Delhi Scenario of HIV/AIDS

Dr. A. K. Gupta MD (Pediatrics)Additional Project Director

Delhi State AIDS Control Society

• Total population - 18 million, First case- 1988• Estimated PLHAs (2011)- 36,000 • Low prevalence state (Prevalence in Gen. population- 0.2%)• Highly vulnerable state- (Migrant labour- 0.88 million, Truckers stationed/day-35000)• Total high risk population ->1.00 Lakh • HIV +VE Regd. In HIV Care At ART Centers : 36452• Eligible patients actually started on ART- 17997• No. Currently Alive & on ART- 10822• LFU (7%), Died (8%) or Transferred out to other states(21%)

DELHI SCENARIO (March 2012)

CATEGORIZATION OF DISTRICTS IN DELHI

OTHERS

PERINATAL

I.D.Us

BLOOD TRANSFUSION

SEXUAL

HIV Trend Among Ante Natal Cases, Delhi

2004 2005 2006 2007 20080

0.05

0.1

0.15

0.2

0.25

0.3

0.350.31000000

00000010.31000000

0000001

0.1

0.2 0.2

ANC

ANC

2005 2006 2007 20080

5

10

15

20

25

7.6

4.08

4.38

2.92

22.8

9.8

10.2

18.620.4

12

11.73

7.92

5.6

2.72

2.64 2.17

HIV Trends among STD clinic attendees, IDUs, MSM and CSWs, Delhi

STD IDUs MSM FSW

Per

cen

t p

osi

tiv

e

Declining HIV Positivity rate in ICTC of Delhi 2007-2011

2007-09 2008-09 2009-10 2010-11 2011-12 (upo to Dec 2011)

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

4.7

3.7

3.12.95 2.93

% Positive

% Positive

Goal: To halt and reverse the epidemic in India over the next five years

Objectives:– Prevent new infections by saturating coverage of HRG

through TI and scaled up interventions in the general population.

– Provide greater care, support and treatment to larger numbers of PLHIV

– Strengthen the infrastructure, systems and human resources in prevention, care, support and treatment programme at district, state and national levels

– Strengthen the nationwide SIMS

NACP-III (2007-12) : Goal & Objectives

•Targeted interventions

•STI care

• Condom promotion

•Enabling environment

•Blood safety

•Integrated Counselling and testing including PPTCT

•STI Care

•IEC and social mobilisation

•Mainstreaming

•ART

•HIV-TB Co-ordination

•Treatment of Opportunistic Infections

•Community Care Centres

•Post-Exposure Prophylaxis

•HIV Sentinel Surveillance

•Behavioural Surveillance

•Monitoring and evaluation

•Operational research

• DAPCU

• Technical Resource Groups

•Enhanced HR at NACO, SACS and districts

•Enhanced training activities

Prevention

High risk populations

Low risk populations

Care & support

Monitoring and

Evaluation

Institutional Strengthening

Care, Support &

Treatment

Strategic Information

Management

Capacity Building

Status Of Targeted Intervention (TI) Projects 2011-12Sub Type (Registered)

No. of TIs

Target No. screened for Syphilis

No. found RPR reactive

No. tested at ICTC

No. detected HIV +ve (%)

No. linked to HIV care (%)

FSW (30982)

40 44350 15682 93 22286 97(0.43) 59 (60.8)

MSM+TG (15624)

17+2 18650 7436 40 8477 116(1.4) 82 (70.7)

IDUs (10124)

19 9600 3498 58 4245 125(2.9) 62(49.6)

Truckers (11602)

4 50000 0 0 930 15(1.6) 11(73.3)

Migrants (43200)

8

80000 0 0 1019 33(3.2) 19(57.6)

Total (111532)

90 202600 26616 191 (0.7%)

36957 386(1.0%)

233 (60.3%)

Integrated Counseling & Testing (I.C.T.C) (93 centres)S. No NEW PHYSICAL TARGETS TARGET(April-

DC 11)Achievement (April- DEC 11)

1 TESTING OF GENERAL PATIENT (ICTC) – annual target 3,00,000

250000 228550(91.5%)

2 No. OF GEN CLIENTS DETECTED HIV +VE 7344(3.21%)

3 TESTING OF ANC (PPTCT)- annual target 2,50.000

225000 204241 (91%)

4 No. OF ANC CLIENTS DETECTED HIV +VE- annual estimate 500 cases

356

5 No. ANC delivered and Mother Baby pair given NVP prophylaxis

356 224 (62.9 %)

6 HIV-TB CROSS REFERRALS- annual target 37000

40000 39038

7 No. OF PEOPLE WITH HIV-TB CO-INFECTION- annual estimate 1000 cases

1000 614

Testing algorithm

Rationale For PPTCT Services in Delhi

• Annual pregnancies - 2.5 lakh

• HIV infected pregnancies - 500

35% Transmission rate *

• Infected newborns - 175

*Risk of transmission without PMTCT intervention (WHO 2010)

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

Procedure for heel prick1. Warm the area2. Wash hands, put on gloves3. Position baby with foot down4. Clean area, dry 30 sec5. Press lancet into foot, prick skin6. Wipe away first drop7. Allow large drop to collect8. Touch blood drop to card9. Fill entire circle with drop10. Fill at least 3 circles11. Clean foot, no bandage

<5kg infants

5-10kg infants

Overhead 4-5

Valid DBS specimen

Overhead 4-34

Status of PMTCT ARV Prophylaxis in 234 MB pair (Feb 11-Jan12)Category (Number) HIV Positive

infant MTCT rate (%)Category I- MB pair received ARV Prophylaxis (n=161)

9 5.6

Category IA Maternal HAART (CD4≤350) in pregnancy & Baby received SdNVP (n=42)

0 0

Category IB- MB pair short course AZT+3TC to mother & AZT to baby (n=19)

0 0

Category IC- MB pair Sd NVP (n=100) 9 9

Category II- Only Mother received ARV prophylaxis (n-9)

1 11.1

Category III- Only baby received ARV prophylaxis (n=26)

3 11.5

Category IV- No. ARV prophylaxis (n=38) 11 28.9

Age of Initiation of ART (in months) through EIDAge of First DBS test

Total Time spent on PCR testing and

receipt of reports

Gap in receiving PCR result and initiation

of ART

Age of Initiation of started

Delay in starting ART*

Outcome after Initiation of ART

1.5 3.1 4.4 9 5.5 stable for last 2 months

1.5 1.9 0.6 4 0.5 stable for last 4 months

1.5 1.6 7.9 11 7.5 OI before starting ART

2 2.5 0.5 5 1 Stable for 4 months on ART, Lost to Follow-up after death of father.

3 1.7 0.3 5 0 Died within 1 month of initiating ART

4 1.3 10.7 16 8.5 OI before starting ART

6 2.5 0.5 9 1 stable for last 1 month

8 2.7 1.3 12 2 stable for last 1 month 9 2.5 0.5 12 1 OI before starting ART, stable for last

5 months. 18 month RHT positive

12 2.9 1.1 16 2 Stable for 6 months. 18 month RHT positive

12 2.8 1.2 16 2 stable for last 4 months

12 2.9 1.1 16 2 stable for last 4.5 months

15 2.4 0.1 17.5 0.5 OI before starting ART, stable for last 6 months. 18 month RHT positive

15 2.4 0.1 17.5 0.5 OI before starting ART, stable for last 5 months. 18 month RHT positive

15 1.7 0.8 17.5 0.5 OI before starting ART, stable for last 2 months. 18 month RHT positive

TB-HIV Collaborative Activities

TB and HIV in India

• Highest TB burden in the world– 1.8 million TB cases per year

• 3rd highest HIV burden– 2.3 million PLHA (2007)– Prevalence 0.34% (adult population)

• Estimated HIV-TB co-infected: 55,000-65,000

Risk of TB in HIV Patients

HIV patients are at an increased risk of:• Acquiring latent TB• Developing active TB once infected with M.

tuberculosis• Becoming re-infected with a second strain of TB• Relapsing after stopping treatment

10%

60%

0%10%20%30%40%50%60%70%

PPD+/HIV-negative PPD+/HIV+

Source: NACO

Lifetime Risk of TB

Revised guidelines for starting ART for HIV TB co-infected patients

• All HIV infected TB patients need to be started on ART – with CD4 count <350 (in case of pulmonary TB)

and – irrespective of CD4 count in case of

extrapulmonary TB – within 2 weeks of starting ATT

• NACO, November 2008

Anti Retroviral Treatment

Goals of ART 1. Clinical goal

To prolong life & improve quality of life

2. Virological goal

Greatest possible reduction in viral load for as long as possible to halt disease progression and to prevent or delay resistance

3. Immunological goal

Immune reconstitution - CD4 within normal range

WHEN TO START? - Initiation of ART in Adults and Adolescents

National GuidelineRevised National Guideline (April 2009)

WHOClinical Staging

CD4 (cells/cu.mm)

I and II Treat if CD4 Count < 350

IIITreat irrespective of CD4 Count

IV

National ART regimen

• First-line ART:• First-line ART is the initial regimen prescribed for an ART naïve patient when the

patient fulfils national clinical and laboratory criteria to start ART. (Current NACO treatment guidelines for first-line ART recommends two classes of

drugs for initial treatment ie 2 NRTI + 1 NNRTI.)Zidovudine / Lamivudine / Nevirapine

Or Stavudine / Lamivudine / Nevirapine

( Efavirenz in place of Nevarapine if coinfected with TB or side effects with NVP,

Tenofovir for special situations only)

Initiating ART: Patient Education

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

Start ART when patient is ready

SUCCESSFUL HIV THERAPY REQUIRES RIGOROUS ADHERENCE

• >95% adherence necessary to achieve viral load <400 copies/mL in 81% of HIV patients

• A 10% reduction in adherence was associated with a doubling of HIV RNA level

• 80% adherence may be sufficient to achieve therapeutic goals in other chronic disease states (e.g., hypertension)

Mar-05 Mar-06 Mar-07 Mar-08 Mar-09 march.-10 march.-11 Mar-05 Mar-06 Mar-07 Mar-08 Mar-09 march.-10 march.-11

Ever Reg-is-tered

NaN NaN 194607 428056 686913 933540 1253498

No. of pa-tient on 1st line

6845 37368 69016 140654 223223 315640 404882

No. of ART cen-tre

25 54 107 147 211 269 300

100000

300000

500000

700000

900000

1100000

1300000

25

75

125

175

225

275

325

Ever Registered No. of patient on 1st line No. of ART centre

Mar-05 Mar-06 Mar-07 Mar-08 Mar-09 Mar-10 Mar-11 Mar-05 Mar-06 Mar-07 Mar-08 Mar-09 Mar-10 Mar-11

Ever Reg-is-tered

NaN NaN 22462 32900 48721 64661 84987

No. of pa-tient

269 2335 6365 9495 14303 19203 23854

No. of ART cen-tre

25 54 107 147 211 269 300

5000

15000

25000

35000

45000

55000

65000

75000

85000

25

75

125

175

225

275

325

ART SCALE UP IN INDIA (CLHA)

Ever Registered No. of patient No. of ART centre

Cumulative Treatment Outcome

Cumulative Outcome of PLHAs on ART, India

ALL 9 ART CENTRES of Delhi SINCE BEGINNING (2004) TO DECEMBER 2011

S. NO INDICATOR CUMULATIVE

1 REGISTRATION 36452

2 EVER STARTED ON ART 17997

3 ALIVE ON ART 10822

4 DEATH 2000

5 TRANSFERRED OUT 2240

6 STOPPED TREATMENT 135

7 LOST TO FOLLOW UP 2340

8 MISS 453

Special Achievements of DSACS under NACP III

•Financial Assistance to Poor PLHAs and Orphan children by Delhi Govt •Free Investigations including CT Scan, MRI, blood and other tests of PLHAs in HIV care at ART centers of Delhi•Free Blood / Blood products for PLHAs without processing fees and without replacement donations•Launch of First Post Exposure Prophylaxis toll free interactive voice response helpline in the country (dial 1097 and select option 6) for prevention of HIV, HBV & HCV in Health care Workers during occupational exposure. •Setting up of First Youth Friendly health Centre in Delhi in collaboration with DSHM/NRHM at Jamia Milia Islamia in August 2010.•Mapping of massage parlors for the first time in the country- in New Delhi, Central, North, North- West and South Delhi districts with aim to assess the Knowledge, Behavior, Attitude and practices of the workers, clients and owners of 1050 massage parlours and categorize them by assessment of vulnerability. 18% massage parlours observed to be having risky behavior activities. •Training of NRHM Grass-root level functionaries –ASHAs, ANMs etc