Presented by:Nayan Gupta

Neha Singh

Nikhil Mishra

Nishtha Jain

Nitisha Bilaye

Guided by:Dr. S.B. Bansal

Dr. Satish Saroshe

1. Introduction

2. PPTCT

3. ICTC

4. ART

5. PEP

6. NACP-IV introduction

7. Care, Support and treatment

8. HIV-TB coinfection

9. Sentinel suviellence

India has the third largest HIV epidemic in the world.

In India (2016)

Approx. 2.5 million people living with HIV.

0.3% adult HIV prevalence.

86,000 new HIV infections.

HIV prevention in India- NACO is the body responsible for

prevention and control of the HIV epidemic in INDIA.

Current programme, NACP-IV (2012-2017) , aims to reduce the

HIV infections by 50%.

The rate of HIV transmission during pregnancy, labor or

delivery from mothers infected with HIV is

25% - 30% with no interventions

But can be reduced

up to <2% with

appropriate intervention.

ANCGroup

education

Offer HIV

test

Pre test

counseling

HIV testPost test

counseling

HIV

positive

HIV

negative

Primary

prevention

Participant

All pregnant women detected positive for HIV should be started

on life long ART irrespective of disease stage and CD4 count.

Preferred regimen-

Tenofovir 300mg + Lamivudine 300mg+ Efavirenz 600mg

Alternate regimen

Azathioprine + Lamivudine + Efavirenz,

Azathioprine + Lamivudine + Nevirapine,

Tenofovir + Lamivudine + Nevirapine

According to NACO guideline- Dec 2013

Previous it was single dose Nevirapine.

Daily Nevirapineprophylaxis for 6 weeks

If mother received ART

adequately in the antenatal period

Daily Nevirapineprophylaxis for 12 weeks

If mother has not received ART

Received ART for less than 24

weeks

OR

According to NACO guideline- Dec 2013

1) Exclusive breastfeeding is the recommended infant feeding

choice in the first 6 months.

2) In situations where breastfeeding cannot be done (maternal

death, severe maternal illness) or individual mother’s choice (at

her own risk), then exclusive replacement feeding may be

considered only if AFASS Criteria for exclusive replacement

feeding is fulfilled.

3) After 6 months complementary feeding should be introduced

gradually.

4) MIXED FEEDING should NOT be done during the first 6

months. (Feeding a baby with both breast feeds and

replacement feeds in the first 6 months is known as mixed

feeding which leads to mucosal abrasions in the gut of the baby

facilitating HIV virus entry through these abrasions).

• Breastfeeding continued until 12 month of age.

If EID Is negative

• Breastfeeding continue until the baby is 2 year old.

If EID Is positive

Breast-feeding should NOT be stopped ABRUPTLY

A• AFFORDABLE

F• FEASIBLE

A• ACCEPTABLE

S• SUSTAINABLE

S• SAFE

Integrated Counsellingand Testing Centres

An ICTC is a place where a person is counseled and tested for

HIV, on his/her own will (self- initiated) or as advised by a

medical provider (provider- initiated).

Functions of ICTC

Early detection of HIV

provide basic information on modes of transmission and

prevention of HIV for promoting behavioural changes and

reducing vulnerability.

Linking PLHIV with other HIV prevention, care and

treatment services.

ICTC

Fixed ICTC

Standalone ICTC

Facility ICTC

Mobile ICTC

In hard to reach areas and remote

areas.

In medical college, district hospital, sub district hospitals

and CHCs.

Below block level in PHCs and 24×7 PHC

Public private partner (PPP) ICTC- These are established in private facilities (NGOs, community based organizations, federation of Self-Help Groups (SHGs), hospitals, nursing homes, clinics and laboratories)

Infrastructure

A counselling room

Laboratory

Sample collection room

Manpower in an ICTC

ICTC manager

Counsellor

Laboratory technician

Outreach workers

Counselling in ICTC done by GATHER approach

G

A

T

H

E

R

Greet the client

Ask the problem

•Active listener

•Access degree of risk behavior

•Show respect and tolerance

•Enable patient to express freely

•Determine assess to support and help in family and

community

Tell the client about the specific information which

he/she desires

Help them to making decision

Explain the myths or misconceptions

Return for follow up or Referral

CLINICAL GOALS : Prolongation of life and improvement in quality of

life

VIROLOGICAL GOALS : Greatest possible reduction in viral load for as

long as possible

IMMUNOLOGICAL GOALS : Immune reconstitution both quantitative

and qualitative

THERAPEUTIC GOALS : Rational sequencing of drugs that achieves

clinical , virological and immunological goals while maintaining treatment

options limiting drug toxicity and facilitating drug adherence

REDUCTION OF HIV TRANSMISSION : By suppression of viral load

ART should be initiated in all adults, adolescent , pregnant and breast

feeding living with HIV regardless of WHO clinical stage and at any

CD4 cell count

As a priority, ART should be initiated in all with severe or advanced

HIV clinical disease{WHO clinical stage 3 and 4}and with CD4 count

<350cells/mm3

In infant and children younger than 10 years of age:

Infants diagnosed in the first year of life

Children living with HIV 1 year old to less than 10 year

Children <2 years and younger than 5 years of age with WHO clinical

stage 3 & 4 & or CD4 count <750 cells/mm3 and 5 years of age and

older with CD4 count <350 cells/mm3

FIRST LINE ART PREFFERED FIRST LINE

REGIMENS

ALTERNATIVE FIRST LINE

REGIMENS

ADULTS TDF+3TC[or FTC]+EFV AZT+3TC+EFV[OR NVP]

TDF+3TC[or FTC]+DTG

TDF+3TC[or FTC]+EFV

TDF+3TC[or FTC]+NVP

PREGNANT OR BREASTFEEDING

MOTHER

TDF+3TC[or FTC]+EFV AZT+3TC+EFV[or NVP]

TDF+3TC[or FTC]+NVP

ADOLESCENTS TDF+3TC[or FTC]+EFV AZT+3TC+EFV[or NVP]

TDF[or ABC]+3TC[or FTC]+DTG

TDF[or ABC]+3TC[or FTC]+EFV

TDF[or ABC]+3TC[or FTC]+NVP

CHILDREN 3 YEARS TO LESS

THAN 10 YEARS

ABC+3TC+EFV ABC+3TC+NVP

AZT+3TC+EFV[or NVP]

TDF+3TC[or FTC]+EFV[or NVP]

CHILDREN LESS THAN 3 YEARS ABC[or AZT]+3TC+LPV/r ABC[or AZT]+3TC+NVP

PHASE OF HIV

MANAGEMENT

RECOMMENDED

HIV DIAGNOSIS HIV TESTING

CD4 CELL COUNT

TB SYMPTOMS SCREENING

FOLLOW UP

BEFORE ART

CD4 CELL COUNT[EVERY 6-12 MONTHS IF ART IS DELAYED]

RECEIVING ART HIV VIRAL LOAD[AT 6 MONTHS AND 12 MONTHS THEN EVERY 12

MONTHS THEREAFTER]

SUSPECTED

TREATMENT

FAILURE

SERUM CREATININE

PREGNANCY TEST

FAILURE DEFINITION COMMENTS

CLINICAL NEW OR RECURRENT CLINICAL EVENT

[SEVERE IMMUNODEFICIENCY]AFTER 6

MONTHS

CONDITION MUST BE DIFFERENTIATED

FROM IRIS OCCURING AFTER INITIATING

ART

IMMUNOLOGICA

L

ADULTS & ADOLOSCENTS-

CD4 COUNT <250 CELLS/MM3

FOLLOWING CLINICAL FAILURE OR

PERSISTENT CD4 LEVELS BELOW 100

CELLS/MM3

CHILDREN-< 5 YEARS PERSISTENT CD4

LEVEL BELOW 200 CELLS/MM3

> 5 YEARS PERSISTENT CD4 LEVELS

BELOW 100CELLS/MM3

WITHOUT CONCOMITANT OR RECENT

INFECTION TO CAUSE A TRANSIENT

DECLINE IN THE CD4 CELL COUNT

VIROLOGICAL VIRAL LOAD ABOVE 1000 COPIES/ml

BASED ON TWO CONSECUTIVE VIRAL

LOAD MEASUREMENTS IN 3 MONTHS

WITH ADHERENCE SUPPORT FOLLOWING

THE FIRST VIRAL LOAD TEST

AN INDIVIDUAL MUST BE TAKING ART

FOR AT LEAST 6 MONTHS BEFORE IT CAN

BE DETERMINED THAT A REGIMEN HAS

FAILED

POPULATION FAILING FIRST –LINE

REGIMEN

PREFERRED SECOND

LINE REGIMEN

ADULTS AND

ADOLESCENTS

2 NRTIs+EFV[ or NVP]

2 NRTIs +DTG

2NRTIs +ATV/r or LPV/r

PREGNANT OR BREAST

FEEDING

2NRTIs+EFV[or NVP] 2NRTIs+ATV/r or LPV/r

CHILDREN

<3 years

>3 years to <10 years

2NRTIs+LPV/r

2NRTIs+NVP

2NRTIs+LPV/r

2NRTIs+EFV[or NVP]

2NRTIs+RAL

2NRTIs+LPV/r

2NRTIs+EFV

2NRTIs +LPV/r

If ABC+3TC or TDF(or FTC) was used in first-failing regimen , AZT +3TC should be used in second line

POPULATION THIRD LINE REGIMEN

ADULTS AND ADOLESCENTS(>10

years)

DRV/r + DTG(or RAL)+1-2 NRTIs

PREGNANT OR BREASTFEEDING

WOMAN

DRV/r + DTG(or RAL)+1-2 NRTIs

CHILDREN(0-10 years) RAL(or DTG)+2 NRTIs

DRV/r+2 NRTIs

DRV/r + RAL(or DTG)+1-2 NRTIs

RAL can be used in children failing PI based treatment when DTG is not available and when RAL has not been used in a previous regimen

DRV/r should not be used in children younger than 3 years of age.

H.I.V.BY NIKHIL

MISHRA

"Post exposure prophylaxis" (PEP) refers to the comprehensive management given to minimize the risk of infection following potential exposure to blood-borne pathogens (e.g.HIV,HBV,HCV).

It includes-1. First aid

2. Counseling

3. Risk assessment Relevant laboratory investigations based on

informed consent of the source and exposed person.

4. Depending on the risk assessment, the provision of short term (4

weeks) of antiretroviral drugs.

6. Follow up and support.

Exposure route risk

Blood transfusion 90-95%

perinatal 20-40%

Sexual exposure 0.1-10%

vaginal 0.05-0.1%

anal 0.065-0.5%

oral 0.005-0.1%

Needle stick exposure 0.3 %

• Immediately wash the wound with water and soap.Skin

• Irrigate exposed eye immediately with water or normal salineEye

• Spit fluid out immediately

• Rinse the mouth thoroughly, using water or saline and spit again

Mouth

Mild exposure

• Mucus membrane /non intact skin with small volume

• e.g. superficial wound with plain or low calibreneedle

Moderate exposure

• Mucus membrane /non intact skin with large volume.

• cut or needle stick injury penetrating gloves.

Severe exposure

• Percutaneous with large vol.

• An accident with caliber needle visibly contaminated with blood.

Step 2.1-assessing nature of exposure and risk of transmission

• PEP is not effective when given more than 72 hours after exposure. A baseline rapid HIV testing should be done before starting PEP.• Initiation of PEP where indicated should not be delayed while waiting for the results of HIV testing of the source of exposure.• Informed consent should be obtained before testing of the source as per national HIV testing guidelines.

PEP must be initiated as soon as possible, preferably within 2 hours

Source h.i.v status

Definition of risk

h.i.v. negative Source is not h.i.v. infected

Low risk h.i.v positive and clinically asymptomatic

Moderate risk h.i.v. positive and clinically symptomatic

unknown Status of patient is unknown (risk assessment will be based upon h.i.v. prevalence in that locality)

• The exposed individual should have confidential counseling and assessment

by an experience physician.

• The exposed individual should be assessed for pre-existing HIV infection

intended for people who are HIV negative at the time of their potential exposure

to HIV.

• Exposed individuals who are known or discovered to be HIV positive should

not receive PEP. They should be offered counseling and information on

prevention of transmission and referred to clinical and laboratory assessment

to determine eligibility for antiretroviral therapy (ART).

• Exposed persons should receive appropriate information about PEP and risk

and benefits of PEP in order to get informed consent.

• It should be clear that PEP is not mandatory.

• Psychological support: Many people will feel anxious after exposure. This

will help to relieve part of the anxiety, but some may require further

specialized psychological support.

.

• HIV testing of the source patient should not delay the decision about

whether or not to start PEP.

• In the case of a high risk exposure from a source patient who has

been exposed to or is taking antiretroviral medications, consult an

expert to choose the PEP regimen, as the risk of drug resistance is

high.

EXPOSURE HIV + AND ASYMPOMATIC

HIV + AND CLINICALLYSYMTOMATIC

HIV SATUS UNKNOWN

MILD Consider 2-drug PEP Start 2-drug PEP Usually no PEP or

Consider 2-drug PEP

MODERATEStart 2-drug PEP Start 3-drug PEP Usually no PEP or

Consider 2-drug PEP

SEVEREStart 3-drug PEP Start 3-drug PEP Usually no PEP or

Consider 2-drug PEP

Step 4.1-Deciding on PEP regimen

There are two types of regimens-

• Basic regimen: 2-drug combination (Zidovudine, Stavudine)• Expanded regimen: 3-drug combination (Zidovudine, Stavudine, Lamivudine)

• All clients starting on PEP must take 4 weeks (28 days) of medication.

Step 4.2 Selection of the PEP regimen when the source patient is

known to be on ART:

The physician should consider the comparative risk represented by the

exposure and information about the exposure source, including-

history of and response to antiretroviral therapy based on clinical response,

CD4cell counts,

viral load measurements(if available)

current disease stage (WHO clinical staging and history).

When the source person's virus is known or suspected to be resistant to one or

more of the drugs considered for the PEP regimen, the selection of drugs to

which the source person's virus is unlikely to be resistant is recommended.

• All clients starting on PEP must take 4 weeks (28 days) of medication.

• In all cases, the first dose of PEP should be offered as soon as possible, once the decision to give PEP is made.

• HIV testing or results of the source HIV test can come later.

Step 4.3 Amount of Medication to dispense for PEP

The reason for HIV testing soon after an occupational exposure is to establish a

"baseline“ against which to compare future test results.

• If the person is HIV-negative at the baseline test, it is in principle possible to prove

that subsequent infection identified by follow-up testing is related to the occupational

exposure (Depending on the timing of infection and consideration of other risks or

exposures) .

• When offered HIV testing, the exposed person should receive standard pre-test

counseling according to the national HIV testing and counseling guidelines, and

should give informed consent for testing.

• Confidentiality of the test result must be ensured..

Do not delay PEP if HIV testing is not available.

Step 5 – Laboratory Evaluation

• An exposed person should be advised to use precautions (e.g., avoid

blood or tissue donations, breastfeeding, unprotected sexual relations or

pregnancy) to prevent secondary transmission, especially during the first

6-12 weeks following exposure. Condom use is essential.

Whether or not PEP prophylaxis has been started, follow up is indicated

to monitor for possible infections and provide psychological support.

Step 6- FOLLOW UP

LABORATORY FOLLOW UP

• Follow-up HIV testing: exposed persons should have post-PEP

HIV tests at the completion of PEP

• Therefore, testing at 3 months and again at 6 months is

recommended.

Adherence and side effect counseling should be provided and

reinforced at every follow-up visit. Psychological support and

mental health counseling is often required.

1986=1st case of HIV detected

1992= NACP1= to slow down the spread

1999=NACP 2=focussing on behaviour change

2007=NACP3

2012=NACP 4

The epidemic continues to progress with the following

characteristics

High risk groups to low risk groups

Urban to rural areas

High prevalence states to all states

High vulnerability of young persons and women

MSM and IDUs not received appropriate attention

Growing number of people living with HIV/AIDS has

increased the need for care , support and treatment

Providing psychosocial support to the infected and affected individual esp. to marginalised woman and children affected by epidemic

Ensure accessible, affordable and sustainable treatment services.

Free antiretroviral therapy

Prevention and treatment of opportunistic infections including TB

Facilitating home based care and impact mitigation

Medicine Departments of Medical Colleges and District hospitals.

Based on prevalence of HIV in the region

Provide free comprehensive services including ART, CD4

testing & drugs required for treatment of Opportunistic Infections.

“306 centres providing freeART to more than 4,12,125 patients in

India”.

Main constraints-- Distance, travel time and costs to access ART services and adherence to treatment.

Leads to--Poor drug adherence, lost to follow up and missed cases.

Make -- Accessible and facilitate delivery of ARV drugs, Link ART Centres are established , located at district level hospitals nearer to the patient’s residence.

Located -- Integrated Counseling and Testing Centres (ICTC) which further helped in linkage between ICTC and ART

April 2011-- “612 Link ART Centres facilitate delivery of services nearer to the patients homes”

Patients needed to travel long distance to access the second line

treatment. This issue has resulted in low uptake of second line treatment.

In View of these, it was decided to expand the number of facilities that

can provide second line ART.Previously till 2009 it was given in 2 COE.

For this, some good functioning ART Centres were upgraded & labelled

as ‘ART Plus Centres’

OBJECTIVES:

To improve health seeking behaviour of high risk groups

Reduce their risk of acquiring STI and HIV infections.

HIGH RISK GROUP INCLUDES:

Female sex workers

Men who have sex with men

transgenders

Injecting drug users

Bridge population include high risk behaviour migrant and long

distance truckers.

SERVICES OFFERED UNDER THE TARGETED INTERVENTION PROGRAMME

Detection and treatment for sexually transmitted infections.

Condom promotion and distribution behaviour change communication Creating and enabling environment with

community involvement and participation Linkages to integrated counselling and

testing centres Linkages with care and support services for

HIV positive HRGs Community organization and ownership

building Specific interventions for IDUs1. Distribution of clean needles and syringes2. Abscess prevention and management

National blood transfusion(NBTA) to be set up as an autonomous body.

Establishment of Centre of Excellence in Transfusion Medicine in

four metro cities of Delhi, Kolkata, Mumbai and Chennai.

Approval for setting up of one Plasma Fractionation Centre has

been obtained, for processing of 1.5 lakh litres of plasma

annually. Land for this purpose has been provided at Chennai.

Achieve 90% of the annual requirement of blood by voluntary

donation.Presently -79.2%

80% of blood collected to be converted to components for appropiate

use.Presently - 155 BCSU with 52% conversion

Standardisation of testing protocol & reagents /kits in use.

Establish blood storage centres in community care centres.

Provide refrigerated vans in 500 districts for networking with blood storage

centres.

It is a mandate to strengthen all public health facilities at and above

district level as designated STI/RTI clinics, with the aim to have at least

one NACO supported clinic per district.

Presently - 1,033 designated STI/RTI clinics which are providing STI/RTI

services based on the enhanced syndromic case management. 90 new

clinics to be set up.

Strengthen 7 regional STI training, reference and research centres.

Role of these centres is to provide etiologic diagnosis to the STI/RTI

cases, validation of syndromic diagnosis, monitoring of drug résistance to

gonococci and implementation of quality control for Syphilis testing.

Safdarjung Hospital acts as the Apex Centre in the country.

STI CLINICS

Increase condom use during sex with non-regular partner, which is the key to limiting HIV spread through sexual route.

Increase the number of condoms distributed by social marketing programmes.

Increase the number of free condoms distributed through STI and STD clinics, reaching those who are at the highest risk of acquiring or transmitting HIV.

Increase access to condoms, especially to men who have sex with non-regular partners.

Increase the number of non-traditional outlets for socially marketed condoms, e.g., paan shops, lodges, etc. in strategically located hotspots

CONDOMS NACP IV

Condom promotion continues to be an important prevention strategy

P=PRACTICE SAFE SEX R=REMOVE MYTHS /MISCONCEPTIONS E=ENSURE EARLY DETECTION & t/t OF CASES V= VERTICAL TRANSMISSION TO BE PREVENTED

BY APPROPRIATE CONTRACEPTION E=ENSURE USE OF STERILISED NEEDLES N=NEGOTIATION SKILL TO BE DEVELOPED T=TRANSFER ONLY SCREENED BLOOD /BLOOD

PRODUCTS/ORGAN TRANSPLANTS I=I.E.C FACILTIY O=OPEN/ONGOING DISCUSSION WITH THE YOUTH N=NOTIFICATION /TRACING OF PARTNER

Programme Title Days

Rural Youth 5 Down MohabbatExpress Monday-Tuesday

Rural women Babli Boli Wednesday-Thursaday

Migrant Youth Kitney Dur Kitney Pass Saturday -Sunday

RADIO PROGRAMMES AIRED BY NACO

• Red, like love, as a symbol of passion and tolerance towards those affected.

• Red, like blood, representing the pain caused by the many people that died of

AIDS.

• Red, like the anger about the helplessness by which we are facing a disease for

which there is still no chance for a cure.

• Red as a sign of warning not to carelessly ignore one of the biggest problems

of our time.“ to carelessly ignore one of the biggest problems of our time."

TB and HIV co-infection is when people have both HIV infection, and also either latent or active TB disease. Each disease speeds up the progress of the other.

The estimated 10% activation of dormant TB infection over the lifespan of an infected person, increases to 10% in one year, if HIV infection is superimposed.

TB is one of the most commonly occurring opportunistic infections in HIV infected patients.

HIV and TB interact in several ways:

- Reactivation of latent infection.- Primary infection.- Recurring infection.- In the community.

“When a virus (HIV) and a bacteria (TB) can work so well together, why can't we?”

- UNAIDS

1. Huge dual burden of both HIV and TB. 2. High mortality of TB-HIV coinfection. 3. Large country with heterogeneous HIV

epidemic. Health system capacity varies tremendously.

4. Late diagnosis of HIV. 5. Leaky care cascade for HIV: difficult to track LFU.6. Airborne infection control difficult due to over-

congested health facilities.

Purpose: The overall purpose is to articulate the national policy for TB/HIV Collaborative Activities between RNTCP and NACP so as to ensure reduction of TB and HIV burden in India.

Objectives:

1. To maintain close coordination between RNTCP and NACP at National, State and District levels.

2. To decrease morbidity and mortality due to TB among persons living with HIV/AIDS

3. To decrease impact of HIV in TB patients and provide accessto HIV related care and support to HIV-infected TB patients.

4. To significantly reduce morbidity and mortality due to HIV/TB through prevention, early detection and prompt managementof HIV and TB together.

CD4 cell count ART recommendationTiming of ART inrelation to treatmentfor MDR-TB

≤ 350 cells/cu mm Recommend ART After 2 wk, as soon as the t/t for MDR-TB is tolerated.

> 350 cells/cu mm Defer ART Re-evaluate patient monthly for consideration of ART. CD4 testing is recommended every 3 months during t/t for MDR-TB.

Not available Recommend ART After 2 wk, as soon as the t/t for MDR-TB is tolerated.

Started from February 1, 2017. People who have been tested positive for HIV, and those affected

with tuberculosis, have to collect Fixed Dose Combination (FDC) from district hospital and ART centre to be taken on a daily basis.

Daily supply of FDC, instead of thrice a week, has been introduced under the 99 DOTS (Directly Observed Treatment, Short-Course) scheme.

The scheme is called 99 DOTS because it has 99% chances of cure of the patients taking the medical course.

Under this initiative, medicines for 28 days will be given to the patient and there will be a tab on the consumption of the medicines. Patient medication is packaged envelopes with dosage instructions, and a series of hidden numbers behind the pills. Each time a patient takes a dose of medication, he will have to call on the number and if a call is not received at the centre, he is called on the registered mobile number to remind him about the dosage.

To determine the level of HIV infection among general population as well as HRGs in different states.

To understand the trends of HIV epidemic among general population as well as HRGs in different states.

To understand the geographical spread of HIV infection and to identify emerging pockets.

To provide information for prioritisation of programme resources and evaluation of programme impact.

To estimate HIV prevalence and HIV burden in the country.