migrants 42.0 42.0 19.11 206 45.5% Truckers 35.0 20.0 20.97 86 59.91% Core 231 Composite Total 1,385

The Link Worker Scheme is a short-term intervention to address the prevention and care needs of population with high-risk behaviours and young people in rural areas. Important services offered are referrals to Integrated Counseling & Testing Centre (ICTC) services and Sexually Transmitted Infection (STI) services, condom promotion and provision of 10 | P a g e

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information related to HIV prevention and related services. As on date this scheme is being implemented in 127 districts of country in 18 states through 9 lead agencies, 132 District Resource Persons, 89 training officers, 127 Monitoring & Evaluation Officers and 5,068 Link Workers. During 2009-10, 82.4 Lakh episodes of Sexually Transmitted Infections were treated till March 2010 through 938 designated STI/Reproductive Tract Infection (RTI) clinics located at District & Teaching hospitals, 1,385 Targeted interventions through 3,523 preferred private service providers for high risk population. Additional 74.96 lakh new STI episodes have been treated in 2010-11(till Nov 2010). Colour-coded drug kits for provision of standardized STI/RTI treatment have been provided at all facilities, including sub-district public health facilities under the National Rural Health Mission. STI clinics have been branded as ―Suraksha Clinic‖. Under the Condom Social Marketing Programme, 24.5 crore pieces condoms were distributed during 2009-10. During 2010-11 (upto November, 2010), 21 crore pieces of condoms were distributed. NACO’s Targeted Condom Social Marketing Program phase- III was launched on 2 August, 2010. Based on the extremely encouraging results from the previous 2 phases, the Targeted Condom Social Marketing Programme is being scaled up to reach 370 high priority districts with the focus on ensuring availability of condoms in rural as well as in high risk areas. The program would be servicing 8 lakh retail outlets situated across 26 states/ UTs.

Fig5: Performance of Condom Social Marketing Programme

Under Blood Safety Programme, 1,125 blood banks are being supported under the programme, including 151 Blood Component Separation facilities. 78.8% of blood units collected during April to October 2010 are through voluntary blood donation by organizing 33,483 blood donation camps. New initiatives include establishment of 4 Metro Blood Banks of one hundred thousand unit’s capacity each in four metropolitan cities, and one large Plasma Fractionation Centre at Chennai with processing capacity of 1.5 lakh liters plasma annually.

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Counseling and testing services have been scaled up significantly and 143.6 lakh persons were counseled and tested through 5,223 Integrated Counseling & Testing Centres, including 61.2 lakh pregnant women, till March 2010 and additional 92.23 lakh persons were counseled and tested in 2010-11 (till nov 2010) including 29.71 lakh pregnant women. Nevirapine prophylaxis was provided to 12,282 mother-baby pairs in 2009-10 and 6,105 mother-baby pairs during 2010-11 (till Sept 2010) to prevent mother to child transmission of HIV.

Fig6: Performance of ICTC &PPTCT Programme

In October 2010, free Anti-Retroviral Treatment (ART) to 3,75,204 patients including 21,644 children, through 290 ART centres and 1,785 more are on second line ART through 10 Centres of Excellence. The second line ART costs nearly Rs 29,000 per patient per year as compared to Rs 5000 per patient per year for first line and it is free to all BPL patients, Widows and children and to those who are in National ART programme on first line ART for at least 2years.

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Fig7: ART Scale Up in India

1400000 350

1200000 300

1000000 250

800000 200

600000 150 No. of Patients of No.

400000 100 Centres ART of No.

200000 50

0 0 Mar Mar Mar Mar Mar Nov 2005 2006 2007 2008 2009 2010 No. of Pts. on First Line ART 6845 37368 69016 140654 223223 375204 Ever Registered 194607 428056 686913 1148269 No. of ART Centres 25 54 107 147 211 290

540 Link ART centres are operational as of November 2010 to facilitate delivery of ART services nearer to the beneficiaries and 254 Community Care Centres are operational as of October 2010 for reinforcing adherence counseling including management of Opportunistic Infections.

Roll out of Second line ART:

The patients started on ART can continue on first line ART for a number of years if their adherence is good. However, over the years some percentage of PLHA on first line ART will develop resistance to these drugs due to mutations in virus. Hence a need was felt for providing second line ART also as ART programme matured over the year. The rollout of second line ART began form Jan.2008 at 2 sites –GHTM, Tambaram, Chennai and JJ Hospital, Mumbai on a pilot basis and has now been expanded to 10 centers of excellence from Jan 2009. Presently, 1785 patients are receiving second line drugs at these 10 centers. The second line ART costs nearly Rs 29,000 per patient per year as compared to Rs 5000 per patient per year for first line.

Currently second line ART is provided free to all BPL patients, Widows and children and to those who are in National ART programme on first line ART for at least 2years.

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Fig8: Second line ART services

PIL IN Hon’ble Supreme Court of India(By SAHARA HOUSE and others vs. UNION OF INDIA, WRIT PETITION (CIVIL) No. 535 of 1998)

This petition calls for free second line ART to all patients irrespective of any criteria as mentioned above. In this regard a statement was filed in the court of Chief Justice of India, Supreme Court on 16th Dec 2010

The Draft Statement for Sahara House matter on 16.12.10 is as below

One of the issues that has arisen in the above-referenced Writ Petition concerns the criteria currently being employed by the National AIDS Control Organization (NACO) for administering second line treatment to persons suffering from HIV / AIDS. Specifically, the Petitioners have sought extension of second line treatment to all persons in need of it - whether they underwent first line treatment in government or private sector, and irrespective of whether they were put on a rational regimen for first line treatment. The NACO has consistently maintained that the ultimate goal is to have universal access to second line treatment, but there were various capacity-related and other constraints on doing so, and this was therefore sought to be achieved in a phased manner. In proceedings before this Hon'ble Court, the parties undertook to hold a review meeting to discuss the modalities for bringing about universal access to second line treatment to all those in need of it. A meeting was held on 13.12.10, where the following decisions were taken:

1. NACO commits to making second line treatment available to all those in need of it - whether they underwent first line treatment in the government sector or private sector, and irrespective of whether they were put on rational / irrational treatment regimen. The private practitioners are required to follow the ART guidelines out lined in the OM no. T- 11020/29/1998 (Admn.-ART) dated 9th September 2010 and earlier OM no. T- 11020/29/1998 (Admn.-ART) dated 26th August 2008 approved by Hon’ble Supreme Court of India in its order dated 1st October 2008.

2. However, there are some immediate constraints that need to be addressed, before second line treatment can be universally available. The process for drug procurement (through international competitive bidding) is likely to take at least six to eight months, and some lead-up time is also required for strengthening viral load capacity and trained personnel.

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3. Further, complete data on the number of persons who would seek second line treatment in the government sector is presently unavailable. Without such data, it is difficult for NACO to gauge the nature and extent of capacity addition that is required to handle the additional inflow of persons in need of treatment without compromising on quality of care.

4. Therefore, it is proposed that in the first phase, universal access to second line treatment would be started at four Centres of Excellence (JJ Hospital in Mumbai, GHTM Tambaram, Maulana Azad Medical College (MAMC), New Delhi and Calcutta School of Tropical Medicines, Kolkata) with immediate effect. This pilot initiative would be studied over a period of three months, which would give an indication of the numbers of additional persons seeking second line treatment, thus enabling capacity addition to proceed in a planned and phased manner. A Status Report would be presented to this Hon'ble Court after three months, along with a plan for Phase II (where such treatment is likely to be made universally available at some more Centres of Excellence).

5. By way of clarification, it is submitted that persons from anywhere in the country (in need of second line treatment) may be referred to these four Centres of Excellence presently.

6. As a matter of procedure, person in need of second line treatment will register at the local ART centre. This could be a person who suspects treatment failure, or a person already on second line treatment. The local ART centre will then refer the person to the State AIDS Clinical Expert Panel (SACEP) in the Centre of Excellence, as per existing operational guidelines and prior appointment shall be given. The person shall then report to SACEP where further viral load tests etc. will be conducted as required, and a decision would be taken on whether there is genuine treatment failure necessitating second line treatment.

7. The precise progression of phases depends, in large part, on the number of persons requiring treatment once access to such treatment is universalized and patients are referred by the practitioners / information provided by networks but NACO shall make best efforts to ensure that such treatment is universally available at the earliest.

Strategic Information Management System (SIMS) was launched on 26 August, 2010 at New Delhi. Capacity building on SIMS was conducted in different phases as below: Phase I: State M&E Officers training for 2 days completed at Regional level. Phase II: SACS officer’s orientation for 1 day completed in all States by 22 November, 2010 Phase III: District AIDS Prevention and Control Unit (DAPCU) level training for 2 days completed by 07 December, 2010 Phase IV: Training for the Reporting Unit User training is currently-on District Epidemiological Profiling using Data Triangulation: NACO has undertaken a detailed exercise of district epidemiological profiling using data triangulation across the country covering around 567 districts in two phases. This has not only provided valuable insights into the epidemic profiles and programme gaps, but also has built the capacities of around 2000 programme staff at state and district level in data management, quality issues and data use. Another key outcome of this exercise is the development of a new framework for district re-prioritisation based on inputs using data from multiple sources. 15 | P a g e

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Information Education & Communication aims at effecting behaviour change with the target of creating an empowering and enabling environment for all. It focuses on promoting safe behaviours, reduction of stigma and discrimination and promotion of services, while giving special emphasis to high risk groups, bridge populations including truckers and migrants and youth and women in general population who are more vulnerable to HIV. Regular campaigns are conducted through TV, radio and newspaper, supported by outdoor activities, mid-media and inter-personal communication to achieve above objectives.

Red Ribbon Express: The Red Ribbon Express (RRE), phase II, the special exhibition train on HIV/ AIDS and other health issues completed one year journey on 1st December, 2010 during its one year journey disseminating messages on HIV prevention, treatment and care and support. There was an overwhelming response to the project all across the country. The train traversed over 25000 kms. Covering 152 stations in 22 states. In addition, outreach programmes and activities were held in the villages through IEC exhibition vans and folk troupes. The Project was implemented by NACO in partnership with Rajiv Gandhi Foundation, NRHM, Ministry of Railways and UNICEF. The first phase of the project was implemented in year 2007-08 covering 180 stations in 22 states.

During the second phase of the RRE, apart from three exhibition coaches on HIV and AIDS, a new exhibition coach on NRHM was added providing information on common diseases. Further, the services for free HIV testing were added in the service coach of the train along with the general health checkup facility

Table4:Coverage: Red Ribbon Express-II surpassed figures of Red Ribbon Express-I

Description RRE-II (2009-10) RRE-I (2007-08) People Reached (it includes 80 lakh (19 lakh visited train 62 Lakh ( 12 lakh visitors to the train and outreach exhibition, 61 lakh covered visited exhibition, 40 activities in villages) through outreach activities) lakh covered through outreach)

District Resource Persons trained 81,000 68,000

People tested for HIV 36,000 Service not provided

General Health Check-ups 28,000 Service not provided

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First time a mass media campaign was conducted on Sexually Transmitted Infections by NACO. Campaign was also released on Voluntary blood donation with thalessimia as theme. A special campaign addressing youth through music and sports has been launched in eight states of NE A central directive has been issued on NACP-NRHM convergence to optimize utilistaion of resources. Campaign to address migrants at source has been launched at 54 transit points where they are given information literature along with a kit on HIV prevention while they are away from homes.

In the process of implementing the wide ranging strategies of NACP-III, there are various key stakeholders in the programme such as:

1. People living with HIV/AIDS 2. High Risk Groups(FSW, MSM, IDU, Transgender) 3. Bridge Population(Client of Sex Workers, Migrants and Truckers) 4. Pregnant Women and Children 5. STI Patients and Tuberculosis patients 6. NGOs and Field level Functionaries 7. Medical Colleges ,Hospitals and Health Centres and Personnel Working there 8. Laboratories 9. Districts AIDS Prevention & Control Unit (DAPCU) 10. State AIDS Control Societies (SACS) 11. National Rural Health Mission (NRHM) 12. Revised National Tuberculosis Control Programme (RNTCP) 13. Development Partners 14. Others Ministries of Government of India (Railways, Women and Child Development, Social Justice and empowerment, Defence & Labour etc.) 15. Private and Corporate firms

BEST PRACTICES

Several Best Practice models have been developed through the initiatives and efforts of the Government of India, State Governments, NACO, SACS, development partners and local NGO/CBO partners. These include India’s experience with the Red Ribbon Express, Parliamentarian Forum and Legislators’ Forums in several states, reading down of Section 377 of the Indian Penal Code, development of a national policy on HIV and AIDS and the world of work, establishing Link ART Centres and provision of pensions and railway concessions for PLHAs.

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Directive of the Supreme Court of India

In response to a Public Interest Litigation, the Hon’ble Supreme Court of India reviewed the steps taken by NACO to respond to HIV-AIDS and the services being provided to PLHA. In this regard, the Hon’ble Court has issued directives for enhancing the extent and efficacy of treatment administered to PLHA. NACO has therefore taken the following steps to ensure compliance with the Court’s directives: . Ensuring that all A & B category districts have at least one fully functional ART centre in the states by 2009. . Identifying sites for Link ART Centres(LAC), based on guidelines. NACO informed the concerned SACS so that necessary administrative sanction is issued and required refurbishment, training of LAC’s manpower, etc., are carried out. LAC will need to be operational at the earliest so that PLHA do not have to travel long distance to access ART. . All states to identify sites for future ART centres — as per GFATM Rounds 4 and 6 targets — so that CD4 machines can be procured accordingly. NACO has entered into a comprehensive maintenance contract for CD4 machines so that any fault or breakage in the machines is rectified at the earliest. The aim is to ensure that all PLHA and Children living with HIV/AIDS registered with ART centres undergo a CD4 test as per National ART Guidelines. . All ART centres have a complaint box so that the PLHA can enter their grievances. The Nodal officers are expected to review the complaints weekly and take the necessary action in a timely manner. Further, a state level committee is being constituted in all states for addressing grievances at ART centre and routinely reviewing its functioning. . NACO has already initiated procurement of drugs for Opportunistic Infections at regional level through State agencies having experience in this regard. Project Directors of SACS are required to ensure that these drugs are procured and supplied to all ART centres on priority basis. . SACS are responsible for ensuring availability of adequate quantity of HIV test kits at all ICTCs and that there are adequate buffer stocks of test kits. Access to testing is a crucial component of NACP and availability of kits is the key factor for increasing HIV testing.

Decision by the hon’ble high court of Delhi

Through coordinated efforts of NACO, civil society and development partners for reforming structural impediments to HRG interventions; an affidavit was submitted to the Hon’ble High Court of Delhi in support of decriminalising article 377 on the Indian Constitution which criminalised homosexual relations. On 2 July 2009, the Hon’ble Court annulled the 150- year-old law — drafted during British rule of India — which criminalized ―carnal intercourse against the order of nature‖ punishable by up to 10 years in prison. The court declared that section 377 of the Indian Penal Code violated the Fundamental Rights enshrined in Articles 14, 15, 19 and 21 of the Constitution of India and that consensual sexual acts of adults in 18 | P a g e

Department of AIDS Control - Strategic Plan Document private should not be criminalized. Chief Justice A.P Shah and Justice S. Muralidhar of the Division Bench have mentioned in their judgement that ―The inclusiveness that Indian society traditionally displayed, literally in every aspect of life, is manifest in recognizing a role in society for everyone.‖ Relaxation of article 377 has facilitated scale up of Targeted Interventions (TI) for MSM and Trans-gender (TG) population. 132 TIs are now functioning exclusively for these groups.

Press Council of India

In November 2008, the Press Council of India — following revision of guidelines compiled in 1993 through a consultative process involving Indian media, government representatives, positive people’s network, health professionals and civil society organisations — issued a new set of media guidelines for reporting on HIV and AIDS. The guidelines were released on the occasion of the National Press Day at a function presided over by the Hon’ble President of India, Mrs. Pratibha Devisingh Patil. The revised Press Council of India guidelines form a major step forward in the HIV response by setting a benchmark for qualitative and responsible coverage of HIV-related issues.

Monthly pension for below-poverty line ART patients

On 5th January 2009, the Cabinet of the south Indian state of Andhra Pradesh approved a monthly pension of INR 200 for each person living with HIV from below-poverty line families and undergoing ART treatment for a minimum of six months at the designated ART centres, and possessing white ration cards. This welfare initiative followed a public hearing in April 2008 and the presentation of a memorandum by the member of the Andhra Pradesh Legislators’ Forum on AIDS to the Chief Minister seeking pensions for those on ART treatment. An estimated 40,000 people living with HIV from Below Poverty Line families in the state are expected to benefit from the pension scheme. The landmark measure will also help remove stigma and discrimination against people living with HIV.

Travel & other concession for people living with HIV

The Railways Ministry of the Government of India announced a 50% train fare waiver for PLHIV accessing ART services in February 2008. The Railway Ministry had, in September 2009, also agreed to extend this concessional travel arrangement to an escort of PLHIV. In July 2009, the Government of India decided to provide Antyodaya Annayojna cards to poor PLHAs, making them eligible for getting subsidised ration. These decisions resulted from NACO’s sustained focus on mainstreaming HIV-AIDS and is a significant advance in provision of a supportive environment for PLHIV. Both the railway ministry and the food ministry have also agreed not to refer to such persons as HIV or AIDS infected but as persons with ―immune deficiency‖.

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Red Ribbon Express - Worlds largest mass mobilization drive on HIV and AIDS

The Red Ribbon Express (RRE) is the world’s largest mass mobilization drive on HIV and AIDS. The train will travel through 22 states, during its one year long journey, halting at 152 stations. Through the RRE, NACO intends to break the silence surrounding the issue of HIV and AIDS, by taking the messages on its prevention, care and support to people living in small towns and villages across the country. The aim is also to create an environment, free from stigma and discrimination faced by people living with HIV, so they can access the services, without fear and prejudice, and live a life of dignity. Regular newspaper reports suggest that the RRE has helped increase not only the awareness on HIV and AIDS, but also the utilisation of services. It has proved to be a successful multi-sectoral initiative of the NACO and a powerful advocacy tool, both at the state and district level, besides enhancing local capacity to deal with HIV prevention.

National Policy on HIV and AIDS and the World of Work

The world of Work becomes the most suitable platform for mainstreaming HIV and AIDS because more than 90 % of HIV infections are in the productive age group. With this view, the Government of India has adopted the ―National policy on HIV/AIDS and the World of work‖, which was launched by Shri Mallikarjun Kharge, Hon’ble Union Minister of Labour and Employment, on 30 October, 2009 in New Delhi. It is broadly based on code of conduct prescribed by the International Labour Organisation and aims to minimize the discrimination of PLHIV at places of work. It covers both organized and unorganized sectors and will help generate awareness about HIV/AIDS, encourage action to prevent its spread and further improve and develop the support and care initiatives at the workplace. The policy aims at preventing transmission of HIV infection amongst workers and their families; protect right of those who are infected and provide access to available care, support and treatment facilities, deal with issues relating to stigma and discrimination related to HIV/AIDS by assuring them equity and dignity at the workplace and ensure safe migration and mobility with access to information services on HIV/AIDS.

Link ART Centres

A NACO study on ―Assessment of ART centres: Clients’ and Providers’ Perspectives‖ revealed that distance, travel time and costs were main constraints faced by PLHA. Based on these findinds, NACO decided to set up Link ART Centres (LAC) to facilitate the delivery of ART services nearer to the beneficiaries. This is a low cost intervention which by ensuring easy access to ART, improves ARV drug adherence; as the LAC is set up in an Integrated Counseling and Testing Centre already functioning in Government health institutions – hospitals and Community Health Centres, expenditure is only on facility development, training and operational costs. Presently, 450 Link ART Centres planned for 2010 (520 functioning).

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Link Worker Scheme (LWS)

Under NACP-III, the Link Worker Scheme (LWS) was launched to saturate the reach of the HIV related services to the high risk groups based in the rural areas. The Link Worker Scheme was formulated for the rural areas of 187 highly vulnerable districts of the country. The LWS aims to address the complex needs of the rural HIV prevention, care and support through Identifying and training village level workforce of Supervisors, Link Workers and volunteers on issues of HIV/AIDS, gender, sexuality, STIs, mobilizing difficult-to-reach, especially vulnerable sub-populations including high risk individuals, youth and women, linking the HRG and vulnerable populations to STI, ICTC, ART services, generating volunteerism among the community for fighting HIV & AIDS, addressing issues regarding stigma and discrimination, condoms and behaviour change among youth. At present, the scheme is being implemented in 126 districts with support from GFATM, UNDP, UNICEF and USAID. It is proposed to expand the scheme to another 61 districts with support from GFATM Rd VII.

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SECTION 3:

Outline of the strategy

Department of AIDS Control adopts a robust evidence-based approach for development of strategy and implementation plan for prevention and control of HIV/AIDS in the country. National AIDS Control Programme (NACP) Phase-III (2007-12) was developed over a period of 2 years through 14 dedicated Working Groups on each technical area, several consultations with stakeholders, reviews, special studies and consolidating evidence on the issues to be addressed as well as the interventions to be put in place.

Being in the last year of NACP-III, NACO has already initiated a similar robust exercise with 18 Technical Working Groups for consolidating the evidence on achievements made till now, effectiveness of current strategies, need for strengthening ongoing interventions and identifying the important programme gaps where the next phase of NACP should focus upon. This exercise shall also examine the need for new strategies, new models of implementation as well as innovative approaches to achieve prevention and control of HIV/AIDS in India through universal access to prevention and care, treatment services. Detailed list of activities in this process are given in Annex-IV.

Since the exact strategy and implementation plan for next five years is in the process of development, this document outlines the broad strategy and plan adopted during NACP-III, strategies rolled out recently and the issues that are important for the next plan.

NACP Strategy and Approaches

The policy framework for the NACP is anchored in the National AIDS Prevention and Control Policy (NAPCP) of 2002. NACP seeks to assemble the efforts of all stakeholders — public and private — in addressing the epidemic which is a significant shift from the first, second and third phase of the programme. NACP III is marked with sustained, coordinated support by partners under ―Three Ones principle,‖ for effective and efficient programme implementation.

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11th five year plan document on health outline strategy for achieving the objectives for AIDS Control: Preventing new infections in high risk groups and general population through: Saturation of coverage of high risk groups with targeted interventions. Scaled up interventions in the general population. Increasing the proportion of PLWHA who receive care, support, and treatment. Strengthening the infrastructure, system, and human resource in prevention, care, support, and treatment programmes at the district and national levels. Enacting and enforcing national legislation prohibiting discrimination against PLWHA and their families in health facilities, schools, places of employment, and other institutions. Including mechanisms for victims and their guardians to lodge complaints and receive quick redressal. Ensuring that women and children living with HIV/ AIDS receive medical care, including antiretroviral (ARV) treatment and use all possible means to remove barriers to their receiving care. Strengthening a nation-wide strategic information management system. Advancing R&D of vaccines suitable for the strains of HIV prevalent in India.

This is also in consonance with NACP-III strategy which NACO is implementing

NACP III has a defined strategic for implementing the national programme from 2007 to 2012 with an implementation approach guided by policy framework. Given that over 99.5 percent of the population in is free of infection, NACP III places the highest priority for preventing HIV proliferation from HRGS and bridge populations — considered as highly vulnerable for HV and amongst whom the epidemic currently remains concentrated — to the general category. For achieving this, a plan of action is developed through experience with NACP I & II implementation: drawing particularly from their strengths.

The plan of action rests on four fundamental principles which are listed below:

i. Prevent infection by saturating coverage of HRG through TI and scaled up interventions in the general population. ii. Provide greater care, support and treatment to larger numbers of PLHIV. iii. Strengthen the infrastructure, systems and human resources in prevention, care, support and treatment programme at district, state and national levels. iv. Strengthen the nationwide strategic information management system.

For achieving the above mandate, mainstreaming HIV and Health and partnering with private health institutions was considered imperative for expanding the reach of services otherwise considered insufficient. Additionally, NGO and CBO were co-opted for preventing HIV transmission amongst HRGs

The guiding principles for NACP-III include:

• The unifying credo of the Three Ones, which are one action framework, one national HIV

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• coordinating authority, and one national M&E system • Equity (to be monitored by relevant indicators in both prevention and impact mitigation • strategies) • Respect for the legal, ethical, and human rights of PLHIV • PLHIV and civil society participation • Creation of an enabling environment • Universal access to HIV prevention, care, support, and treatment services • Implementation strategy based on qualifications, competence, commitment, and continuity

The key priority areas for NACP-III activities are discussed in the following sections:

I. Scaling-up Prevention Efforts II. Strengthening Care, Support, and Treatment III. Mainstreaming and Partnering • Enabling Environment and Greater Involvement of People Living with HIV/AIDS (GIPA) IV. Programme Management • Augmenting Capacity • Decentralizing the Programme V. Strengthening Strategic Information Management VI. Monitoring and Evaluation

i. Scaling-up Prevention Efforts

Prevention has been and will continue to be India's primary response to the HIV epidemic. Prevention includes delivering a package of HIV services focused on high-risk groups. NACP-III seeks to move beyond treatment service delivery at the tertiary and district level health institutions and expand them to the sub-district and community level, with a significant increase in the number of Integrated Counselling & Testing Centres (ICTCs), STI clinics, and PPTCT centres. At the district level, services will be available in medical colleges or district hospitals, to: • Provide prevention services including treatment and cure for STIs, psychosocial counselling, and • support for PLHAs.

• Manage opportunistic infections and provide anti-retroviral therapy for PLHAs. • Ensure counselling and testing for prevention of parent-to-child transmission of HIV. • Provide specialised pediatric HIV care and treatment. • Provide referrals for special needs such as surgery and ophthalmology.

At the sub-district and community level, community health centres and primary health centres provide prevention services including promotion of condoms, counselling and testing for HIV (ICTCs), PPTCT, treatment and cure for STIs, and management of opportunistic infections. NGOs and CBOs will provide outreach, peer support services, and home-based care for PLHAs in the community. 24 | P a g e

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HIV prevention efforts are being scaled-up under NACP-III by: a. Saturating programme interventions (at least 80%) and coverage of HRGs b. Promoting condom use c. Providing information, education, and communications d. Managing STIs e. Developing integrated counselling and testing f. Ensuring prevention of parent-to-child transmission g. Ensuring greater blood safety a. Saturating programme interventions and coverage of HRG, and bridge populations,

High-risk groups (HRG)

An overall estimate of HRG in the country by an expert group in January 2006 revealed the presence of 830,000 - 1,250,000 female sex workers; 2,350,000 MSM; 235,000 male sex workers; 96,000 - 189,000 male IDUs; and 10,000 - 33,000 female IDUs. NACP-III aims to reach at least 80% of this high-risk group population and reduce new infections in this group. NACP-III increases attention on MSM and IDUs to provide better coverage of these groups. Key activities for reaching HRGs include:

• Providing behaviour change communication (BCC) interventions to increase demand for products and services. • Providing STI services, including counselling to increase compliance of patients with treatment regimens, risk reduction training, and partner referral. • Promoting condoms and ensuring availability and access. • Creating an enabling environment to motivate safe behaviours. • Increasing programme sustainability through community mobilization. • Integrating prevention with care, support, and treatment to facilitate access and use of services.

Bridge populations

As important conduits for transmitting HIV from HRGs to the general population, bridge populations (e.g., truckers, migrant workers) are receiving more focus under NACP-III. The 2.3 million long distance truckers in India have an estimated HIV prevalence of 3-7%, and 1- 7% percent have at least one STI.The HIV prevalence for the over eight million short-term or temporary migrants in India is uncertain, and the socioeconomic and situational pressures make this group particularly vulnerable to HIV.

To reach this group better with prevention services, NACP-III includes: • Establishing peer-led interventions to create awareness of vulnerability and increase demand for products and services. • Promoting and providing condoms through free supplies and social marketing. • Developing linkages with local public sector, private sector, and NGO-supported centres for HIV testing, counselling, and STI treatment services. • Creating "peer support groups" and "safe spaces" at destination sites for migrants. b. Promoting condom use 25 | P a g e

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Despite increases in condom awareness during NACP-I and NACP-II, increasing the use of condom remains a priority. NACP-III seeks to significantly improve condom use, ensuring adequate and convenient supplies, and promoting condom negotiation skills among HRG. NACP-III has a target of 3.5 billion condoms off taken per year (1.6 billion in 2006) and increasing the number of outlets distributing condoms to 3 million by 2010 with focus on non-traditional outlets. c. Providing information, education and communication (IEC) and mainstreaming

The key principle that drives the NACP-III programme is the scaled-up synergy between communication response and service delivery. There has been a shift in emphasis from just awareness generation to behaviour change communication. The NACP-III communication strategy aims at:

• motivating behaviour change in population at risk including HRG • raise awareness levels about risk • generate demand for services and promote condom use • create an enabling environment free from stigma and discrimination

General population

Youth, women, and tribal groups are seen as vulnerable and heterogeneous populations with differing risk levels in the general population. NACP-III supports activities that:

• Set up a cadre of link workers to approach women and young people in villages and tribal areas with BCC, condoms, and referrals to health services. • Enhance access to HIV testing facilities with links to associated programmes and to counseling and treatment services through integrated counselling and testing centres. • Establish Red Ribbon Clubs of youth-friendly information services. • Improve access to PPTCT services. • Improve availability, testing, and safety of blood and blood products. • Expand STI treatment in public and private health facilities for easy access to the community. • Provide effective communication programmes to reduce stigma and discrimination. d. Managing STI

An estimated 4-6% of the adult population in India has an STI or reproductive tract infection. NACP III expands STI services through effective integration with the National Rural Health Mission's reproductive and child health programme. NACO also supports NGOs and not-for- profit private sector providers to provide STI services. e. Developing integrated counselling and testing centres

Under NACP-III integrated counselling and testing centres (ICTCs) function as a hub, or entry point, for men and women requiring different HIV-related services. ICTCs ensure that clients are linked to required services, such as early management of opportunistic infections,

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Department of AIDS Control - Strategic Plan Document access to legal services, antiretroviral treatment (ART), STI services, community care centres, PPTCT, and psychosocial support services.

f. Ensuring prevention of HIV from parent-to-child transmission

Of the 27 million yearly deliveries in India, an estimated 65,000 occur in HIV-positive mothers, which lead to 19,500 infected babies each year. The PPTCT programme, which was initiated in 2001 using Nevirapine, is being scaled-up to cover at least 80% of these deliveries for HIV-positive mothers. g. Ensuring greater blood safety

Ensuring access to safe blood is required by law, and NACP-III seeks to ensure that safe and quality blood is available within one hour at health facilities. NACP-III has a target of reducing HIV transmission through blood and blood products to less than 1% and increasing voluntary blood donation to 90% of total requirement. This will be achieved through: • Ensuring that regular voluntary blood donors constitute the main source of blood supply through phased increase in donor recruitment and retention • Vigorously promoting appropriate use of blood, blood components, and blood products among the clinicians • Developing long-term policy for capacity building to achieve efficient and self- sufficient blood transfusion services

Service Packages by Area under NACP-III Prevention: • Targeted interventions for HRG • Other interventions for bridge groups (truckers, prison inmates, migrants) • Integrated counselling and testing centres • Blood safety (including mobile blood banks) • Communication, advocacy and social mobilization • Condom promotion Care, Support and Treatment: • ART • Pediatric ART • Centres of Excellence • Care and support (community care centres and impact mitigation) Capacity Building: • Establishment support and capacity strengthening • Training • Managing programme implementation and contracts Strategic Information Management • Monitoring and evaluation • Surveillance • Research

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Department of AIDS Control - Strategic Plan Document ii. Strengthening Care, Support and Treatment

Expanding care, support and treatment and linking them with prevention services can help reduce AIDS-related mortality and help counter poverty, stigma, and discrimination. NACP III adopts a comprehensive approach intended to strengthen care, support and treatment to provide psychosocial support, and to ensure accessible and affordable treatment services.

Key priorities for NACP-III include:

• Strengthening PLHA and other networks of vulnerable populations. • Enhancing linkages to service centres and promoting risk reduction strategies. • Implementing standard protocol for treatment of HIV/AIDS and opportunistic infections. • Improved linkage between NACP-III and the Revised National Tuberculosis Control Programme for treatment of HIV/TB co-infection. • Establishing community care centres that provide outreach, referral, counseling, treatment, adherence and patient management services. • Undertaking advocacy, community mobilization, and BCC to integrate HIV positive persons into society and reduce stigma and discrimination.

Care and support

Improving the quality of life, social integration, and dignity of PLHA has been an ongoing effort under NACP. In the third phase, care and support services through partnerships with NGOs will be enhanced.Expanding access to care is intended to increase the demand for services and motivate PLHAs to adopt and sustain safe behaviour. NACP-III plans to support 350 community care centres in partnership with PLHA in high prevalence and moderate prevalence districts based on patient volumes.

Treatment

Anti-retroviral therapy is now available free to all those who need it. ART effectively suppresses viral replication, if taken at the right time and correctly. However, adherence to an ART regimen is critical. Any irregularity in following the prescribed regimen can lead to resistance to HIV drugs. Public health facilities are mandated to ensure that ART is provided to PLHAs. Special emphasis is given to the treatment of HIV-positive women and infected children. Currently 272 ART centres are providing free ART to 322,561 PLHA including 19,613 children. 1215 PLHIV are receiving second line ART.

III. Mainstreaming and Partnerships

NACP-III takes an integrated and multi-sectoral approach to transfer the ownership of HIV/AIDS issues to various stakeholders, including the government, the corporate sector, and civil society organisations. NACP-III seeks to mainstream HIV prevention, care and treatment into all government schemes and activities, corporate sector and civil society such as NGOs who are especially important in building awareness about HIV issues among the poor and high-risk 28 | P a g e

Department of AIDS Control - Strategic Plan Document groups. Mainstreaming HIV issues into other government department agendas is supported by an institutional mechanism to ensure that national and state objectives related to HIV prevention, care and treatment are met. This mechanism draws commitment from the National Council on AIDS, chaired by the Honourable Prime Minister and has 31 ministries and departments on its board. The National AIDS Control Organisation works with a number of international organisations who contribute their technical expertise and financial resources to address HIV/AIDS issues. This collaboration is as old as the government programmes on HIV/AIDS.

NGOs and civil society organisations (CSOs) have made significant contributions to HIV prevention and care services outreach to the highly vulnerable population groups at the local, state, and national levels. The National AIDS Control Programme recognises the importance of their participation, particularly in preventive or targeted interventions for high-risk groups, care and support of PLHA, and in general awareness campaigns. The corporate or private sector has taken up mainstreaming activities in a significant way. ―National Policy on HIV/ AIDS and the World of Work‖ has been adopted by the Government of India to address issue of stigma and discrimination against PLHIV at work places and provide linkages with the services.

Enabling environment and the greater involvement of people living with HIV/AIDS (GIPA)

Prevention, care, and support for HIV/AIDS are most effective in an environment where human rights are respected and those infected with or affected by HIV live a life of dignity, without stigma or discrimination.

NACP-III seeks to further build partnerships with PLHA networks and other stakeholders. Key NACP-III GIPA activities include:

• Supporting PLHIV networks in all states and most districts • Developing criteria for accrediting PLHIV networks and formalising partnerships with them Building capacity of PLHIV networks • Developing institutional structures at the district, state, and national government • levels to plan, implement, and monitor GIPA • Developing and implementing guidelines for direct involvement of PLHIVs in service delivery. iv. Programme Management

Another priority for NACP-III is improving and strengthening the management structures that were created under the earlier programmes. This includes strengthening capacity as well as systems such as the financial and strategic information management systems. The process of decentralization that began under NACP-II is being further devolved to better reach populations at the district and sub-district levels.

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The institutions, systems, and processes designed to implement NACP-I and -II achieved significant results in most parts of the country with systems for surveillance, management, and financial monitoring, and providing a solid foundation for scaling-up the programme under NACP-III. Better donor coordination and impact mitigation are also priorities for the overall management strategy.

Focus areas for improving programme management under NACP-III include augmenting capacity, strengthening the strategic information management system, and decentralizing programme management.

Augmenting Capacity

Since skilled and competent human resources are essential for the success of NACP-III, the programme seeks to strengthen the skills of health care providers such as doctors, nurses, counsellors, lab technicians, public health workers, civil society organisations, and managers at the national, state, and district levels.

Key activities for augmenting capacity include:

• Collaborating with partners on developing standard operating procedures and operational guidelines for crucial HIV services. • Adopting standard, performance-based contractual arrangements linked to delivery of HIV-related services. • Providing high quality training in areas such as support to community-based organisations, and ART training in the public and private sectors. • Providing technical support to all levels through Technical Support Groups at the national level and Technical Support Units at the state level. • Engaging the services of appropriate agents for procuring medicines, medical supplies, and other goods required by the programme.

Decentralizing the Programme

Under NACP-III, the decentralization that began under NACP-II will be further devolved to better reach populations at the district and sub-district levels through District AIDS Prevention and Control Units (DAPCUs). State level SACS will remain responsible for key services in the states. To enhance convergence with the National Rural Health Mission (NRHM), the new District AIDS Prevention and Control Units will share the administrative and financial structures of the NRHM. These units will also allow more locally appropriate interventions given India's heterogeneous epidemic, beside medical interventions, the units will also be responsible for non-health-related activities such as adolescent education programmes, monitoring and evaluation, and mainstreaming. v. Strengthening Strategic Information Management

Apart from the sentinel surveillance, a nationwide computerised management information system

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Department of AIDS Control - Strategic Plan Document provides strategic information for programme monitoring and evaluation. To strengthen the existing system, NACP-III contains several significant changes in data collection and analysis, which includes:

• Establishing one national Monitoring and Evaluation Framework. • Enhancing the Computerised Management Information System (CMIS). • Creating new Strategic Information Management Units (SIMU).

Key activities for strengthening strategic information management include:

• Reviewing and validating information for planning and programme implementation. • Strengthening programme monitoring to provide more accessible information. • Enhancing surveillance systems to provide data at the state and district level. • Reviewing models used to generate various state and national estimates on the basis of surveillance data. • Supporting independent evaluation and research. vi. Monitoring and Evaluation

Over the years, the national programme has built a robust monitoring system, which includes largescale data collection efforts. The HIV surveillance system in India is characterized by a growing number of sentinel and facility-based HIV sero-prevalence surveys, used for measuring trends in HIV prevalence and developing state and national prevalence estimates. NACO and development partners have also conducted behavioural surveys and research studies in a number of states to track HIV-related risk behaviours. The computerized management information system, established nation-wide, is another source of strategic information for programme monitoring and evaluation. Similarly, NACP has also successfully established a Computerized Project Financial Management System and a new Strategic Information Management Unit.

CMIS

NACP-III is updating the CMIS to address existing gaps and add features to support decentralization to the district level. NACP-III is also enhancing the capacity of primary data reporting units and programme managers at national and state levels for evidence-based planning and to monitoring of NACP-III at all levels.

SIMU

To maximize effective use of all available information and implement evidence-based planning, NACPIII has established Strategic Information Management Units at national and state levels to address strategic planning, monitoring and evaluation, surveillance, and research. The SIMU assists in tracking the epidemic and the effectiveness of the response and helps assess how well NACO, SACS, and all partner organizations are fulfilling their commitment to meet agreed objectives.

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Evaluation

Under NACP-III, all intervention programmes include evaluation plans, with tools developed for each programme component to support such evaluation. Ongoing evaluation of district and state programmes and mid-term and terminal external evaluation of such programmes are being carried out. NACP-III is using five key data streams to strengthen programme management, accountability, learning, and planning:

1. Programme reports on a monthly or quarterly schedule at the national, state, and district level using information from the CMIS, to be used by programme managers at national, state, and district levels.

2. A "dashboard" with information on key indicators, produced quarterly, to serve as a key monitoring tool at the national and state levels. (These indicators inform managers on the programme implementation status and provide early warnings of weaknesses or processes that are failing. The dashboard will facilitate management oversight starting from NACB, NACO, and SACS. Dashboard indicators are based on data from the CMIS and state monthly programme reports).

3. A report on the "State of the Epidemic and Response" produced annually at the national level using data from the CMIS, surveillance, special surveys, research, CPFMS, and other sources. 4. External programme evaluations undertaken at mid-term and at the end of NACP-III. 5. Key research findings, surveys, special studies, and other reports published as needed to inform NACO, SACS, partners, and a wider audience.

HIV Surveillance in India

One of the significant achievements of NACP is a credible HIV sentinel surveillance system. NACO formalized annual sentinel surveillance in 1998 with 176 sentinel sites in collaboration with the National Institute of Health and Family Welfare and the National Institute of Medical Statistics, Indian Council for Medical Research. Since then, the number of sites has increased to 703 in 2005 and was again expanded to 1,122 sites (usually antenatal clinics and STI clinics) in 2006. Currently there are 1215 sentinel sites in India. Surveillance for HIV infection falls in four broad areas: 1) HIV Sentinel Surveillance, 2) AIDS Case Surveillance, 3) Behavioural Surveillance, and 4) Sexually Transmitted Infections Surveillance. HIV Surveillance closely monitors and tracks the level, spread, and trends of the epidemic as well as the risk behaviours that lead to the growth of epidemic. Inputs from the robust sentinel surveillance system of India, routine AIDS case reporting, and periodic behavioural surveillance surveys give direction to the NACP. Estimation of HIV prevalence is done annually to provide a picture of the HIV epidemic at the national as well as the sub- national levels. AIDS case reporting from all states, through monthly reporting formats, provides inputs on the distribution of reported full-blown AIDS cases in the country as well as the proportional significance of different routes of transmission. Behavioural Surveillance 32 | P a g e

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Surveys provide data on the knowledge, awareness, and behaviours related to HIV/AIDS among the general population, youth, and different high-risk groups.

Following are the Priorities of NACP:

Sl.no. Strategic Initiatives Weight 1 Scaling-up Prevention Efforts 30 2 Strengthening Care, Support, and Treatment 30 3 Strengthen the infrastructure, systems and human 20 resources in prevention, care, support and treatment programme at district, state and national levels. 4 Strengthening Strategic Information Management 20 Total 100

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SECTION 4:

Implementation Plan

The institutions, systems and processes designed to implement the first three phases of the National AIDS Control Programme achieved significant results in most parts of the country. By outsourcing and contracting of services, the required management skills were mobilized at the national and state levels. During NACP-III, systems for surveillance, management and financial monitoring were developed, providing a solid foundation for scaling up the programme.

Notwithstanding the significance of the efforts indicated above, the rapidly evolving nature of the epidemic did entail a large amount of ad-hocism. This was inevitable. NACP-II was essentially designed for a strategy aimed at prevention. But, in the course of its implementation, a range of new services were added. The definition of primary prevention was broadened to include a set of services such as prophylactic treatment to HIV pregnant women. Likewise, ART treatment was introduced in the programme necessitating provision of competencies not available at NACO or SACS. The unplanned growth, compounded by the diversity of expertise required to manage the programme, prevented the emergence of an effective framework of governance based on the principle of integrating prevention with treatment. Since NACP-III proposes to scale up and broaden the programme components to provide for such integration, the reconfiguration of the institutional arrangements is a clear necessity for achieving programme objectives.

Institutional Frameworks

Under NACP-III take the programme implementation further, down to the district levels by establishing HIV Resource Units within District Health Societies. The organizational structure and the complex web of relationships that will be forged at each of these administrative levels for securing the required level of involvement and participation from all stakeholders may be seen.

National AIDS Control Organisation (NACO)

NACO provides leadership to the HIV/AIDS Control Programme in India, implementing one National Plan within one monitoring system. NACO was set up as an administrative unit within the Ministry of Health when the first National AIDS Control Programme was launched in 1992. During Phase I of the programme, NACO undertook direct implementation of many of the programmes as capacities were not available in states. With the formation of autonomous State AIDS Control Societies in NACP-II & III, NACO has decentralised the implementation of a large number of service delivery components, albeit, under the direct superintendence of and with financial assistance from NACO.

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During NACP-IV, NACO will continue to work on the decentralized model evolved during NACP-II&III. Under NACP-IV, the capacity of NACO will be further strengthened for coordinating with the large number of partners within and outside the government, laying down and enforcing technical protocols and operational guidelines on the interventions to be undertaken, ensuring quality and assisting SACS to build its technical capacity for managing the programme implementation based on evidence. NACO will, however, undertake a more interventionist role in states that fail to deliver till such time their capacity is built.

Governance structure of NACO will consist of: i) National Council on AIDS

National Council on AIDS (NCA), under the chairmanship of the Prime Minister, and 31 participating ministries and civil society representatives as members, is the highest body overseeing the National AIDS Control Programme. This body will provide the political will and support to the implementation of the national framework on AIDS Control, particularly in the context of mainstreaming HIV prevention within all organs of government as well as the private sector and civil society. Accordingly, all agencies will be called upon to develop action plans and provide information on the status of implementation at periodic intervals. ii) National AIDS Control Board

Programme management of NACO will be overseen by the National AIDS Control Board, chaired by Secretary (Department of AIDS Control). The Board shall meet at least once a quarter. It will approve the Annual Plans of Department of AIDS Control and review quarterly performance reports. The Board will also have access to reports of the Development Partners’ forum and will be empowered to seek clarifications from programmes being implemented by donor partners outside the national budget framework. Minutes of the meeting of the National AIDS Control Board shall be posted on the NACO website within a month of its meeting. iii) Technical Advisory Groups

For guiding and assuring technical oversight of the programmes, NACO will constitute Technical Advisory Groups on various thematic areas i.e. public health, clinical services, surveillance, monitoring and evaluation, IEC, Targeted Interventions and Research. These Groups will be expected to meet as per need and also visit states to review the quality of implementation of interventions and provide guidance.

Programme Management by NACO

NACO, as an integral constituent of the Ministry of Health & Family Welfare, will be responsible for the implementation of the National Policy on HIV/AIDS and directly accountable to the NCA and NACB. Due to the special vulnerabilities of north-eastern states, a sub-office of NACO, embedded in the governance structure of NRHM, will be set up to provide programme implementation support to the north-eastern states.

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Department of AIDS Control - Strategic Plan Document

State AIDS Control Societies (SACS)

At the commencement of the HIV/AIDS Control Programme, State AIDS Cells were constituted as a part of the health departments. During NACP-II, decentralised autonomous societies were set up, which provided the required level of functional independence to upscale and innovate. Even today, states that have not delegated adequate authority to SACS are the ones that are lagging in programme implementation. Experience gained so far clearly points to the advantage of having empowered and independent units to push through this programme. Therefore, the characteristics of SACS will continue to be maintained even in the event of any State seeking to merge these societies as part of the State Health Societies. SACS will be the main implementing arm of NACO but will also have a governance structure at the state level for programme support and oversight:

Governing Body

Governing Body is the highest policy making structure of SACS and is headed either by the Minister in charge of health or the Chief Secretary. For the sake of uniformity and administrative convenience, it is suggested that the Governing Body should be headed by the Chief Secretary while the Executive Committee should continue to be headed by the Principal Secretary/Secretary (Health). Governing Body is required to meet at least twice a year. Represented in the Governing Body will be key government departments, representatives of the civil society (elected by the state level civil society forum), representatives of trade and industry, private health sector and representatives from PLHA Networks. Governing Body of SACS will approve its annual action plan, annual budget, appoint statutory auditors and accept the annual audit report. It will also approve new policy initiatives, if any. For better financial and operational efficiency, the Governing Body will delegate adequate administrative and financial powers to the Executive Committee and the Programme Director. It will also exercise all other statutory powers as ordained under the Societies Registration Act.

Executive Committee

Executive Committee of SACS will exercise powers as delegated to it by the Governing Body. For functional efficiency it should be a small and compact body with limited representation from key departments (finance being mandatory).

Project Director

Project Director (PD) is a pivotal position in SACS. Frequent transfer of PDs has interfered with programme implementation in many states. In order to avoid this, as part of the MOU, states will be requested to set up a selection committee with a representative of NACO as member for selecting a suitable person as PD. All PDs will be mandated to undergo an orientation and induction training within three months of their joining. The tenure of the PD should be a minimum of 3 years.

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Functions of SACS

With the setting up of District AIDS Prevention and Control Unit, there will be an increased emphasis on improving coordination functions at state level and in supporting programme implementation at district level. Health related interventions will continue to be delivered through the public health system. This would entail collaboration with NRHM, RCH, RNTCP and other health programmes as required.

Functions of SACS have been categorized into three groups:

 Medical and Public Health Services;  Communication and Social Sector services; and  Administration, Planning, Coordination, M&E, Finance and Procurement.

Since the work load in SACS is contingent on the size and population of the state and the burden of disease, states have been divided into three categories:

Category I AP, Karnataka, Maharashtra, Tamil Nadu, U.P., M.P., Bihar, Jharkhand, West Bengal, Orissa, Chhattisgarh, (Large) Rajasthan, Punjab, Gujarat, Assam, Kerala, J&K, Nagaland, Manipur

Category II Mizoram, Haryana, Delhi, Mumbai, Arunachal Pradesh, Tripura, Goa, Himachal Pradesh, Uttaranchal, Meghalaya, (Medium & Small) Sikkim, Chennai, Ahmedabad; and

Category III All Union Territories

While all states will receive assistance from NACO to provide for the posts indicated in the category I states will be provided with additional support in the form of a Technical Support Unit.

State Council on AIDS

Political commitment and support at the highest level is crucial for successful implementation of the HIV/AIDS programme. All States will be requested to constitute a State Council on AIDS (SCA), patterned on the National Council on AIDS, to be headed by the Chief Minister, with the Minister (Health) as the Vice Chairperson. The State Council with representation from various departments of the government and civil society will set policy guidelines, review the State’s performance including mainstreaming by key departments.

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Technical Support Unit

Since the emphasis of the strategic framework is on prevention of infection among high risk groups and since the Technical Support Units have been found to be successful in most states, every SACS will have the option to obtain external technical support to facilitate social mobilization in all components of the programme.

District AIDS Prevention and Control Unit (DAPCU)

DAPCU will operate within the District Health Society, sharing the administrative and financial structures of NRHM. While the unit will report to and work through the Chief Medical Officer of the District for medical interventions, it will also be responsible for non- health related activities such as Adolescent Education Programme, supportive supervision of TIs, M&E and mainstreaming. These activities will be carried out through the office of District Collector or Zilla Panchayat.

Support to States with weak Capacities

During the first three phases of NACP, states varied in scale and quality of their programme delivery, partly by political support and partly by technical assistance available in the state. However, the experience of Project Management Unit (PMUs) established with development partners assistance has been positive.

During NACP-IV, NACO will ensure that all states perform at the planned level. The MoU between NACO and SACS will be revised to ensure greater accountability on the part of SACS and responsiveness on the part of NACO. It will secure the commitment of state governments for remedial action to prevent frequent changes of senior level functionaries including the PD, assignment of dual charge to the PD and a large number of posts lying vacant in these areas. If the states fail to abide by these commitments, NACO will undertake the responsibility of recruiting the personnel and appointing them in SACS. In the event of further default on any of these commitments, the MoU will have enabling provisions authorising NACO to allocate budgets earmarked for the state to agencies identified by NACO for direct execution.

Civil Society Partnership Forums

Civil society organisations have been active partners in the national response to HIV/AIDS. Their partnership in the planning and implementation process will be formalised. The task of facilitating partnership at district and state level will be entrusted to Technical Support Units where they exist or an NGO with recognised work in HIV in states where TSUs do not exist. The facilitating institution will undertake mapping of civil society organisations working in each district. The base unit of civil society partnership will be at the district, to be organised if the number of potential partners exceed ten. Any civil society organisation, including NGOs, CBOs, Red Ribbon Clubs and PLHA networks, private sector organisations and

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Department of AIDS Control - Strategic Plan Document academic institutions working in the area of HIV in the district can become member of the District Forum. The Forum will be informed of the district implementation plans and will be provided data to review progress.

The State Level Forum will consist of representatives of the District Forums, not exceeding two per district, while the National Forum will have representatives from the state level fora. States which do not have district forums can constitute the same directly if the number is below 30. Where any of constituencies (e.g. primary stakeholders such as sex workers, MSM, IDUs and PLHA; secondary stakeholders such as academic institutions) is not represented at the national or state level forum, NACO or SACS will nominate a representative from that constituency. District and state fora will meet quarterly, while the National Forum annually. The civil society fora at different levels will have access to programme reports from the District, State and National AIDS Control units.

Steering Committee of Development Partners

In line with the principle of ―Three Ones‖, all agencies working in the area of HIV/AIDS will be required to enter into an MoU with NACO with a clause to align their work to the national framework approved by the National Council on AIDS and to provide inputs into the national M&E framework.

As part of the MoU, all agencies – government, private foundations, UN agencies etc. – will be members of the Steering Committee of Partners at the national and state level. The Steering Committee will be chaired by the DG, NACO and by the PD at the state level. Following are the main objectives of this Committee:

1. Ensuring no duplication and a harmonised working relationship. 2. Sharing of information on action plans. NACO will compile these plans into a common template and make it available on the public domain. NACO will also negotiate with partners so as to avoid duplication and to move resources to underserved areas. The final decision on these issues will be taken by NACO. 3. Review of performance. All partners will make available to the forum their performance on the agreed parameters. Consolidated data on performance will be available to the public. 4. Development of and adherence to a common monitoring and evaluation framework. NACP-III has indicated common parameters that all development partners are to report on. Development partners’ forum will facilitate systems, structures and skills of all partners to report into the M&E framework and to access results of the analysis of this data. Development partners who work in the state and satisfy eligibility criteria will be invited to be members of a state forum, convened by SACS. They will carry out functions parallel to the national forum at state level. DPs will have to dovetail their action plans in line with the unified framework prepared for the state as directed by the SACS. Any dispute between SACS and DPs will be referred to NACO for resolution.

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Institutional arrangements for Outsourcing

NACO and SACS will outsource services where there is comparative advantage in outsourcing. The services to be outsourced are:

 Procurement and logistics: One National Procurement Support Agency;  Condom Programming: Five regional social marketing agencies;  Strategic Information Management;  Surveillance: One national agency for technical support to surveillance and another for management of the operation. In addition, one institution will be built up in every state for epidemiological support to SACS;  Behavioural surveillance: One national agency;  Research and Knowledge Management: Five institutions or consortia of institutions with skills in bio-medical and social sectors will serve as Research and Knowledge Management Centres;  External Quality Assurance: One National Reference Laboratory supported by five regional laboratories in year one, going up to 12 in year 3 and thereafter;  Development and production of communication protypes and materials;  Migrant support: One national agency to support NACO; and  Technical support: Technical support will be provided by national and regional institutions and development partners with expertise in the area.

The institutions/agencies to provide these services would be selected on the basis of clear terms of reference through the process laid out in the section on procurement.

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SECTION 5:

Linkage between Strategic Plan and RFD

Results Framework Document of Department of AIDS Control incorporates the core indicators that help in monitoring the progress of each strategy outlined under NACP-III and measures the achievement against the objectives set at the start of the programme. These core indicators are monitored on a monthly basis and performance of different programme units is reviewed from time to time. For the new strategies and approaches being adopted in the programme, similar core indicators will be identified that not only help in monitoring the progress, but also in development of RFDs for the next few years.

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SECTION 6:

Cross departmental and cross functional issues

Specific Performance Requirements from other Departments

Convergence with NRHM Convergence of NACP III with NRHM is a key strategy for ensuring decentralization of the programme as district and sub-district level public health systems is managed within a framework for the health and family welfare sector developed in 2005. This framework set in place by the NRHM, proposes to address gaps effective health care service provision in the least developed areas of the country; create a common architecture for all health care programmes at the district level; strengthen local public health provision with infrastructure and manpower; and facilitate the participation of the not-for-profit and for-profit sectors more fully in achieving desirable health outcomes. The NRHM thus aims at providing an overarching superstructure for existing programmes of Health and Family Welfare including Reproductive and Child Health-II, Malaria, Blindness, Filaria, Kala Azar, T.B., Leprosy and Integrated Disease Surveillance. There are six areas which are the focus of convergence efforts namely, ICTC; PPTCT; Blood safety; STI/RTI; Condom programming; and ART. The administration of the public health system takes place through District Health Societies which comprise of the staff functions at the district level. NACO and NRHM are working together in planning, developing operational guidelines and co-ordinating the district level through the DAPCU.

Convergence with other Departments of GOI: Requirements from other Departments of GOI are summarized below. Department / Relevant Success What do you Why do you How much What Ministries Indicator need? need it? you need? happens if you do not get it? Panchayati Raj No of persons Guidelines for To strengthen Full support It would Women and trained under incorporating the National and hamper Child Mainstreaming HIV/AIDS in response to commitment the Development training their schemes HIV/AIDS achieve programmes, and training Rural ment of Development Number of programmes, National Housing and districts/ stations Ensuring Poverty covered through running of targets Alleviation, Red Ribbon RRE as per and HRD, Express (RRE), schedule. program Railways, No of ITDP NSS to me Tribal Affairs, areas where continue the outcome Tribal action support for Home, s. Defence, Plan is rolled formation of Youth affairs out RRCs in colleges

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SECTION 7:

Monitoring and Reviewing arrangements

Monitoring & Evaluation:

Routine data collection under the programme is done through Computerized Management Information System (CMIS). Monthly reports are received from 35 SACS with 285 Anti- retroviral Treatment Centre, 1,082 Blood Bank, 254 Community care centre, 5135 Integrated Counseling &Testing Centre, 938 Sexually Transmitted Infection Clinic, 1366 Targeted Intervention facilities. Timeliness and completeness of reporting is monitored on monthly basis, and feedback is provided to SACS for improving the quality and completeness of reporting. A data quality assessment and auditing guide is being developed based on current data collection formats, and state level epidemiologists have been hired to strengthen capacity for data analysis. M&E officers at DAPCU, SACS and NACO are regularly trained on different areas of data management, analysis and reporting. Bulletins and reports are prepared from time to time for dissemination of the programme data.

NACO has a web-site www.nacoonline.org which is currently being maintained by M&E Division. NACO is in the process of developing a Knowledge Hub that consolidates all the available information on HIV/AIDS, nationally and internationally, through features such as digital libraries, customized reports and presentations, data extraction, on-line discussion forums and e-learning.

M&E division is also responsible for coordination, compilation and submission of Monthly progress report for Cabinet Secretariat and Results Framework Document (RFD) for Performance Monitoring Division, Government of India.

Strategic Information Management System (SIMS):

The SIMS was developed as a mechanism for improving on the CMIS. Under CMIS, data are aggregated at national, state, district and sub-district levels through the various government reporting units; the challenge is integrating HIV data generated or captured by non-NACO funded HIV projects. It is envisaged that following the launch of SIMS; data generated at different levels could be comprehensively utilised for guiding effective response formulation. Concerns over gaps in data reporting, data quality issues will also be addressed.

SIMS is a web-based application with a central server and sophisticated tools aiding in data analysis and integration from different data sources/platforms. It is proposed to increase the efficiency of computerized M&E system by having adequate data quality through centralized validated data. Data transfer mechanisms shall be improved by using the web-enabled application and efficient data management rights (Access Rights Control) from reporting unit to national level will be there. It will provide evidence to track the progression of epidemic with respect to demographic characteristics, geographical area including GIS support. This

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Department of AIDS Control - Strategic Plan Document system will enable individual level data collection for key programme areas (e.g., ICTC, ART) and has built-in real-time analytic, triangulation and data validation capabilities.

SIMS provides tools for better decision making through data triangulation from different sources and thereby facilitates ease of evaluation, monitoring and taking policy decisions at strategic or tactical level. The Built in rules, regulations and policies to facilitate alerts and data integrity checks, The Ad-hoc reporting through data warehousing, drill-down and slice- n-dice facility shall also be available through cubes. SIMS was launched by Secretary & DG, NACO in August 2010 and is scheduled to be fully implemented during 2011.

Research (Clinical, Biomedical & Operational) and Evaluation:

SIMU coordinates, reviews, processes various research proposals related to HIV/AIDS in the fields of social, behavioural, biomedical, epidemiological, clinical and operational areas. SIMU also carries out evaluation of different programme components. The main activities carried out under Research and Evaluation are:

1. Prioritization of Research Areas and Development of Research Plan for NACO 2. Technical Resource Group on Research & Development 3. NACO-Ethics Committee (NACO-EC) 4. Dissemination of HIV/AIDS Research Outcomes 5. Network of Indian Institution for HIV/AIDS Research (NIIHAR) 6. NACO-Research Fellowship Scheme (NRFS) 7. Capacity Building Initiatives

Surveillance and other Strategic Information Areas:

NACO conducts annual HIV Sentinel Surveillance (HSS) in different risk groups across the country and provides insights into levels, trends and geographic spread of HIV. The data from HSS is used in estimation of HIV burden, incidence, AIDS-related deaths and other programme parameters, to inform planning and policy making. NACO plans to conduct capacity building workshops in EPP & Spectrum during 2011 to build pools of expertise in HIV modeling in the country. It is proposed to constitute an expert committee to review various models available for HIV estimation and projections, identify the advantages and limitations of each, and develop a systematic plan for using different models in the programme and building capacity in modeling.

Behavioural Surveillance Surveys are conducted once in 3-5 years to monitor the changes in knowledge, safe practices and risk behaviours. NACO plans to roll out Integrated Biological & Behavioural Surveillance in 2011-12, that provides district level estimates of key behaviours correlated with the HIV prevalence in different risk groups.

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NACO plans to initiate systematic review & consolidation of available evidence on three special areas of Strategic Information through Technical Working Groups - HIV Incidence, AIDS-related mortality & HIV among children in India. NACO is working with CDC in developing a protocol for laboratory based incidence assay using HIV Sentinel Surveillance samples.

District Epidemiological Profiling using Data Triangulation has been completed in 26 states in two phases. The new framework for District Re-categorisation using data triangulation has been developed and all the 639 districts in the country are re-categorised accordingly.

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Annex-I Statewise Estimated Adult (15-49) HIV Prevalence and Number of HIV Infections with Uncertainty Bounds, 2009 Estimated Adult Estimated Number of HIV Prevalence, 2009 (%) HIV Infections, 2009 State/UT Uncertainty Uncertainty bounds Estimate bounds Estimate Lower Upper Lower Upper Andaman & Nicobar Islands 0.26 0.19 0.36 395 292 536 Andhra Pradesh 0.90 0.77 1.07 4,99,620 4,24,214 5,96,011 Arunachal Pradesh 0.16 0.12 0.22 1,082 808 1,481 Assam 0.08 0.06 0.12 14,244 10,400 21,599 Bihar 0.22 0.18 0.27 1,20,470 1,00,493 1,47,676 Chandigarh 0.39 0.32 0.47 3,067 2,571 3,716 Chattisgarh 0.28 0.20 0.38 39,774 29,188 53,885 D & N Haveli 0.15 0.11 0.20 285 217 383 Daman & Diu 0.16 0.12 0.21 251 192 336 Delhi 0.30 0.25 0.36 34,216 28,735 41,076 Goa 0.49 0.31 0.73 5,440 3,584 8,027 Gujarat 0.37 0.30 0.55 1,36,875 1,09,952 2,00,826 Haryana 0.10 0.09 0.13 15,852 13,189 19,122 Himachal Pradesh 0.19 0.16 0.24 8,878 7,105 11,069 Jammu & Kashmir 0.08 0.06 0.11 5,403 3,971 7,444 Jharkhand 0.13 0.11 0.17 23,574 19,133 29,301 Karnataka 0.63 0.46 0.88 2,45,522 1,79,205 3,35,119 Kerala 0.19 0.15 0.24 40,060 32,654 49,352 Madhya Pradesh 0.19 0.16 0.24 84,803 69,916 1,03,540 Maharashtra 0.55 0.44 0.71 4,19,789 3,31,891 5,48,366 Manipur 1.40 1.16 1.64 26,773 22,113 32,374 Meghalaya 0.08 0.06 0.12 1,332 1,002 1,921 Mizoram 0.81 0.60 1.12 6,025 4,448 8,361 Nagaland 0.78 0.66 0.93 13,120 11,005 15,578 Orissa 0.29 0.24 0.37 71,813 58,879 90,117 Puducherry 0.28 0.22 0.36 2,254 1,768 2,860 Punjab 0.32 0.26 0.39 56,928 47,077 67,967 Rajasthan 0.19 0.16 0.23 76,316 63,998 92,466 Sikkim 0.06 0.05 0.08 231 173 296 Tamil Nadu 0.33 0.26 0.41 1,54,742 1,21,000 1,94,611 Tripura 0.15 0.10 0.21 3,425 2,381 4,845 Uttar Pradesh 0.09 0.08 0.11 1,09,352 90,199 1,37,193 Uttarakhand 0.10 0.07 0.15 5,539 3,893 8,597 West Bengal 0.29 0.24 0.35 1,67,994 1,38,348 2,06,930 India 0.31 0.25 0.39 23,95,444 19,33,994 30,42,981

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Annex-II

Status of Facilities under National AIDS Control Programme as on Dec 2010

State AIDS S.No.

Control Society of . DIC

Centre

o

No. ART ART No.

No. of TI No.

supported

No. of STI No.

N

No. of CCC No. of RRC No.

No. of ICTC No.

Blood Banks Blood No. of NACO of NACO No. 1 A & N Islands 0 2 13 1 0 0 3 2 Andhra Pradesh 38 96 34 677 85 70 24 3500 3 Arunachal Prad. 1 12 0 35 16 2 0 20 4 Assam 3 32 3 83 23 58 2 6 5 Bihar 6 47 9 207 42 45 3 75 6 Chandigarh 1 4 0 11 3 13 1 19 7 Chhatisgarh 4 15 6 100 19 33 1 100 8 D & N Haveli 0 1 0 1 1 3 0 1 9 Daman & Diu 0 1 0 4 1 3 0 4 10 Delhi 9 19 5 87 17 84 5 82 11 Goa 1 3 1 14 4 19 2 3 12 Gujarat 17 74 14 270 41 114 14 482 13 Haryana 1 20 1 88 24 41 2 93 14 Himachal Prad 2 14 1 47 16 23 2 218 15 J & K 2 20 0 34 17 6 0 79 16 Jharkhand 4 22 3 64 27 31 4 0 17 Karnataka 40 65 30 561 39 34 10 281 18 Kerala 8 45 7 162 21 53 14 264 19 Lakshadweep 0 1 0 0 1 0 0 0 20 Madhya Pradesh 7 59 7 143 61 67 2 400 21 Maharashtra 51 97 36 604 72 87 16 165 22 Manipur 7 3 10 54 10 54 4 35 23 Meghalaya 1 5 0 9 8 12 1 11 24 Mizoram 1 8 1 27 8 41 7 20 25 Nagaland 5 8 4 60 11 39 14 50 26 Orissa 4 56 5 184 36 67 8 600 27 Puducherry 1 5 1 10 4 1 2 50 28 Punjab 5 52 4 71 23 47 2 95 29 Rajasthan 6 45 8 182 47 55 2 232 30 Sikkim 1 2 1 12 6 7 1 85 31 Tamil Nadu 37 94 35 783 106 53 37 2,189 32 Tripura 1 6 2 18 9 18 0 11 33 Uttar Pradesh 10 70 11 217 86 96 8 149 34 Uttarakhand 2 17 1 47 10 27 1 118 35 West Bengal 9 62 14 256 43 63 8 449 Grand Total 285 1,082 254 5,135 938 1,366 197 9,889

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Annex - III: Achievement of NACP-III

XI Plan Achievements up

Indicators (2007-2012) 2008-09 2009-10 2010-11 to Jan 2011 Targets Targets Achievement. Targets Achievement Targets Achievement

364 413 1 Setting new core group targeted interventions 114 119 110 152 2,100 Set up new bridge population targeted 206 158 2 47 45 30 23 interventions 1,50,00,000 per 3 Treat new STI cases 100 lakh 66.7 lakh 100 lakh 82.4 lakh 100 lakh 74.96 lakh** year 80 40 19 4 Set up new Blood Component Separation Units 40 28 12 10

5 Set up new District Level Blood Banks 39 4 3 8 4 6 5

Treat persons living with HIV/AIDS with anti 3,00,000 2,00,000 2,17,781 6 3,00,000 3,15,640 4,04,815 3,87,205* retroviral drugs(Cumulative) Set up Anti Retroviral Therapy 250 150 215 7 200 267 332 292* Centres(Cumulative) 350 221 267 8 Set up Community Care Centres(Cumulative) 261 287 316 259*

Set up new Integrated Counselling and Testing 4,955 583 460 9 176 191 40 23 Centres 75,00,600 56.2 46.31 10 Mothers Counselled & tested at ICTC 70.15 lakh 59.49 lakh 86.49 lakh 46.51 lakh*

2,20,00,000 66.7 55.87 11 Persons Counselled & tested at the ICTC 85.19 lakh 81.08 lakh 111.71 lakh 61.53 lakh* per year

Achievements Up to Dec 2010; ** Up to November 2010

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Annexure IV: Process of Developing NACP-IV Strategy & Plan Document

Key Activities

1. Setting up working groups-identifying themes and members, making ToRs of Working Group - Examining studies done, evidence collected and identification of actionable points for feeding into project design.

2. Submission of Draft Report by Working Groups on each Technical Area.

3. Vetting of these recommendation and drawing up Project Proposal by Core Team

4. Consultation with States, Civil Society Organization, Positive Networks and other stakeholders

5. Submission of Project Proposal to Planning Commission & EFC for approval

Steering Committee Department of AIDS Control

Secretary, Department of AIDS Control & DG, NACO Head of Steering Committee National AIDS Control Organisation Ministry of Health & Family Welfare

Additional Secretary Deputy Directors General Assistant Directors General Members of Steering Committee Joint Director Directors Donor Representative

Monthly Meeting frequency

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