India Operational Plan Report FY 2010 Custom Page 1 of 346 FACTS Info v3.8.3.30 2012-10-03 14:37 EDT Operating Unit Overview OU Executive Summary India has the third largest HIV epidemic in the world. According to the 2007 Government of India (GOI) national estimates, there are 2.31 million people living with HIV/AIDS (PLHIV). However, because India is such a large country, the estimated adult HIV prevalence is a mere 0.34% of the population. This low prevalence rate is misleading given that nominal elevations in the HIV/AIDS rates in India have global ramifications. Fortunately, since 1990 the Government of India has been dedicated to combating the HIV/AIDS epidemic through a series of progressively stronger national programs. The most recent National AIDS Control Program, Phase III (NACP III) has increased efforts to expand services and tailor interventions to the unique dynamics of the epidemic in India. Given NACP III’s current momentum and significant advances in scale-up and capacity development, at the central and state level, reversing the epidemic is within reach over the next five to ten years. India’s success influences the global HIV/AIDS pandemic reaching the Millennium Development Goals and meeting UNAIDS principles of the “Three Ones.” Working in close cooperation with the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and international partners, India is implementing “One” HIV/AIDS action framework, NACPIII, with “One” national AIDS coordinating authority, the National AIDS Control Organization (NACO). Now India is working towards unifying the country-level monitoring and evaluation (M&E) systems under “One” authority. PEPFAR/India is successfully implementing an aggressive transition from direct services to technical assistance. This fits well with the large scale $2.5 billion NACP III. The USG is strategically focusing on addressing the capacity gaps and TA needs at the national and state level in India to enhance GOI efforts to effectively combat HIV/AIDS. The HIV/AIDS Epidemic in India India has a concentrated epidemic with the highest prevalence among Most at Risk Populations (MARPs): female sex workers (FSW), men who have unprotected sex with men (MSM) and injection drug users (IDU). USG support predominately focuses on these MARPs along with bridge populations, pregnant women and Orphans and Vulnerable Children (OVC). HIV prevalence among men continues to be higher (0.45%) than females (0.27%). Out of the total estimated number of PLHIV, 39% are females and 3.5% are children. India has 3-4 million children affected by AIDS, out of which 95,000 children are living with HIV. Out of an estimated 27 million annual deliveries in India, approximately 85,000 infected women become pregnant and give birth to 25,000 infected babies each year. In 2008, 4.15 million pregnant women (15.3% of all pregnancies) received PMTCT services of which 19,986 tested HIV positive. HIV estimates for India (2007) Category Estimation Total population 1.027 billion Number of people living with HIV (adults and children) 2.31 million HIV prevalence (15-49 years) 0.34% HIV prevalence among men (15-49 years) 0.40% HIV prevalence among women (15-49 years) 0.27% Source: HIV Sentinel Surveillance and estimation is conducted annually by NACO. The latest report available is HIV data 2007. The HIV Sentinel Surveillance data 2008 is expected by November 2009. While India’s national HIV prevalence appears to be declining with an estimated 0.36% in 2006 to 0.34% in 2007, this national statistic masks the more complex variation in state and district-level prevalence Custom Page 2 of 346 FACTS Info v3.8.3.30 2012-10-03 14:37 EDT throughout the south and north east. In fact, there are several states and districts where prevalence appears to be rising. A third of FSW sentinel sites have >5% prevalence, with the highest rates in Mumbai (42%) and Pune (59%). Similarly 50% of MSM sentinel sites have >5% prevalence. USG Focus Groups HIV Prevalence 2007 IDUs 7.2% MSMs 7.4% FSWs 5.1% Migrants 3.6% (defined as temporary change of residence) Truckers 2.5% (defined as mobile populations) Antenatal Clinic Attendees .48% Pediatric 95,000 (based on public sector registration) OVC 3-4 million (currently being estimated) Source: HIV Sentinel Surveillance and estimation is conducted annually by NACO. The latest report available is HIV data 2007. The HIV Sentinel Surveillance data 2008 is expected by November 2009. The USG is focused on five high burden areas: Tamil Nadu, Karnataka, Andhra Pradesh, Maharashtra and the North East region. Distribution of PLWHA among high burden states: State Percentage 1. Andhra Pradesh 21% 2. Maharashtra 20% 3. Karnataka 11% 4. West Bengal 10% 5. Tamil Nadu 8% 6. Gujarat 6% 7. Uttar Pradesh 4% 8. Rest of the states 20% The GOI and USG Response The GOI is now implementing the third phase of a $2.5 billion NACP-III, 2007-2012, a plan developed with input from the donor community, including critical support from the USG. This GOI strategy outlines a decentralized response to the epidemic to deliver expanded prevention, treatment and care services, with the goal of integrating HIV/AIDS services within the National Rural Health Mission (a national Primary Health Care (PHC) strategy reaching about two-thirds of India’s population) by 2012. The integration of HIV/AIDS services will strengthen routine health and public health services in India. NACP III has four primary objectives: i. Prevent infections through saturation of coverage of high-risk groups with targeted interventions and scaled up interventions in the general population. ii. Provide greater care, support and treatment to larger numbers of PLWHA. iii. Strengthen the infrastructure, systems and human resources in prevention, care, support and treatment Program at district, state and national levels. iv. Strengthen the nationwide strategic information management system. Custom Page 3 of 346 FACTS Info v3.8.3.30 2012-10-03 14:37 EDT With strong GOI leadership under the National AIDS Control Organization (NACO), and strategic USG support, there has been a swift roll-out of the third phase of NACP III, significantly increasing India’s response to the HIV epidemic. NACP III outlines an ambitious time-line to deliver large-scale outcomes. For example, NACP III has set targets to scale-up prevention interventions at over 2,000 sites MARPs across 31 states; antiretroviral therapy (ART) in more than 200 centers; and the provision of counseling and testing (CT) services in nearly 5,000 centers. The USG has a vital role to play supporting NACO’s implementation of large-scale, multi-faceted HIV/AIDS program. Leveraging relatively modest resources, $30 million annually, in FY 2010 the USG will continue to meet NACO’s critical need for technical assistance and capacity building at the national and state levels in select priority regions primarily: Tamil Nadu, Maharashtra, Andhra Pradesh, Karnataka and the North East (in Nagaland and Manipur). Transitioning to targeted technical assistance, the USG has dramatically reduced the number of districts receiving direct service provision. For example in Tamil Nadu the USG moved from working in 23 to 7 districts. The planned transition has allowed the GOI at all levels to support and maintain those services previously supplied by the USG. In line with NACP III and PEPFAR priorities, the USG will continue to increase the amount of TA through a mix of technical expertise and capacity building for NACO and State AIDS Control Society (SACS) to manage MARP interventions, care and support demonstration projects, OVC programming, laboratory strengthening and strategic information (SI) support. PEPFAR/India has established good working relations with each of the SACS in the focus states, and has supported effective partners on the ground. USG efforts have recently resulted in a number of sustainable HIV/AIDS prevention, counseling and testing, treatment and SI programs. Maintaining a focus on sustainability, PEPFAR/India has established a four pillar approach including: capacity building at all levels of government; an ambitious transition from direct services to technical assistance, demonstration or pilot programs to test effective interventions and private sector expansion to guide India’s NACP III. In FY 2010, PEPFAR/India will develop an innovative four-year HIV/AIDS Partnership Framework to better support the TA needs of a reinvigorated national program currently implemented with strong national leadership and formidable resources to carry out its mandate to reverse the HIV/AIDS epidemic in India. Program Areas: Strengths, Weaknesses and Opportunities: Program Area: Prevention: PMTCT/Sexual Prevention/ Biomedical Prevention/ Testing and Counseling The NACO has a well-articulated, decentralized strategy. Dedicated HIV/AIDS efforts have led to a platform of data to support evidence based programming. Continued emphasis on prevention with set targets for saturating coverage of MARPs has maintained the momentum of HIV/AIDS efforts throughout the country. India has high quality behavioral and sentinel surveillance data on MARPs. In addition, migration patterns and MARPs hot spots have been mapped throughout the country to promote prevention and effective treatment programs. In FY 2010 the USG will continue to be a primary source of TA and capacity building at all levels of the Indian government. At NACO’s request the USG has established a critical mechanism for on-going technical support that is the Technical Support Units (TSU) to strengthen the capacity of SACS, with a priority on strengthening Targeted Interventions (TIs) for MARPs. NACO’s annual evaluation of the TSUs revealed that the seven USG-supported TSUs were among the better-performing TSUs in terms of scaling-up and monitoring activities. These temporary TSUs are an excellent conduit to provide state level technical assistance and capacity building.