NATIONAL AIDS CONTROL PROGRAMME 3rd Sem

NATIONAL AIDS CONTROL
PROGRAMME
Introduction
 Human Immunodeficiency Virus (HIV) is a lanti virus that belongs to the retroviruses
group may cause HIV infection/AIDS. Acquired Immunodeficiency Syndrome (AIDS)
has emerged as one of the most serious public health problem in the country after
reporting of the first case in 1986. The initial cases of HIV/AIDS were reported among
commercial sex workers in Mumbai and Chennai and injecting drug users in the north-
eastern State of Manipur. The disease spread rapidly in the areas adjoining these
epicentres and by 1996 Maharashtra, Tamil Nadu and Manipur together accounted for
77 percent of the total AIDS cases. Out of these, Tamil Nadu reporting almost half the
number of cases in the country. However, the overall prevalence in the country is very
low, as compared to many other countries in the Asia-Pacific region.
For 2020, the theme is, “Ending the HIV/AIDS Epidemic: Resilience and Impact”,
which will focus on creating global solidarity among people who live with HIV and also
seek to destigmatize the health issue.
Burden of Disease
World
 According to UNAIDS/WHO estimates, 11 men, women and children were infected

per minute during 1998. More than 95% of all HIV-infected people now live in
developing world.
India
 The trends of HIV infection in India are alarming. Following characteristics of the
AIDS epidemic have been observed:
 In the recent years it has spread from urban to rural areas and from individuals
practicing risk behaviour to the general population.
 More and more women attending antenatal clinics are being found testing HIV-
positive thereby increasing the risk of perinatal transmission. One in every 4 cases of
HIV positive reported is a woman.
 About 84% of the infections occur through the sexual route (both heterosexual and
homosexual).
 Other roots of transmission are blood transmission, injectable drug use and perinatal
transmission.
 Another 4% through injecting drug use.
 About 80% of the reported cases are occurring in sexually active and economically
productive age group of 15-44 years.
 HIV positive in antenatal clinic varied from 0% in Assam to 1.71% in Maharashtra.
The average prevalence work out as a low 0.7% but with more than 500 million adult in
the country. NACO calculates that 4.8 million people are infected.
The milestones of the programme are summarized as follows :

1986 First case of HIV detected.
AIDS Task Force set up by the JCMR.
National AIDS Committee established under the Ministry of Health.
1990- Medium Term Plan launched for four states and the four metros.
1992 NACP-1 launched to slow down the spread of HIV infection.
- National AIDS Control Board constituted.
- NACO set-up
. 1999- NACP-11 begins, focussing on behaviour change,
increased decentralization and NGO involvement
. State AIDS Control Societies established.
2002 National AIDS Control Policy adopted.
- National Blood Policy adopted.
2004- Anti-retroviral treatment initiated.
2006 - National Council on AIDS constituted under chairmanship of the Prime Minister.
- National Policy on Paediatric ART formulated.
2007 NACP-III launched for 5 years (2007-2012).
2014- NACP-IV launched for 5 years (2012-2017).
2016- National strategic plan for HIV/AIDS and sexually transmitted infection
(2017-2024)
GLOBAL STASTISTICS
17 million people were accessing antiretroviral therapy
• 36.7 million [34.0 million–39.8 million] people globally were living with HIV
• 2.1 million [1.8 million–2.4 million] people became newly infected with HIV
• 1.1 million [940 000–1.3 million] people died from AIDS-related illnesses
• 78 million [69.5 million–87.6 million] people have become infected with HIV since the start
of the epidemic
• 35 million [29.6 million–40.8 million] people have died from AIDS-related illnesses since
the start of the epidemic
INDIAN STASTISTICS
12,70,678 People on ART
• 2116581 people were living with HIV
• 75948 people became newly infected with HIV
• 67612 deaths due to AIDS
• 35255 pregnant woman needs PPTCT
HIGH RISK GROUP

● Female Sex Worker(FSW)
● Men who have Sex with Men(MSM)
● Transgender
● Injecting drug users(IDU)
VULNERABLE POPULATION
● Women having casual partners
● Spouses of high risk groups
BRIDGE POPULATION
● Migrant
● Truckers
● Clients of sex worker
PREVELANCE IN INDIAN STATES

High prevalence
• >5% in HRG & >1% in ANC
• MR, TN, Andhra, Manipur, Karnataka, Nagaland
Moderate prevalence
• >5% in HRG & <1% in ANC
• Gujarat, Puducherry, Goa
Low prevalence
• <5% in HRG & <1% in ANC
• All other states/UTs
CLASSIFICATION OF DISTRICTS
Districts are classified into four categories A to D
• Category A: • More than 1% ANC prevalence in district in any of the sites in the last 3
years.
• Category B: • Less than 1% ANC prevalence in all the sites during last 3 years with more
than 5% prevalence in any HRG site (STD/FSW/MSM/IDU)
• Category C: • Less than 1% ANC prevalence in all sites during last 3 years with less than 5%
in all HRG sites, with known hot spots (Migrants, truckers, large aggregation of factory
workers, tourist etc.,)
• Category D: • Less than 1% ANC prevalence in all sites during last 3 years with less than
5% in all HRG sites with no known hot spots OR no or poor HIV data
CASE DEFINITION
ADULTS –
● Positive test for HIV antibody by 2 separate test using 2 different Antigens plus Any
one or more of the following
● Weight loss>10% of bw
● Chronic diarrhoea >1 month
● Chronic coughè >1 month
● Disseminated ,miliary or extrapulmonary TB
● Neurological impairment
● Esophageal candidiasis
● Kaposi sarcoma
CHILDREN
● Major –Weight loss,
● Failure to thrive,
● chronic diarrhea,
● prolonged fever,
● Candidiasis,
● Tuberculosis, Herpes zoster
● Minor—Generalised lymphadynopathy, Oropharyngeal candidiasis,
● Persistant cough for >I month , Generalised dermatitis, Confirmed maternal HIV
infection
1. WHO clinical staging of HIV disease in adults, adolescents and children
Adults and adolescents Children

Clinical stage 1
Asymptomatic Persistent generalized Asymptomatic Persistent generalized
lymphadenopathy lymphadenopathy
Clinical stage 2
Moderate unexplained weight loss Unexplained persistent
(<10% of hepatosplenomegaly
presumed or measured body weight) Recurrent or chronic upper respiratory
Recurrent respiratory tract infections tract infections
(sinusitis, (otitis media, otorrhoea, sinusitis,
tonsillitis, otitis media, pharyngitis) tonsillitis)
Herpes zoster Herpes zoster
Angular cheilitis Lineal gingival erythema
Recurrent oral ulceration Recurrent oral ulceration
Papular pruritic eruption Papular pruritic eruption
Fungal nail infections Fungal nail infections
Seborrhoeic dermatitis Extensive wart virus infection
Extensive molluscum contagiosum
Unexplained persistent parotid
enlargement
Clinical stage 3
Unexplained severe weight loss (>10% of Unexplained moderate malnutritionb
presumed or measured body weight) not adequately responding to standard
therapy
Unexplained chronic diarrhoea for longer
than 1 month Unexplained persistent diarrhoea (14
days or more)
Unexplained persistent fever (intermittent
or Unexplained persistent fever (above
constant for longer than 1 month) 37.5°C, intermittent
or constant, for longer than one 1 month)
Persistent oral candidiasis
Persistent oral candidiasis (after first 6
Oral hairy leukoplakia weeks of life)
Pulmonary tuberculosis Oral hairy leukoplakia
Severe bacterial infections (such as Lymph node tuberculosis

pneumonia, empyema, pyomyositis,
bone or Pulmonary tuberculosis
joint infection, meningitis, bacteraemia)
Severe recurrent bacterial pneumonia
Acute necrotizing ulcerative stomatitis,
gingivitis or periodontitis Acute necrotizing ulcerative gingivitis or
Periodontitis
Unexplained anaemia (<8 g/dl),
neutropaenia (<0.5 x 109/l) and/or Unexplained anaemia (<8 g/dl),
chronic neutropaenia
thrombocytopaenia (<50 x 109/l) (<0.5 x 109/l) or chronic
thrombocytopaenia
(<50 x 109/l)
Symptomatic lymphoid interstitial
pneumonitis Chronic HIV-associated lung
disease, including bronchiectasis
Clinical stage 4
HIV wasting syndrome Unexplained severe wasting, stunting or
Pneumocystis (jirovecii) pneumonia severe
Recurrent severe bacterial pneumonia malnutritiond
Chronic herpes simplex infection (orolabial, not responding to standard therapy
genital or anorectal of more than 1 month’s Pneumocystis (jirovecii) pneumonia
duration or visceral at any site) Recurrent severe bacterial infections
Oesophageal candidiasis (or candidiasis of (such as
trachea, bronchi or lungs) empyema, pyomyositis, bone or joint
Extrapulmonary tuberculosis infection,
Kaposi sarcoma meningitis, but excluding pneumonia)
Cytomegalovirus infection (retinitis or Chronic herpes simplex infection
infection of other organs) (orolabial or
cutaneous of more than 1 month’s
Central nervous system toxoplasmosis
duration or
HIV encephalopathy
visceral at any site)
Extrapulmonary cryptococcosis, including Oesophageal candidiasis (or candidiasis
meningitis of trachea,
Disseminated nontuberculous mycobacterial bronchi or lungs)
infection Extrapulmonary tuberculosis
Progressive multifocal leukoencephalopathy Kaposi sarcoma
Chronic cryptosporidiosis Cytomegalovirus infection (retinitis or
Chronic isosporiasis infection of
Disseminated mycosis (extrapulmonary other organs with onset at age more than
histoplasmosis, coccidioidomycosis) 1 month)
Lymphoma (cerebral or B-cell non-Hodgkin) Central nervous system toxoplasmosis
Symptomatic HIV-associated nephropathy or (after the
cardiomyopathy neonatal period)
Recurrent septicaemia (including HIV encephalopathy
nontyphoidal Salmonella) Extrapulmonary cryptococcosis, including
meningitis
Invasive cervical carcinoma
Disseminated nontuberculous
Atypical disseminated leishmaniasis
mycobacterial
infection
Progressive multifocal
leukoencephalopathy
Chronic cryptosporidiosis (with diarrhoea)
Chronic isosporiasis
Disseminated endemic mycosis
(extrapulmonary
histoplasmosis, coccidioidomycosis,
penicilliosis)
Cerebral or B-cell non-Hodgkin
lymphoma
HIV-associated nephropathy or
cardiomyopathy
NACP I (1992-99)
● Formal NACP was launched in 1992 as Phase I. National AIDS Control Board (NACB) was
formed and National AIDS Control Organization (NACO), an autonomous apex body for
HIV/AIDS prevention and control was created.
● NACP got strategized for preventive activities like HIV/AIDS education and awareness
program, blood safety measures, condom promotion, control of hospital infection and
strengthening of clinical services.
NACP-I was launched as 100% centrally sponsored project from September 1992 to
September 1997.
OBJECTIVE
 Slow and prevent the spread of HIV through a major effort to prevent HIV transmission.
KEY STRATEGIES
 Focus on raising awareness, Blood safety, Prevention among high-risk populations,
 Improving surveillance
ACHIEVEMENTS
  National AIDS response structures at both the national and state levels and
provided critical financing.
  Strong partnership with the World Health Organisation (WHO) and later helped
mobilize additional donor resources.
  Established the State AIDS Control Cells.
NACP 2 (1999-2007)
● In November 1999, NACP-II was launched with World Bank credit of US $191 million.
● While in Phase I central agencies were the main players, during Phase II states were
put in front seat.
● Prevention of new infection was the key strategy and Female Sex Workers (FSWs),
Men who have Sex with Men (MSM), Injecting Drug Users (IDUs) and client of sex
workers were the key target groups.
● During the second half of NACP-II, establishment/scaling up of counseling and testing
services for HRG people, provision of the Anti-Retroviral Treatment and Prevention
of Parent to Child Transmission (PPTCT) gained attention, Phase II witnessed more
decentralized, strategized and focused activities in prevention and service delivery in
contrast to largely central-driven generalized type of activities of Phase I.
OBJECTIVE
 Reduce the spread of HIV infection in India through behavior change and increase capacity
to respond to
HIV on a long-term basis.
KEY STRATEGIES
Targeted Interventions for high-risk groups
 Preventive interventions for general populations
 Involvement of NGOs
 Institutional strengthening
ACHIEVEMENT
 At the operational level 1,033 targeted interventions set up, 875 Voluntary counseling and
testing centers (VCTC) and 679 STI clinics at the district level.
 Nation-wide and state level Behaviour Sentinel Surveillance (BSS) surveys were conducted
 PPTCT Expanded.
 A computerized management information system (CMIS) created.
 HIV prevention and care and support organizations and networks were strengthened.
 Support from partner agencies increased substantially.
NACP 3 (2007-2010)
With a rich learning of about two decades, NACP III was launched in 2007 with the goal to
halt and reverse the epidemic in India in next 5 years.
The NACP-III program further moved down from state to district. Phase II was viewing state
as an implementing unit, while Phase III is viewing district as an implementing unit.
In the year 2006, based on the HIV surveillance data of previous three years, NACO classified
all districts into four categories viz. A, B, C and D.
OBJECTIVE
 Reduce the rate of incidence by 60 per cent in the first year of the programme .
STRATEGIES
 Prevention – Targeted intervention (TI), ICTC, blood safety
 Care, support and treatment –
 Capacity building – establishment, support and capacity strengthening, training, managing
programme implementation and contracts, mainstreaming/private sector partnerships.
 Strategic information management – monitoring and evaluation.
ACHIEVEMENTS
 There were 306 fully functional ART Centres .
 Nearly 12.5 lakh PLHIV were registered and 420000 patients were on ART.
 612 Link ART centre (LAC) had been established wherein, 26023 PLHIV were taking
Services
 There were 10 Centres of Excellence,
 7 Regional Pediatric centres also functional.
 259 Community Care Centres across the Country
 6000 condoms & 6000 village information centres established
 3000 Red ribbon clubs established
 Link Workers training module updated
NACP IV
Launched on 12 February 2014
• Total budget outlay Rs 14295 crores.
• Goal: Accelerate Reversal and Integrate Response
Objective 1:
• Reduce new infections by 50% (2007 Baseline of NACP III)
• Objective 2:
• Provide comprehensive care and support to all persons living with HIV/AIDS .
Key Strategies under NACP-IV

1) Intensify &consolidate preventive services
2) Increase access &promote comprehensive care, support & treatment :
a) First line & second line ART
b) Care &Support Centres
c) HIV-TB Coordination
d) Focus on PPTCT
e) Treatment of Opportunistic Infections
3) Expanding IEC services

4) Capacity building
5) Strengthening Strategic Information Management system:
a) Needle-Syringe Exchange Programme and Opioid Substitution Therapy for IDUs
b) Targeted Interventions for High Risk Groups (FSW, MSM, IDU, Truckers & Migrants)
Link Worker Scheme for rural population
c) Prevention & Control of Sexually Transmitted Infections
d) IEC, Social Mobilization & Mainstreaming
e) Condom promotion
f) Blood safety
g) Counselling & Testing Services (ICTC, PPTCT, HIV/TB)
NATIONAL STRATEGIC PLAN FOR HIV/AIDS AND SEXUALLY

TRANSMITTED INFECTION (STI) 2017-2024
Based on the recommendations of a mid-term appraisal of NACP-IV held in 2016, the

National Strategic Plan was proposed to steer the program forward.
Vision
Paving the way for an AIDS free India.

Mission
Attain universal coverage of HIV prevention, universal care, continuum of services that are
effective, inclusive, equitable and adapted to needs.
Goal
Managing Community Health in India
Achieving zero new infections, zero AIDS related deaths and zero discrimination.
Table: Objectives and outcomes of NACP under NSP 2017-24

Objectives Outcomes
Reduce new infections by 80% by 2024 ew infections reduced from
>1,00,000 to <21,000
Link 95% of estimated PLHIV to services 2.01 million PLHIV know their status
by 2024
Ensure ART initiation and retention of 90% 1.90 million PLHIV on ART are retained and
of PLHIV for sustained viral suppression by have sustained viral suppression
2024
Eliminate mother-to-child transmission of Attain dual elimination by 2020
HIV and syphilis by 2020
Eliminate HIV-related stigma and HIV/AIDS considered as a chronic
discrimination by 2020 Facilitate manageable disease
sustainable NACP
Facilitate sustainable NACP i. Integration of identified components of

service delivery by 2024 NACP with NHM
ii. Domestic funding for NACP is 100%
Priorities
• Accelerating HIV prevention in "at risk group" and key population.
• Expanding quality assured HIV testing with universal access to comprehensive HIV
care.
Elimination of mother to child transmission of HIV and syphilis.
• Addressing the critical enablers in HIV programming.

• Restructuring the strategic information system to be efficient and patient-centric.
Package of Services Under NACP IV¹9

These include:
prevention services;
care, support and treatment services;
IEC services;
capacity building; and
SIMS.
Prevention Services
Targeted interventions for high-risk groups and bridge population: Targeted
Interventions are preventive. interventions for HRGS in a defined geographic area. HRGS
include female sex workers/commercial sex workers (FSW/ CSW), men who have sex with
men (MSM), transgenders (TG) and injecting drug users (IDU). Bridge population includes
long distance truck drivers (LDT) and single male migrants (SMM).
Specific interventions available for IDUS are (i) distribution of clean needles and syringes,
(ii) abscess prevention and management, (iii) opioid substitution therapy (OST), and (iv)
linkage with detoxification/rehabilitation services. MSMs and TGS are provided with
lubricating materials and FSWS are distributed female condoms
Interventions for bridge population are important to prevent the infection from
entering the general population. For migrants, services like distribution of condoms
and IEC are provided at source (their villages), at transit point (rail or bus
stations) and at destination (places of work). For truckers, clinics for preventive,
diagnostic and treatment services are conducted at trans-shipment locations and are
co-branded as Khushi-Suraksha clinic.
Link worker scheme: In this scheme link workers, who are trained members of the
community, provide information and skills on HIV/AIDS prevention to vulnerable members of
the community like youth, PLHIV, women having casual sex partners and also to members
belonging to HRG and bridge population. Currently this scheme is active in high prevalence
districts of selected endemic states.
Management of STI/RTI: Strategies for STI/RTI control are (i) Strengthen STI/RTI control
and prevention, and (ii) Eliminate parent to child transmission of HIV and syphilis.
Strengthen STI/RTI control and prevention This is done by provision of standardized
services and giving Inje treatment for STI/RTI, Strategy followed is syndromic case
management (SCM) with appropriate surveillance
 laboratory test at all levels of care, for general as well as at risk populations,
 partner management,
 counseling services and
 free supply of condoms.
 STI/RTI clinics (DSRC) supported by Department of AIDS
 at least 1 center per district, for case management.
 Collaborationalence of s between organized public and private sector
 static and mobile clinics,
 health camps,
Prepacked color-coded STI/RTI kits are available for syndromic management of
STIS/RTIS
Kit no. Syndrome Color Contents

KIT 1 UD, ARD, Grey Tab, azithromycin 1
cervicitis/ g (1) and tab
CD, PSS, PT cefixime 400 mg (1)
KIT 2 Vaginitis/VD Green Tab. secnidazole 2 g

(1) and tab
fluconazole 150 mg
(1)
Kit 3 GUD/NH White Inj. benzathine

penicillin 2.A MU
(1) and tab,
azithromycin 1 g
(1) and disposable
syringe 10 mL with
21 gauge needle
(1) and sterile
water 10 mL
KIT 4 GUD-NH (for patient White Tab. doxycycline

allergic to penicillin) 100 mg (30) and
tab
azithromycin 1g
(1)
KIT 5 GUD-H Blue Tab. acyclovir 400

mg (21)
KIT 6 LAP/PID Yellow Tab. cefixime 400
mg (1)
Metronidazole 400
mg (28) and Cap
and
tab.doxycycline
100 mg (28)
KIT 7 IB Black Tab. doxycycline

100 mg (42) and
Tab azithromycin 1
g (1)
(ARD: anorectal discharge; CD: cervical discharge; GUD: genital ulcerative disease He
herpetic IB: inguinal bubo; LAP: lower abdominal pain; NH: nonherpetic PID: pelvic
inflammatory disease; PSS: painful scrotal swelling: PT: presumptive treatment UD: urethral
discharge: VD; vaginal discharge)
Eliminate parent-to-child transmission of HIV and syphilis (e-PTCT)
In accordance with UN's SDGs India has set the goal to eliminate parent-to-child
transmission of syphilis by 2017 with a target to reduce the incidence of congenital
syphilis to less than 0.3 cases per 1000 live births by 2017.
The objectives are to :
 ensure universal and early registration of pregnant women at first ANC visit in
first trimester
 ensure early screening of pregnant women for both syphilis and HIV at least
once during the pregnancy,
 identify and provi prompt treatment to all seroreactive pregnant women,
 promote institutional delivery, and
 follow up the newborn up to 18 months of age.
Eliminate parent-to-child transmission of HIV and syphilis (e-PTCT)
In accordance with UN's SDGs India has set the goal to eliminate parent-to-child
transmission of syphilis by 2017 with a target to reduce the incidence of congenital
syphilis to less than 0.3 cases per 1000 live births by 2017.
The objectives are to
(i) ensure universal and early registration of pregnant women at first ANC visit in
first trimester
(ii) ensure early screening of pregnant women for both syphilis and HIV at least once
during the pregnancy,
(iii) identify and provi prompt treatment to all seroreactive pregnant women,
(iv) promote institutional delivery, and
(v) follow up the newborn up to 18 months of age.
Guidelines for diagnosis have been given along with

criteria for suspect and confirmed cases.
Managements by giving Injection benzathine penicillin to the mother or
alternatively oral erythromycin or azithromycin.
Prophylactic or curative treatment is given to the baby as required.
STI surveillance
In India includes passive syndromic case reporting from designated STI/RTI clinics and TI
sites.
Management of sexual violence:

revention of unwanted pregnancy: Emergency contraception with levonorgestrel or
combined oral contraceptive pill Mala D.
Postexposure prophylaxis against STI

Postexposure prophylaxis against HIV
Follow-up services
Psychological support
Condom Promotion:
Blood safety
HIV counseling and testing services (HCTS):

The HIV counseling and testing services include the following components:
1. Integrated counseling and testing centers (ICTC)
2. Prevention of parent-to-child transmission of HIV (PPTCT)
3. HIV/Tuberculosis collaborative activities
Integrated counseling and testing centers:

ICTCs have been classified into two types:
 Facility-based HIV testing and
 community-based HIV testing centers.
Prevention of parent-to-child transmission of HIV:

" The primary route of transmission of HIV in children is mother to-child transmission
which occurs during pregnancy, childbirth and breastfeeding with equal frequency.
PPTCT is a four-pronged program:
Prong 1: Primary Prong 2: Preventing

prevention of HIV, unintended pregnancies
especially among among women living with
women of child bearing HIV
age.
Prevention of parent-
to-child transmission
of HIV:
Prong 3: Prevent
HIV transmission from Prong 4: Provide care,
pregnant women support and treatment to
infected with HIV to their women living with HIV,
child. her children and family.
HIV/TB Collaborative activities:

Prevention Early detection of TB/HIV
1.Isoniazid prevention 1)100% coverage of provider initiated testing and
treatment counselling in TB patient
2.Air borne infection control PITC in presumptive TB cases
3.Awareness generation Rapid diagnosis of TB and DR-TB in PLHIV
4. Intensified case finding case finding activities at
all HIV setting – ICTC, ART, LAC and TI setting
Prompt treatment of TB/ HIV Management of special TB/HIV cases
1.early initiation of ART 1.TB/HIV Patient on protease inbitiorbased ARV.
regardless of CD4 count 2.TB/HIV in children.
2. prompt initiation of TB 3.TB/HIV in Pregnant women.
treatment 4.Drug- resistant TB/HIV.
Postexposure prophylaxis
Step 1: Management of exposure site-first aid
und wash with water and soap/Irrigation of eye with water/Rinsing of mouth with water.
Step 2: Establish eligibility for PEP
Depending upon the nature of exposure and status of source patient.
Step 3: Counseling for PEP
Explain risks and benefits of PEP and seek informed consent.
Step 4: Prescribe PEP
Iformation, Education and Communication (IEC)

Services IEC is an important part of HIV/AIDS control. The services include promotion of
safe behavioral practices, reduction of stigma and discrimination, promotion of services for
counseling and testing, anti-retroviral therapy, increasing condom use.
Care, Support, and Treatment Services

Antiretroviral therapy
Service delivery mechanism

Care, support and treatment services are provided through ART and ART Plus centers
overlooked by Centers of Excellence (COE). Pediatric ART centers and CoE are also in
place for providing pediatric ART
Capacity building
It involves training of manpower and technical staff. Involving the private sector in care,
support and treatment of PLHIV has effectively aided HIV/AIDS control efforts.
Surveillance of HIV/AIDS
Under the program, components of surveillance are
1).AIDA case surveillance,
2) HIV sentinel surveillance,
3) STD surveillance, and
4) Behavioral surveillance.
5)AIDS case surveillance: It is done by all medical institutions identifying the
suspected cases and referring them to the referral hospitals for confirmation.
ICTC Integrated counselling and testing center

VCTC
• Voluntary Counseling and Testing Centres
• People motivated were referred to these centres
VCCTC
• Voluntary Confidential Counseling and Testing Centres
• Emphasis on maintaining confidentiality
ICTC
• Integrated Counseling and Testing Centres
• Integration of VCCTC + PPTCT
ICTC
Stand- Alone ICTC- Supported financially and logistically by NACP
Facility ICTC(F-ICTC)- Staff from existing facilities trained in counseling and testing
PPP-ICTC- Established in private facilities based on F-ICTC model
Mobile ICTC- Takes the package of services to community
ICTC AND ITS LINKAGE
WHO GUIDELINES FORTREATMENT:

Goals of ART Therapy:
• Reduce HIV-associated morbidity
• prolong the duration and quality survival.
• Restore and preserve immunologic function
• Maximally suppress viral load
• Prevent HIV transmission
Highly Active Anti Retroviral Therapy (HAART)

GUIDELINES TO START ART:
• Start ART in all adults, adolescent with a CD4 < 500
Priority to stage 3, 4 HIV disease and CD4 < 350 .
• ART at any CD4 count in PLHIV

 Active TB disease
 HBV co-infection
 HIV-positive partners in sero-discordant couples
 Pregnant and breastfeeding women and
 Children younger than five years of age
When to start ART in people living with HIV:
1) Adults and adolescents (≥10 years):
Initiate ART if CD4 cell count ≤500 cells/mm3

• As a priority,
 Severe/advanced HIV (WHO clinical stage 3 or 4) or
 CD4 count ≤350 cells/mm3
Regardless of WHO clinical stage and CD4

• Active TB disease
• HBV coinfection with severe chronic liver disease
• Pregnant and breastfeeding women with HIV
• HIV-positive individual in a serodiscordant partnership (to reduce HIV transmission risk)
2) Infants <1 year old

In all , Regardless of WHO clinical stage and CD4 cell count.
3) Children < 5 yrs old

ART in all regardless of WHO clinical stage and CD4
4) Children 5 to 10 yrs
CD4 ≤500 cells/mm3
• As a priority,
 All WHO clinical stage 3 or 4 or
 CD4 count ≤350
Targeted intervention:
Key risk groups covered under the Targeted Intervention programme:
• Female Sex Workers
• Men who have Sex with Men
• Transgenders
• Injecting Drug Users
• Bridge Populations
• Long Distance Truckers
• High Risk MigrantsMonitoring ART response and diagnosis of treatment failure
Services offered under the Targeted Intervention Programme:

• Detection and treatment for Sexually Transmitted Infections (STIs)
• Condom promotion and distribution
• Behaviour change communication
• Creating an enabling environment with community involvement and participation
• Linkage to Integrated Counseling and Testing Centres
• Linkage with care and support services for HIV positive HRG.
• Specific Interventions for IDUs
• Specific Interventions for MSM / TGs
• Specific Interventions for FSWs
LINE WORKER SCHEME
Community based outreach services by link worker. for HRG, and vulnerable groups.
• Objective of scheme include- information on prevention of HIV, Counselling, referral to
ICTC, STI clinic, promotion and distribution of condoms.
MANAGEMENT OF RTI/STI
Provision of RTI/STI in high risk group population includes:
• Free consultation and treatment for their symptomatic STI /RTI.
• SURAKSHA CLINICS
• Syndromic management
• Prepacked colour coded kits
• 7 kits- Grey, green, white , blue, red,yellow, black.
BLOOD TRANSFUSION SERVICE

• Increasing regular voluntary blood donation.
• Professional blood donation prohibited.
• Only licenced blood banks are permited.
• Promoting component preparation.
• BLOOD SAFETY programme renamed as blood transfusion service.
As per national blood policy, testing of every unit of blood is mandatory for HIV, HBV, HCV,
malaria, syphilis.
• ACESS TO SAFE BLOOD is primary responsibility of NACO.
It is supported by network of 1137 blood bank, 258 BCSU, 258 model blood banks.
IEC AND MAINSTREAMING

● Mass media campaign
• Radio or TV program
• Red ribbon express project
• Advertisement through newspaper
• Hoarding
• Folk media
• Inter Ministerial conference
• Training of frontline worker
• Greater involvement of PLHIV
• Social protection
Behavior Change Communication

• Communication : key to generating awareness on prevention as well as motivating
access to treatment, care and support.
• Information, Education & Communication (IEC) and Behaviour Change

Communication
• Mass Media Campaigns through Radio & TV
• Mid-media campaigns through Folk Media, display panels, banners, wall writings
etc.,
• Special campaigns through music and sports, flagship programmes, such as Red
Ribbon Express
Condom Promotion
• Ensuring availability and creating demand for condoms.
• Free Condom, Socially Marketed Condom (Paid-subsidized)
Innovative Approaches
A-Condom Vending Machines (CVM)
B-Female Condoms (FC)
C-Special Condom for MSM
POST EXPOSURE PROPHYLAXSIS

Comprehensive management given to minimize the risk of infection following potential
exposure to blood-borne pathogens e.g. HIV.
This includes:
1. First aid
2. Counseling
3. Risk assessment
4. Relevant laboratory investigations based on informed consent of the exposed person.
5. Depending on the risk assessment, the provision of short term (4 weeks) of ART.
6. Follow up and support
Post-exposure prophylaxis (PEP) has its greatest effect if begun within 2 hours of exposure.
There is little benefit if started >72 hours.
• The prophylaxis needs to be continued for 4 weeks (28 days).
Preferred PEP regimen :
• Initially:
2 drug regimen (Zidovudine + Lamivudine)
then 3 drug regimen : after expert opinion ( AZT + 3TC + NVP)
• Clinical follow-up: the exposed person must be monitored for the eventual appearance of
signs indicating an HIV. These symptoms almost always appears within 3 to 6 weeks after
exposure.
• Laboratory follow-up : after exposure testing at 3 months and 6 months is recommended.
Post-exposure prophylaxis for women within 72 hours of a sexual assault

•Recommended duration of PoEP is 28 days,
•First dose as soon as possible within 72 hours
•The choice based on first-line ART regimen.
HIV-TB Co-infection
• A setting with a high burden of TB and HIV refers to settings with adult HIV prevalence
≥1% or HIV prevalence among people with TB ≥5%
• Among PLHA, TB is the most frequent life-threatening opportunistic infection and a
leading cause of death(25%).
• HIV care settings should implement the WHO Three I’s strategy:
1) Intensified TB case-finding,
2) Isoniazid preventive therapy (IPT)
3) Infection control at all clinical encounters
Link between TB and HIV

• HIV is the strongest known risk factor for the progression of recent and latent TB infection
to active TB disease
• TB is the most common OI in HIV infected individuals and is the leading cause of death in
PLWHA
• TB causes immunological deterioration of HIV leading to a rapid progression of HIV disease
Impact of HIV on TB
Infection with HIV aggravates TB by:
increasing risk of TB infection
increasing risk of TB disease
increasing case fatality
increasing MDR TB
Impact of TB on HIV
PLWHA.
• In HIV-infected TB patient, the immune response to TB bacilli increases HIV replication,
leading to more rapid progression of HIV infection.
• Patient develops symptoms of various OIs & patient’s health may deteriorate more
rapidly.
• TB treatment complicates ongoing HIV treatment because of pill burden, additional side
effects, and drug-drug interactions.
HIV/TB Collaboration
• Linkage between RNTCP and NACP for prevention and control of both diseases.
At HIV care settings-
• Intensified TB case finding
• Fast-track referral of TB suspects for diagnosis and treatment into the RNTCP
At RNTCP settings -
• Routine offer of HIV counselling and testing to all TB patients with unknown HIV status
• Appropriate referral to NACP
TB/HIV Collaborative Interventions:
• HIV testing of TB patients

• Linkage of HIV-infected TB patients to HIV care and Treatment Centres
• Early detection of TB in HIV-infected patients through Intensified TB Case Finding
• Involvement of NGOs in TB/HIV activities
• Implementation of airborne infection control measures in HIV care settings.
Intensified TB/HIV Package of Services

• Routine offer of HIV test to all TB patients,
• Decentralized cotrimoxazole prophylaxis for HIV-infected TB patients,
• Referral of HIV-infected TB patients to ART Centre for evaluation and initiation of ART,
• Expanded recording and reporting on TB-HIV activities
VCT for All TB Patients
• Voluntary HIV counselling and testing to all TB patients
• This will facilitate early detection of HIV infection in TB patients, and
• Lead to early access to HIV care and treatment
SHARED CONFIDENTIALITY & COMMUNICATION
• Provide appropriate diagnosis and treatment for other illnesses
• Provide patient counselling to reduce risk of HIV spread to others
• Initiate Cotrimoxazole Preventive Therapy (CPT)
• Prompt referral for anti-retroviral treatment
• Linkage to social support services
HIV VACCINE
Need
Despite the remarkable achievements in development of antiretroviral therapies and recent
advances in new prevention technologies, the rate of new HIV infections continues to
outpace efforts on prevention and control.
Challenges
• H.I.V. mutates rapidly; H.I.V. mutates in one day as much as influenza viruses do in a year.
• The virus has developed multiple mechanisms to evade the body’s defenses
• HIV not infect animals. So study of vaccine efficacy in animals restricted.
SWOT ANALYSIS
Strengths
• Political commitment
• Programme decentralized through state and district societies in order to effective
implementation and ensure local planning.
• Budget allocation is high.
• Surveillance component both sentinel and behavior.
Weakness
• Stigma
• Conflicting roles of national and international agency.
• Under utilization of funds in many states
• More expenditure on ART .BUT prevention is more cost effective.
Opportunities
• WHO and UNICEF should provide central leadership and uniform guidelines worldwide.
• Indian pharmaceuticals are strong and prompted to produce drugs in india. That will
reduce cost.
• Social and religious groups involved in raising awareness.
• Awareness in rural areas can be increased.
• Srategy for rehabilitation should also be made.
Threats
• Reduced Budget can hamper the progress.
• Withdrawal of international agencies could hamper progress.
• Some states have banned sex education due to religious and cultural sentiments which is a
serious setback to programme.
NGOS WORKING FOR HIV:

• Vihan
• For FSW- Ashasadan
• For MSM- Hamsaya, hamsafar, darpan
• Network of PLHIV- at National, State, District level
• NPM + (Network of people living with aids in Mumbai)
REPORT
Ministry of Health and Family Welfare
HIV/AIDS Patients in India

Posted On: 20 SEP 2020 8:24PM by PIB Delhi
As per the latest HIV estimates report (2019) of the Government, India is estimated to have
around 23.49 lakh people living with HIV/AIDS (PLHIV) in 2019. The HIV epidemic has an
overall decreasing trend in country with estimated annual New HIV infections declining by
37% between 2010 and 2019.
HIV infection in India is mainly caused by engagement in high risk behaviours. The main
high-risk behaviours identified for HIV infection in India includes unprotected heterosexual
behaviour, unprotected homosexual behaviour, and unsafe injecting drug use behaviour.
There are no dedicated hospitals for the treatment of HIV/AIDS patients. However, under the
National AIDS Control Programme (NACP) of the Government, as on July 2020, there are
570 Anti-retroviral treatment (ART) Centers and 1264 Link ART Centers.
State/UT-wise details of people living with HIV/AIDS in 2018 and 2019 as per the latest HIV estimates
report (2019)
Andhra Pradesh
2018 2019
3.28 3.14
Assam
2018 2019
0.21 0.21
Delhi
2018 2019
0.66 0.68
ROLE OF NURSE
1) Planning and Policy Development
• Assign specific roles and responsibilities

• Define essential pathways of communication between providers, laboratories, and the
public health system
• Assign sufficient resources, both human and financial, to ensure its implementation,
including a responsible case manager for each suspected and verified case of disease
• Provide provisions for expert consultation and oversight for HIV/AIDS-related matters to
clinicians, institutions, and communities
• Provide special guidance to local laboratories that process HIV-related samples
• Assist local authorities in conducting contact or outbreak investigations and
• Provide culturally appropriate information to patients, persons at risk, and the community
2) Clinical and diagnostic services for patients and their contacts

• nurse should ensure that patients with suspected or confirmed disease have ready
access to diagnostic and treatment services that meet national standards.
• To ensure that standards of care are met, health departments should develop and
maintain close working relationships with:
1. Local laboratories;
2. Pharmacies
3. Health-care providers.
4. Clinical facilities should provide screening, diagnostics, and monitoring tests,

including radiology services.
5. Radiology services include access to radiograph equipment, trained radiograph
technicians, and radiograph interpretation by a qualified person.
• Coordinating care with other health-care providers and facilities is crucial to the
prevention and control of HIV. HIV patients often receive care in a variety of settings,
including
1. Private practices
2. Hospitals
3. HIV clinics
4. Community clinics
5. Correctional facilities
6. Nursing homes.
3) Training and Education
• She should ensure that education and training in the clinical and public health
aspects of HIV to all program staff.
• Staff members should receive education at regular intervals on their particular

responsibilities in the program and should demonstrate proficiency in those areas.
4) Surveillance and Information Management
• Surveillance and information management systems should be monitored at regular

intervals.
• Information technology can improve care of patients with TB disease through

standardized collection of data and tracking of test results.
• Other benefits include ready access to details of treatment regimens, administration

of medications, drug-drug interactions.
• Advancements in information technology allow for the analysis and rapid

distribution of epidemiologic data, as well as management of individualized
treatment plans.
5) Monitoring and Evaluation
• The systematic monitoring and evaluation of program activities is a critical factor in

enhancing program performance.
• Evaluation techniques provide programs with an evidence-based means of
assessing and improving their HIV-control strategies by helping them understand
what causes good or bad program performance.
Evaluation can also be used for the following:

1. • Program advocacy
2. • Assessing staffing needs
3. • Focusing training and capacity building
4. • Directing limited resources to the most productive activities;
5. • Accounting for available resources
6. • Generating additional resources
7. • Recognizing achievement
CONCLUSION
India’s AIDS Control Programme is globally acclaimed as a success story. The National AIDS
Control Programme (NACP), launched in 1992, is being implemented as a comprehensive
programme for prevention and control of HIV/AIDS in India. Over time, the focus has shifted
from raising awareness to behavior change, from a national response to a more
decentralized response and to increasing involvement of NGOs and networks of PLHIV.
The capacities of State AIDS Control Societies (SACS) and District AIDS Prevention and
Control Units (DAPCUs) have been strengthened. Technical Support Units (TSUs) were
established at National and State level to assist in the Programme monitoring and technical
areas. A dedicated North-East regional Office has been established for focused attention to
the North Eastern states. State Training Resource Centres (STRC) was set up to help the
state level implementation units and functionaries. Strategic Information Management
System (SIMS) has been established and nation-wide rollout is under way with about 15,000
reporting units across the country. The next phase of NACP will build on these achievements
and it will be ensured that these gains are consolidated and sustained.
ROLE OF NURSE


• Local laboratories;
• Pharmacies
• Health-care providers.
• Clinical facilities should provide screening, diagnostics, and monitoring tests,
• including radiology services.
• Radiology services include access to radiograph equipment, trained radiograph
including
• Private practices
• Hospitals
• HIV clinics
• Community clinics
• Correctional facilities
Nursing homes.


intervals.



treatment plans.



• Program advocacy
• Assessing staffing needs
• Focusing training and capacity building
• Directing limited resources to the most productive activities;
• Accounting for available resources
• Generating additional resources
• Recognizing achievement
CONCLUSION
BIBLIOGRAPHY
• Textbook of national health programmes of india , national policies and legislations
related to health, J. KISHORE, 11 TH Edition
• Textbook of Park, 23 rd Edition, page no. 343-354 , 431-438
• National AIDS Control Organisation. About NACO;NACO 2018. Available from:
http://www.nacoonline.org/About_NACO/ .
 pib.gov.in/PressReleaseIframePage.aspx.PRID=1657057
NATIONAL AIDS CONTROL PROGRAME
INTRODUCTION
● HIV infection first detected in India in 1986 from Pune, when 10 HIV positive samples
were found from a group of 102 female sex workers from Chennai
● 62 AIDS surveillance centers was gradually established nationwide.
MILESTONES
• 1986 : first case of HIV detected , AIDS task force set by ICMR
. • 1990 : medium term plan launched for 4 states & 4 metro
• 1992 : NACP 1 launched & NACB constituted.
• 1999 : NACP 2 begins , SACS established
• 2002 : NACP adopted.
• 2004 : ART started.
• 2007 : NACP 3 launched for 5 years .
• 2012 :NACP 4 launched for next 5 year .
GLOBAL STASTISTICS
17 million people were accessing antiretroviral therapy
• 36.7 million [34.0 million–39.8 million] people globally were living with HIV
• 2.1 million [1.8 million–2.4 million] people became newly infected with HIV
• 1.1 million [940 000–1.3 million] people died from AIDS-related illnesses
• 78 million [69.5 million–87.6 million] people have become infected with HIV since the start
of the epidemic
• 35 million [29.6 million–40.8 million] people have died from AIDS-related illnesses since
the start of the epidemic
INDIAN STASTISTICS
12,70,678 People on ART
• 2116581 people were living with HIV
• 75948 people became newly infected with HIV
• 67612 deaths due to AIDS
• 35255 pregnant woman needs PPTCT
HIGH RISK GROUP
● Female Sex Worker(FSW)
● Men who have Sex with Men(MSM)
● Transgender
● Injecting drug users(IDU)
VULNERABLE POPULATION
● Women having casual partners
● Spouses of high risk groups
BRIDGE POPULATION
● Migrant
● Truckers
● Clients of sex worker
PREVELANCE IN INDIAN STATES

High prevalence
• >5% in HRG & >1% in ANC
• MR, TN, Andhra, Manipur, Karnataka, Nagaland
Moderate prevalence
• >5% in HRG & <1% in ANC
• Gujarat, Puducherry, Goa
Low prevalence
• <5% in HRG & <1% in ANC
• All other states/UTs
CLASSIFICATION OF DISTRICTS
Districts are classified into four categories A to D
• Category A: • More than 1% ANC prevalence in district in any of the sites in the last 3
years.
• Category B: • Less than 1% ANC prevalence in all the sites during last 3 years with more
than 5% prevalence in any HRG site (STD/FSW/MSM/IDU)
• Category C: • Less than 1% ANC prevalence in all sites during last 3 years with less than 5%
in all HRG sites, with known hot spots (Migrants, truckers, large aggregation of factory
workers, tourist etc.,)
• Category D: • Less than 1% ANC prevalence in all sites during last 3 years with less than
5% in all HRG sites with no known hot spots OR no or poor HIV data
CASE DEFINITION
ADULTS –
● Positive test for HIV antibody by 2 separate test using 2 different Antigens plus Any
one or more of the following
● Weight loss>10% of bw
● Chronic diarrhoea >1 month
● Chronic coughè >1 month
● Disseminated ,miliary or extrapulmonary TB
● Neurological impairment
● Esophageal candidiasis
● Kaposi sarcoma
CHILDREN
● Major –Weight loss,
● Failure to thrive,
● chronic diarrhea,
● prolonged fever,
● Candidiasis,
● Tuberculosis,Herpes zoster
● Minor—Generalised lymphadynopathy, Oropharyngeal candidiasis,
● Persistant cough for >I month , Generalised dermatitis, Confirmed maternal HIV
infection
AIDS CONTROL PROGRAMME IN INDIA
HIV infection first detected in India in 1986, when 10 HIV positive samples were found from
a group of 102 female sex workers from Chennai.
• In 1986 Government set up an AIDS Task Force under ICMR and established a National
AIDS Committee (NAC) chaired by Secretary, Department of Health and Family Welfare.
• In 1987, National AIDS Control Programme was initiated, with help from the World Bank.
• In 1989, a Medium Term Plan for AIDS Control was developed with the support of
theWHO.
First National AIDS Control Programme (NACP-I) was launched in 1992.

• NACP-II launched in 1999: decentralization of programme implementation to State level
and greater involvement of NGOs.
• NACP- III implemented during 2007-2012:
• NACP-IV has been developed for the period 2012-2017
NACP I (1992-99)
● Formal NACP was launched in 1992 as Phase I. National AIDS Control Board (NACB)
was formed and National AIDS Control Organization (NACO), an autonomous apex
body for HIV/AIDS prevention and control was created.
● This was the giant step towards institutionalization of NACP. With advent of the
central-nodal institute, NACP got strategized for preventive activities like HIV/AIDS
education and awareness program, blood safety measures, condom promotion,
control of hospital infection and strengthening of clinical services.
NACP-I was launched as 100% centrally sponsored project from September 1992 to
September 1997.
● It was implemented with an objective to slow down the HIV spread so as to reduce
the resultant morbidity, mortality and impact in the country.
● Large-scale mass media activities (partly centrally managed), licensing of the blood
banks, banning of professional donors, expansion of surveillance network and
collaboration with non-government organizations (NGOs) for preventive
interventions were important output under Phase I.
● Counseling and testing services started in 1997. But increase in the capacity of states
(technical and managerial) to respond to HIV epidemic and formation of the state-
level institutes i.e. State AIDS Control Societies (SACSs) in 25 States and 7 Union
Territories (UTs) were the most important achievement.
● NACP-I was extended beyond five-year period i.e. from 1992 to 1999. It was devoted
largely towards system building. Capacity building of the State Governments to deal
the epidemic developed, thus owning and implementation by states started during
Phase I.
OBJECTIVE
 Slow and prevent the spread of HIV through a major effort to prevent HIV transmission.
KEY STRATEGIES
 Focus on raising awareness, Blood safety, Prevention among high-risk populations,
 Improving surveillance
ACHIEVEMENTS
 National AIDS response structures at both the national and state levels and provided
critical financing.
 Strong partnership with the World Health Organisation(WHO) and later helped mobilize
additional donor resources.
 Established the State AIDS Control Cells
NACP 2 (1999-2007)
● In November 1999, NACP-II was launched with World Bank credit of US $191 million.
● While in Phase I central agencies were the main players, during Phase II states were
put in front seat. For program implementation purpose, state was considered as a
unit. Based on epidemiological situation analysis, states were categorized as high,
moderate and low prevalence/vulnerable sates.
In NACP-II, focus shifted from raising awareness to changing behavior and
decentralization of program implementation at the state level.
● Prevention of new infection was the key strategy and Female Sex Workers (FSWs),
Men who have Sex with Men (MSM), Injecting Drug Users (IDUs) and client of sex
workers were the key target groups.
● During the second half of NACP-II, establishment/scaling up of counseling and testing
services for HRG people, provision of the Anti-Retroviral Treatment and Prevention
of Parent to Child Transmission (PPTCT) gained attention. Thus with moving down of
the NACP from center to state, Phase II witnessed more decentralized, strategized
and focused activities in prevention and service delivery in contrast to largely
central-driven generalized type of activities of Phase I.
● As part of decentralization, in all States, UTs and three cities, i.e. Chennai, Mumbai
and Ahmadabad, autonomous nodal implementing agency, i.e. AIDS Control Society
developed.
OBJECTIVE
 Reduce the spread of HIV infection in India through behavior change and increase capacity
to respond to
HIV on a long-term basis.
KEY STRATEGIES
Targeted Interventions for high-risk groups
 Preventive interventions for general populations
 Involvement of NGOs
 Institutional strengthening
ACHIEVEMENT
 At the operational level 1,033 targeted interventions set up, 875 Voluntary counseling and
testing centers (VCTC) and 679 STI clinics at the district level.
 Nation-wide and state level Behaviour Sentinel Surveillance (BSS) surveys were conducted
 PPTCT Expanded.
 A computerized management information system (CMIS) created.
 HIV prevention and care and support organizations and networks were strengthened.
 Support from partner agencies increased substantially
NACP 3 (2007-2010)
With a rich learning of about two decades, NACP III was launched in 2007 with the goal to
halt and reverse the epidemic in India in next 5 years.
The NACP-III program further moved down from state to district. Phase II was viewing state
as an implementing unit, while Phase III is viewing district as an implementing unit.
Phase II is strategized based on the epidemiological categorization of the states, Phase III is
strategized taking the epidemiological situation of the districts in consideration.
In the year 2006, based on the HIV surveillance data of previous three years, NACO classified
all districts into four categories viz. A, B, C and D. Category A districts are the districts with
generalized epidemic i.e. HIV positivity was found >1% in pregnant women in HIV Sentinel
Surveillance, Category B districts are the districts where epidemic was concentrated type
i.e. HIV positivity was <1% in pregnant women but was >5% in the clients of Sexually
Transmitted Diseases (STDs), Category C and D districts are the vulnerable districts i.e. HIV
positivity was <1% in pregnant women and <5% in STD clients or adequate data was not
available.
OBJECTIVE
 Reduce the rate of incidence by 60 per cent in the first year of the programme .
STRATEGIES
 Prevention – Targeted intervention (TI), ICTC, blood safety
 Care, support and treatment –
 Capacity building – establishment, support and capacity strengthening, training, managing
programme implementation and contracts, mainstreaming/private sector partnerships.
 Strategic information management – monitoring and evaluation.
ACHIEVEMENTS
 There were 306 fully functional ART Centres .
 Nearly 12.5 lakh PLHIV were registered and 420000 patients were on ART.
 612 Link ART centre (LAC) had been established wherein, 26023 PLHIV were taking
Services
 There were 10 Centres of Excellence,
 7 Regional Pediatric centres also functional.
 259 Community Care Centres across the Country
 6000 condoms & 6000 village information centres established
 3000 Red ribbon clubs established
 Link Workers training module updated
NACP IV
Launched on 12 February 2014
• Total budget outlay Rs 14295 crores.
• Goal: Accelerate Reversal and Integrate Response
Objective 1:
• Reduce new infections by 50% (2007 Baseline of NACP III)
• Objective 2:
• Provide comprehensive care and support to all persons living with HIV/AIDS .
Key Strategies under NACP-IV

1) Intensify &consolidate preventive services
2) Increase access &promote comprehensive care, support & treatment :
a) First line & second line ART
b) Care &Support Centres
c) HIV-TB Coordination
d) Focus on PPTCT
e) Treatment of Opportunistic Infections
3) Expanding IEC services

4) Capacity building
5) Strengthening Strategic Information Management system:
a) Needle-Syringe Exchange Programme and Opioid Substitution Therapy for IDUs
b) Targeted Interventions for High Risk Groups (FSW, MSM, IDU, Truckers & Migrants)
Link Worker Scheme for rural population
c) Prevention & Control of Sexually Transmitted Infections
d) IEC, Social Mobilization & Mainstreaming
e) Condom promotion
f) Blood safety
g) Counselling & Testing Services (ICTC, PPTCT, HIV/TB)
KEY PRIORITIES UNDER NACP-IV
1. Preventing new infections by sustaining the reach of current interventions and effectively
addressing emerging epidemics.
2. Prevention of Parent to Child transmission
3. Focusing on IEC. Providing comprehensive care, support and treatment to eligible PLHIV
5. Reducing stigma .
6. De-centralizing rollout of services including technical support
7. Ensuring effective use of strategic information at all levels of Programme
8. Building capacities of NGO and civil society partners especially in states with emerging
epidemics.
9. Integrating HIV services with health systems in a phased manner.
10. Mainstreaming of HIV/ AIDS activities.
PREVENTION SERVICES:
• Targeted Interventions for High Risk Groups and Bridge Population.

• Needle-Syringe Exchange Programme (NSEP) and Opioid Substitution Therapy (OST) for
IDUs
• Prevention Interventions for Migrant population at source, transit and destination
• Link Worker Scheme (LWS) for HRGs and vulnerable population in rural areas
Prevention & Control of Sexually Transmitted Infections/Reproductive Tract Infections
(STI/RTI)
• Blood Safety
• HIV Counseling & Testing Services
• Prevention of Parent to Child Transmission
• Condom promotion
• Information, Education & Communication (IEC) & Behavior Change Communication (BCC).
Care, Support & Treatment Services

• Laboratory services for CD4 Testing and other investigations.
• Free First line & second line Anti-Retroviral Treatment (ART) through ART centres and Link
ART Centres
(LACs), Centres of Excellence (COE) & ART Plus Centres
• Pediatric ART for children.
• Early Infant Diagnosis for HIV exposed infants and children below 18 months. HIV-TB
Coordination (Cross referral, detection and treatment of coinfections)
• Treatment of Opportunistic Infections
• Drop-in Centres for PLHIV networks
New Initiatives under NACP-IV

• Scale up of Multi-Drug Regimen for Prevention of Parent to Child Transmission(PPTCT).
• Social protection for marginalized populations through mainstreaming and earmarking
budgets for HIV among concerned government departments.
• Establishment of Metro Blood Banks and Plasma Fractionation Centre.
● Launch of Third Line ART and scale up of first and second Line ART.
• Demand promotion strategies specially using media, e.g., National Folk Media Campaign &
Red Ribbon Express and buses.
ICTC
VCTC
• Voluntary Counseling and Testing Centres
• People motivated were referred to these centres
VCCTC
• Voluntary Confidential Counseling and Testing Centres
• Emphasis on maintaining confidentiality
ICTC
• Integrated Counseling and Testing Centres
• Integration of VCCTC + PPTCT
ICTC
Stand- Alone ICTC- Supported financially and logistically by NACP
Facility ICTC(F-ICTC)- Staff from existing facilities trained in counseling and testing
PPP-ICTC- Established in private facilities based on F-ICTC model
Mobile ICTC- Takes the package of services to community
ICTC AND ITS LINKAGE

PPTCT
● Prevention of HIV in women
● Prevention of unintended pregnancies in HIV+ women
● Prevention of HIV transmission from HIV+ women to infants
● Provision of care, treatment and support to mothers living with HIV and their
families PPTCT
● Without any intervention risk of transmission of HIV from infected mother to her
child is between 20-45%.
● SD-NVP is highly effective in reducing risk of transmission from about 45% to less
than 10%
● Multiple drugs for PPTCT can reduce transmission to less than 5% if started early in
pregnancy and continued throughout period of delivery and breast feeding.
● NACP Launched PPTCT during 2001-2002.

● Single dose Navirapine at the time of delivery to the mother and her newborn child
soon after birth.
From june 2013, WHO recommended lifelong multidrug ART (Triple drug regimen) for all
pregnant and breastfeeding women irrespective of CD4 count or WHO clinical staging.
Essential package of PPTCT services

• Offer HIV counselling and testing.
• Moving from ANC centric to Family Centric
• ART to all HIV pregnant women regardless of CD4 count and who staging. • Promoting
institutional delivery
• Provision of care for associated conditions.
• Counselling for exclusive breastfeeding upto 6 months.
• Provision of ART prophylaxis to infants upto 6 weeks.
• Ensuring Initiation of CPT To infant.
SERVICES TO HIV EXPOSED INFANTS(HEI)

• Exclusive breastfeeding upto 6 months
• ARV prophylaxis upto 6 weeks with Navirapin syrup
• CPT initiated after 6 weeks .
• For HIV negative babies at 6 months- continue breastfeeding + complementary feeding
after 6 months upto 1 yr .
• for EID positive babies Continue breast feeding upto 2 yrs, who r receiving Paediatric ART.
• Confimatory test done at 6m, 12 m, and 6 weeks after cessation of breast feeding.
WHO GUIDELINES FORTREATMENT:

Goals of ART Therapy:
• Reduce HIV-associated morbidity
• prolong the duration and quality survival.
• Restore and preserve immunologic function
• Maximally suppress viral load
• Prevent HIV transmission
Highly Active Anti Retroviral Therapy (HAART)
GUIDELINES TO START ART:

• Start ART in all adults, adolescent with a CD4 < 500
Priority to stage 3, 4 HIV disease and CD4 < 350 .
• ART at any CD4 count in PLHIV

 Active TB disease
 HBV co-infection
 HIV-positive partners in sero-discordant couples
 Pregnant and breastfeeding women and
 Children younger than five years of age
When to start ART in people living with HIV:
5) Adults and adolescents (≥10 years):
Initiate ART if CD4 cell count ≤500 cells/mm3

• As a priority,
 Severe/advanced HIV (WHO clinical stage 3 or 4) or
 CD4 count ≤350 cells/mm3
Regardless of WHO clinical stage and CD4

• Active TB disease
• HBV coinfection with severe chronic liver disease
• Pregnant and breastfeeding women with HIV
• HIV-positive individual in a serodiscordant partnership (to reduce HIV transmission risk)
6) Infants <1 year old

In all , Regardless of WHO clinical stage and CD4 cell count.
7) Children < 5 yrs old

ART in all regardless of WHO clinical stage and CD4
8) Children 5 to 10 yrs
CD4 ≤500 cells/mm3
• As a priority,
 All WHO clinical stage 3 or 4 or
 CD4 count ≤350
Targeted intervention:
Key risk groups covered under the Targeted Intervention programme:
• Female Sex Workers
• Men who have Sex with Men
• Transgenders
• Injecting Drug Users
• Bridge Populations
• Long Distance Truckers
• High Risk MigrantsMonitoring ART response and diagnosis of treatment failure
Services offered under the Targeted Intervention Programme:

• Detection and treatment for Sexually Transmitted Infections (STIs)
• Condom promotion and distribution
• Behaviour change communication
• Creating an enabling environment with community involvement and participation
• Linkage to Integrated Counseling and Testing Centres
• Linkage with care and support services for HIV positive HRG.
• Specific Interventions for IDUs
• Specific Interventions for MSM / TGs
• Specific Interventions for FSWs
LINE WORKER SCHEME
Community based outreach services by link worker. for HRG, and vulnerable groups.
• Objective of scheme include- information on prevention of HIV, Counselling, referral to
ICTC, STI clinic, promotion and distribution of condoms.
MANAGEMENT OF RTI/STI
Provision of RTI/STI in high risk group population includes:
• Free consultation and treatment for their symptomatic STI /RTI.
• SURAKSHA CLINICS
• Syndromic management
• Prepacked colour coded kits
• 7 kits- Grey, green, white , blue, red,yellow, black.
BLOOD TRANSFUSION SERVICE

• Increasing regular voluntary blood donation.
• Professional blood donation prohibited.
• Only licenced blood banks are permited.
• Promoting component preparation.
• BLOOD SAFETY programme renamed as blood transfusion service.
As per national blood policy, testing of every unit of blood is mandatory for HIV, HBV, HCV,
malaria, syphilis.
• ACESS TO SAFE BLOOD is primary responsibility of NACO.
It is supported by network of 1137 blood bank, 258 BCSU, 258 model blood banks.
IEC AND MAINSTREAMING

● Mass media campaign
• Radio or TV program
• Red ribbon express project
• Advertisement through newspaper
• Hoarding
• Folk media
• Inter Ministerial conference
• Training of frontline worker
• Greater involvement of PLHIV
• Social protection
Behavior Change Communication

• Communication : key to generating awareness on prevention as well as motivating
access to treatment, care and support.
• Information, Education & Communication (IEC) and Behaviour Change

Communication
• Mass Media Campaigns through Radio & TV
• Mid-media campaigns through Folk Media, display panels, banners, wall writings
etc.,
• Special campaigns through music and sports, flagship programmes, such as Red
Ribbon Express
Condom Promotion
• Ensuring availability and creating demand for condoms.
• Free Condom, Socially Marketed Condom (Paid-subsidized)
Innovative Approaches
A-Condom Vending Machines (CVM)
B-Female Condoms (FC)
C-Special Condom for MSM
POST EXPOSURE PROPHYLAXSIS

Comprehensive management given to minimize the risk of infection following potential
exposure to blood-borne pathogens e.g. HIV.
This includes:
1. First aid
2. Counseling
3. Risk assessment
4. Relevant laboratory investigations based on informed consent of the exposed person.
5. Depending on the risk assessment, the provision of short term (4 weeks) of ART.
6. Follow up and support
Post-exposure prophylaxis (PEP) has its greatest effect if begun within 2 hours of exposure.
There is little benefit if started >72 hours.
• The prophylaxis needs to be continued for 4 weeks (28 days).
Preferred PEP regimen :
• Initially:
2 drug regimen (Zidovudine + Lamivudine)
then 3 drug regimen : after expert opinion ( AZT + 3TC + NVP)

• Clinical follow-up: the exposed person must be monitored for the eventual appearance of
signs indicating an HIV. These symptoms almost always appears within 3 to 6 weeks after
exposure.
• Laboratory follow-up : after exposure testing at 3 months and 6 months is recommended.
Post-exposure prophylaxis for women within 72 hours of a sexual assault

•Recommended duration of PoEP is 28 days,
•First dose as soon as possible within 72 hours
•The choice based on first-line ART regimen.
HIV-TB Co-infection
• A setting with a high burden of TB and HIV refers to settings with adult HIV prevalence
≥1% or HIV prevalence among people with TB ≥5%
• Among PLHA, TB is the most frequent life-threatening opportunistic infection and a
leading cause of death(25%).
• HIV care settings should implement the WHO Three I’s strategy:
4) Intensified TB case-finding,
5) Isoniazid preventive therapy (IPT)
6) Infection control at all clinical encounters
Link between TB and HIV

• HIV is the strongest known risk factor for the progression of recent and latent TB infection
to active TB disease
PLWHA
• TB causes immunological deterioration of HIV leading to a rapid progression of HIV disease
Impact of HIV on TB
Infection with HIV aggravates TB by:
increasing risk of TB infection
increasing risk of TB disease
increasing case fatality
increasing MDR TB
Impact of TB on HIV
PLWHA.
• In HIV-infected TB patient, the immune response to TB bacilli increases HIV replication,
leading to more rapid progression of HIV infection.
• Patient develops symptoms of various OIs & patient’s health may deteriorate more
rapidly.
• TB treatment complicates ongoing HIV treatment because of pill burden, additional side
effects, and drug-drug interactions.
HIV/TB Collaboration
• Linkage between RNTCP and NACP for prevention and control of both diseases.
At HIV care settings-
• Intensified TB case finding
• Fast-track referral of TB suspects for diagnosis and treatment into the RNTCP
At RNTCP settings -
• Routine offer of HIV counselling and testing to all TB patients with unknown HIV status
• Appropriate referral to NACP
TB/HIV Collaborative Interventions:
• HIV testing of TB patients

• Linkage of HIV-infected TB patients to HIV care and Treatment Centres
• Early detection of TB in HIV-infected patients through Intensified TB Case Finding
• Involvement of NGOs in TB/HIV activities
• Implementation of airborne infection control measures in HIV care settings.
Intensified TB/HIV Package of Services

• Routine offer of HIV test to all TB patients,
• Decentralized cotrimoxazole prophylaxis for HIV-infected TB patients,
• Referral of HIV-infected TB patients to ART Centre for evaluation and initiation of ART,
• Expanded recording and reporting on TB-HIV activities
VCT for All TB Patients
• Voluntary HIV counselling and testing to all TB patients
• This will facilitate early detection of HIV infection in TB patients, and
• Lead to early access to HIV care and treatment
SHARED CONFIDENTIALITY & COMMUNICATION
• Provide appropriate diagnosis and treatment for other illnesses
• Provide patient counselling to reduce risk of HIV spread to others
• Initiate Cotrimoxazole Preventive Therapy (CPT)
• Prompt referral for anti-retroviral treatment
• Linkage to social support services
HIV VACCINE
Need
Despite the remarkable achievements in development of antiretroviral therapies and recent
advances in new prevention technologies, the rate of new HIV infections continues to
outpace efforts on prevention and control.
Challenges
• H.I.V. mutates rapidly; H.I.V. mutates in one day as much as influenza viruses do in a year.
• The virus has developed multiple mechanisms to evade the body’s defenses
• HIV not infect animals. So study of vaccine efficacy in animals restricted.
SWOT ANALYSIS
Strengths
• Political commitment
• Programme decentralized through state and district societies in order to effective
implementation and ensure local planning.
• Budget allocation is high.
• Surveillance component both sentinel and behavior.
Weakness
• Stigma
• Conflicting roles of national and international agency.
• Under utilization of funds in many states
• More expenditure on ART .BUT prevention is more cost effective.
Opportunities
• WHO and UNICEF should provide central leadership and uniform guidelines worldwide.
• Indian pharmaceuticals are strong and prompted to produce drugs in india. That will
reduce cost.
• Social and religious groups involved in raising awareness.
• Awareness in rural areas can be increased.
• Srategy for rehabilitation should also be made.
Threats
• Reduced Budget can hamper the progress.
• Withdrawal of international agencies could hamper progress.
• Some states have banned sex education due to religious and cultural sentiments which is a
serious setback to programme.
NATIONAL STATEGEIC PLAN (2017-2024)

Vision: An AIDS Free India
Mission: Attain universal coverage of HIV prevention, testing, treatment to care continuum
that is effective, inclusive, equitable and adapted to population and local needs.
Goal: 1) Achieving zero new infections,
• 2) zero AIDS-related deaths
• 3) and zero AIDS related stigma & discrimination.
Objectives
1: Reduce 80% new infections by 2024 (Baseline 2010)
2: Ensure 95% of estimated PLHIV know their status by 2024
3: Ensure 95% PLHIV have ART initiation and retention by 2024, for sustained viral
suppression
4: Eliminate mother-to-child transmission of HIV and Syphilis by 2020
5: Eliminate HIV/AIDS related stigma and discrimination by 2020
6: Facilitate sustainable NACP service delivery by 2024
By 2020, the focus of the national programme will be on achieving the following fast track
targets:
(i) 75% reduction in new HIV infections,
(ii) 90-90-90: 90% of those who are HIV positive in the country know their status, 90% of
those who know their status are on treatment and 90% of those who are on treatment
experience effective viral load suppression,
(iii) Elimination of mother-to-child transmission of HIV and Syphilis, and
(iv) Elimination of stigma and discrimination
By 2024, the further achievements envisaged are:

(i) 80% reduction in new HIV infections,
(ii) Ensuring that 95% of those who are HIV positive in the country know their status, 95% of
those who know their status are on treatment and 95% of those who are on treatment
experience effective viral load suppression
To this effect, two key achievements in early 2017 to ‘Ending of AIDS by 2030’ include the
enactment of the ‘HIV/AIDS Bill’ as a law protecting the rights of people living with and
affected by HIV as well as the announcement and implementation of the ‘Test and Treat’
policy in line with global guidelines.
HIV/AIDS ACT 2017

The Union Ministry of Health and Family Welfare on September 11, 2018 issued a
notification for bringing the Human Immunodeficiency Virus and Acquired Immune
Deficiency Syndrome (Prevention and Control) Act, 2017 in force with effect from
September 10, 2018.
The Bill was introduced by senior Congress leader Ghulam Nabi Azad in 2014, was passed by
the Rajya Sabha on March 22, 2017, and on April 12, 2017, it was passed by the Lok Sabha. It
received the assent of the President on April 20, 2017.
The HIV/AIDS Act, 2017 safeguards the rights of people living with HIV and affected by HIV.
Provisions of HIV/AIDS Act, 2017

The provisions of the Act address HIV-related discrimination, strengthen the existing
programme by bringing in legal accountability, and establish formal mechanisms for
inquiring into complaints and redressing grievances.
• The Act seeks to prevent and control the spread of HIV and AIDS, prohibits discrimination
against persons with HIV and AIDS.
• Informed consent and disclosure of HIV status: The Bill requires that no HIV test, medical
treatment, or research will be conducted on a person without his informed consent.
• Every HIV infected or affected person below the age of 18 years has the right to reside in
a shared household and enjoy the facilities of the household.
• The Act also prohibits any individual from publishing information or advocating

feelings of hatred against HIV positive persons and those living with them.
• Guardianship: A person between the age of 12 to 18 years who has sufficient maturity in
understanding and managing the affairs of his HIV or AIDS affected family is competent to
act as a guardian of another sibling below 18 years of age in the matters relating to
admission to educational establishments, operating bank accounts, managing property, care
and treatment.
• Role of the Ombudsman: An ombudsman shall be appointed by each state government

to inquire into complaints related to the violation of the Act and the provision of health care
services.
• It penalises "propagation of hatred" against HIV affected person where a violator could

be punished with a minimum jail term of three months to a maximum of two years and can
be fined up to Rs 1 lakh.
• It makes Anti-Retroviral Treatment (ART) a legal right for all HIV/AIDS patients.

• It adopted "test and treat" policy which means any person testing positive will be entitled
for free treatment by the state and central government. Earlier, this was restricted by a CD4
count rate.
• Every person in the care and custody of the state shall have right to HIV prevention,
testing, treatment and counseling services.
Grounds on which discrimination against HIV positive persons is prohibited

The 2017 Act lists various grounds on which discrimination against HIV positive persons and
those living with them is prohibited. These include the denial, termination, discontinuation of
unfair treatment with regard to:
(i) Employment
(ii) Educational establishments
(iii) Health care services
(iv) Residing or renting property
(v) Standing for public or private office
(vi) Provision of insurance (unless based on actuarial studies)
The requirement for HIV testing as a pre-requisite for obtaining employment or accessing
health care or education is also prohibited.
NGOS WORKING FOR HIV:
• Vihan
• For FSW- Ashasadan
• For MSM- Hamsaya, hamsafar, darpan
• Network of PLHIV- at National, State, District level
• NPM + (Network of people living with aids in Mumbai)
ANNUAL REPORT
National AIDS Control Organization (NACO), Ministry of Health and Family Welfare
(MoHFW), Government of India carries out biennial HIV estimations in collaboration with
the Indian Council of Medical Research (ICMR) - National Institute of Medical Statistics
(NIMS).
HIV Estimations 2017, the latest round, provide updated information on the status of HIV
epidemic in India at national and State/Union Territory (UT) levels, on key indicators: adult
HIV prevalence, annual new infections (HIV incidence), AIDS-related mortality and
prevention of mother-to-child transmission (PMTCT) needs.
HIV Estimations 2017 used latest Spectrum 5.63 as recommended by UNAIDS. The State/UT
models in this round are improved over previous rounds in terms of data inputs, approach
to handling the survey data as well as assumptions of various epidemiological parameters.
The improvements included updating of sex/age pattern of incidence using data from the
3rd and 4th rounds of National Family Health Survey.
In view of these improvements, results from HIV estimations 2017 are more robust, cannot
be compared with previous rounds of estimations and replace all previous estimations on
the level and trends of the HIV epidemic as well as programme needs.
By the end of 2017, there were an estimated 21.40 [15.90 - 28.39] lakh people living with
HIV (PLHIV) in India. There was an adult (15-49 years) HIV prevalence of 0.22%. Slightly more
than two fifths (42%) of the total estimated PLHIV were females. Around 87.58 [36.45 –
172.90] thousand new HIV infections and 69.11 [29.94 -140.84] thousand AIDS-related
deaths occurred in 2017. Meanwhile, an estimated 22,677 [10,927-40,605] pregnant women
needed ART to prevent mother-to-child transmission of HIV. 4. At 2.04% [1.57-2.56],
ROLE OF NURSE

7. Pharmacies

including
8. Hospitals
9. HIV clinics
12. Nursing homes.


intervals.



treatment plans.


14. • Recognizing achievement
CONCLUSION
BIBLIOGRAPHY
• Textbook of national health programmes of india , national policies and legislations
related to health, J. KISHORE, 11 TH Edition
• National AIDS Control Organisation. About NACO;NACO 2018. Available from:
http://www.nacoonline.org/About_NACO/ .
• India HIV estimations 2017 Technical Report , NACO AND National Institute of
Medical statistics , ICMR, Ministry of Health and Family Welfare, New Delhi
RAJKUMARI AMRIT KAUR
COLLEGE OF NURSING
NATIONAL AIDS CONTROL
PROGRAMME
SUBMITTED TO: SUBMITTED By

Mrs. Sarita Shokanda ma’am Vaishali
Aassistant Proffesor M.Sc Nursing(F)
R.A.K College of Nursing RAKCON
REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAMME
INTRODUCTION:
Revised National Tuberculosis Control Program ('RNTCP) is the state-run tuberculosis (TB)

control initiative of the Government of India. As per the National Strategic Plan 2012–17,
the program has a vision of achieving a "TB free India", and aims to achieve Universal Access
to TB control services. The program provides, various free of cost, quality tuberculosis
diagnosis and treatment services across the country through the government health system.
It seeks to employ the WHO recommended tuberculosis control strategy, DOTS(Directly
Observed Treatment, Short Course), to the Indian scenario.
TUBERCULOSIS(TB)
Tuberculosis is an infectious disease caused by a mycobacterium tuberculosis.
TB is a droplet infection and is highly contagious.
Patients are infective as long as they remain untreated.
An effective anti- microbial treatment reduces infectivity by 90% within 48 Hrs.
BURDEN OF DISEASE WORLD:

● TB continues to be one of the most important public health problems worldwide.
● In 2014, an estimated 9.6 million people developed TBè and 1.5 million died from
the disease, 400,000 of whom were HIV positive
● Worldwide the proportion of new cases with MDR-TBè was 3.3% in 2014, whereas
those for previously treated cases was 20.0%
INDIA
● Accounts for nearly 1/4 th of the global burden of TB
● Around 2.2 million develop TB in 2013-14. During the same period, 0.27 million
people died due to TB
● Everyday about 20,000 people become infected, 5000 develop TB and more than
1000 die due to the disease
● In simple terms, 2 persons become sputum +ve for TB and almost 1 person is killed
every minute due to the disease ( WHO 2007)
● The proportion of new cases with MDR-TB was 2.2% in 2014, whereas those for
previously treated cases was 15.0%
● EVERYDAY IN INDIA: more than 900 people die of TB (˜2 deaths every 3
minutes)
TUBERCULOSIS CONTROL IN INDIA
• National TB Control Programme (NTP) 1962
• RNTCP – 1993 as pilot project
• RNTCP: 1997 expanded across the country in a phased manner with support from the
World Bank and other development partners
• RNTCP I: 1997-2006
• RNTCP II: 2006-2012(Sept.)
 PHASE III: 2012- 2017
National Tuberculosis Programme (NTP)

During the 1950s and 1960s, significant research on TB was undertaken in India, and in 1962
the National TB Control Programme (NTP) was launched.
The previous program strategies were as follows:
● Early detection and treatment
● Diagnosis through radiology and sputum microscopy
● Free domiciliary services through PHC services.
● Establishing district tuberculosis centre in every district.
● Extend coverage under short course chemotherapy.
● Strengthen state TB training and demonstrations centers.
FAILURE OF NTP
• Inadequate budget and insufficient managerial capacity
• Shortage of drugs
• Less than 40% of patients completed the treatment
• Emphasis on x-ray diagnosis resulting in inaccurate diagnosis
• Poor quality sputum microscopy
• Multiplicity of treatment regimens.
• 1992 Govt. of india and WHO reviewed of the NTP and TB situation
an conclude that
• the desired results had not been achieved.
• There was over-dependence on X-rays for diagnosis.
• NTP suffered from managerial weakness.
• Frequent interrupted supplies of drugs.
• Incomplete treatment was the norm rather than the exception.
• The 1992 review revealed that only 30% of existing TB cases were being diagnosed,
and of these only 30% were completing treatment .
Revised National Tuberculosis Control Programme

o The National TB Programme (NTP) was started in 1962 for TB control in India. This
programme was not able to give expected results in India
o The NTP was reviewed in 1992
o As a result of the review and pilot studies in 1993, the DOTS strategy was adopted in India
under the Revised National TB control Programme - RNTCP
o The programme was implemented in a phase manner and by 24th March 2006, the entire
country was covered under the programme
Goal
● The goal of RNTCP is to decrease the mortality and morbidity due to tuberculosis
and cut down the chain of transmission of infection until TB ceases to be a public
health problem
Objectives
To achieve and maintain:
o Cure rate of at least 90% among newly detected smear positive (infectious) pulmonary TB
cases and
o Case detection of at least 85% of the expected new smear positive PTB cases in the
community
Strategies
1. Augmentation of organizational support at the central and state level for meaningful
coordination
2. Increase in budgetary outlay
3. Use of Sputum microscopy as a primary method of diagnosis among self reporting

patients
4. Standardized treatment regimens.
5. Augmentation of the peripheral level supervision through the creation of a sub

district supervisory unit
6. Ensuring a regular uninterrupted supply of drugs up to the most peripheral level
7. Emphasis on training, IEC, operational research and NGO involvement in the

program
Core elements of Phase I (1997-2006)

• The core element of RNTCP in Phase I (1997-2006)was to ensure high quality DOTS
expansion in the country, addressing the five primary components of the DOTS
strategy
– Political and administrative commitment
– Good Quality Diagnosis through sputum Microscopy
– Directly observed treatment
– Systematic Monitoring and Accountability
– Addressing stop TB strategy under RNTCP
RNTCP Phase II( 2006-11)

• The RNTCP phase II is envisaged to:
– Consolidate the achievements of phase I
– Maintain its progressive trend and effect further improvement in its

functioning
– Achieve TB related MDG goals while retaining DOTS as its core strategy
TB in MDGs
• Goal 6 – to combat HIV/AIDS, malaria and other diseases
• Target 8 – to have halted by 2015 and begun to reverse the incidence of malaria and
other major diseases, including tuberculosis.
• Indicator 23: Between 1990 and 2015, to halve the prevalence and death rates associated
with tuberculosis.
• Indicator 24: by 2005, to detect 70% of new smear positive TB cases arising annually, and
to successfully treat 85% of these cases
STOP TB STRATEGY (2006 COMPONENTS WERE):-

• Pursuing quality DOTS --- expansion and enhancement
• Addressing TB/ HIV and MDR
• Health system strengthening
• Engaging all care providers
• Empowering patients and communities
• Enabling and promoting research

COMPOI
Components of DOTS :
DOTS is a systemic strategy to control TB diseases. It has the following 5 components –
1. Political and administrative commitment
2. Good quality diagnosis, primarily by sputum smear microscopy
3. Uninterrupted supply of quality drugs
4. Directly observed treatment (DOT)
5. Systemic monitoring and accountability
DOTS Strategy
DOTS is a systematic strategy which has five components:
• Political and administrative commitment. – TB is the leading infectious cause of death . –
Since TB can be cured and the epidemic reversed, it warrants the topmost priority as given
by GoI.
• Good quality diagnosis. – Good quality microscopy is essential to identify the infectious
patients who need treatment the most.
• Good quality drugs. – An uninterrupted supply of good quality anti-TB drugs must be
available.
• Directly observed treatment short-course chemotherapy – The DOTS strategy along with
the other components of the Stop TB strategy, implemented under the Revised National
Tuberculosis Control Programme (RNTCP) in India, is a comprehensive package for TB
control.
• Systematic monitoring and accountability. – The programme is accountable for the
outcome of every patient treated. The RNTCP shifts the responsibility for cure from the
patient to the health system.
Unique features of RNTCP
• District TB Control Society
• Modular training
• Patient wise boxes
• Sub-district level supervisory staff (STS, STLS) for treatment & microscopy
• Robust reporting and recording system
DIAGNOSTIC ALGORITHM OF PULMONARY TB

Identification of Tuberculosis Suspects
The most common symptom of pulmonary TB is persistent cough, usually with
expectoration.Persistent cough may be accompanied by other symptoms such as weight
loss, tiredness, fever with evening rise, night sweats, chest pain, shortness of breath,
anorexia and haemoptysis.
Pulmonary TB Suspects
Pulmonary smear-positive tuberculosis patients expel tubercle bacilli into the air while
coughing/sneezing. Contacts of undiagnosed/untreated pulmonary smear-positive patients
become infected when they inhale these tubercle bacilli.
A pulmonary TB suspect is defined as:

● An individual having cough of 2 weeks or more
● Contacts of smear-positive TB patients having cough of any duration
● Suspected/confirmed extra-pulmonary TB having cough of any duration
● HIV positive patient having cough of any duration
Persons having cough of 2 weeks or more, with or without other symptoms, are referred to
as pulmonary TB suspect. They should have 2 sputum samples examined for AFB.
A patient with extra-pulmonary TB may have general symptoms like weight loss, fever with
evening rise and night sweats. Other symptoms depend on the organ affected.
Examples of these symptoms are, swelling of a lymph node in TB lymphadenitis, pain and
swelling of a joint in TB arthritis, neck stiffness and disorientation in a case of TB meningitis.
Patients with EP TB who also have cough of any duration, should have sputum samples
examined. If the smear result is positive, the patient is classified as pulmonary TB and his/
her treatment regimen will be that of a case of smear-positive pulmonary TB.
In a health facility, atleast 2% of new adult out-patients are estimated to be TB suspects.
However, it can vary greatly in secondary and tertiary level health care settings. In a DMC,
on an average, 5-15% of TB suspects are expected to have sputum smear-positive
pulmonary TB.
Referral for Sputum Examination

Pulmonary TB suspect (PTB suspects) at designated microscopy centers (DMC) are subjected
for two sputum examinations, with one of them being a morning sputum specimen. PTB
suspects attending health facilities other than DMC, are either referred to the nearest DMC
for sputum examination or their sputum specimens are collected and transported to the
DMC as per guidelines.
Results of sputum tests should be reported within a day. In case the patient is not able to
travel to the DMC, then both the morning and the spot specimens could be collected at the
nearest health facility or sputum collection centre and transported to the DMC.
Designated Microscopy Centre
Generally, a PHI covering a population of 1 lakh and having a new adult OPD attendance of
atleast 100 per day is selected as a DMC. In difficult areas, more laboratories are required.
Hence, in such areas, a PHI may be allowed to function as a DMC even if it covers a
population of 50,000 and has a new adult OPD attendance of 60-100 per day. In addition,
DMCs can be established in private or NGO or other public sector undertakings (other than
Health Ministry) which fulfills the criteria.
The DMCs should satisfy the following criteria:

1. A qualified and RNTCP trained laboratory technician should be present
2. A functional Binocular Microscope should be present in the laboratory
3. Physical infrastructure in laboratory should meet RNTCP guidelines
4. Daily new adult OPD of at least 60-100 and/or workload of at least 3-5 sputum smears per
day for the laboratory technician in the laboratory.
5. The laboratory should be under functional RNCTP Quality Assurance Programme. RNTCP
laboratory form for sputum examination has to be filled by the Medical Officer/ Health
worker of the health facility appropriately and sent along with the patient for sputum
examination.
There are 2 basic approaches for the diagnostic of tuberculosis:

Direct and indirect
DIRECT METHODS include:
● Sputum smear microscopy
● Culture
● Chest X-ray
● Rapid methods (micro cultural methods)- BACTEC
● PCR
● Phenotypic methods- Phase Based assays
INDIRECT METHODS:
● Antibody detection by TB STAT-PAK

● ELISA test
● Restriction Fragment Length Polymorphism (RFPL)
● FTB (Fast Plaque TB)
● QTB-G (Quantiferon TB Gold)
● Tuberculin Test
Sputum Microscopy
Sputum smear microscopy is the most widely used and acceptable testing tool for
diagnosing smear-positive pulmonary TB. Ziehl-Neelsen staining technique is used in RNTCP.
Sputum microscopy has the following advantages:
● Simple, inexpensive, requires minimum training

● High specificity
● High reliability with low inter-reader variation
● Can be used for diagnosis, monitoring and defining cure
● Results are available quickly
● Feasible at peripheral health institutions
● Correlates with infectivity in pulmonary TB cases
Therefore, this is the key diagnostic tool used for case detection in RNTCP.
X-ray
Chest X-ray as a diagnostic tool is more sensitive but less specific with higher inter and intra
reader variation. However, it should be used judiciously. It should always be preceded by a
repeat sputum smear examination, following treatment with antibiotics (refer to diagnostic
algorithm). It is also useful for diagnosing extra pulmonary TB like pleural effusion,
pericardial effusion, mediastinal adenopathy and miliary TB. The following are the
limitations of chest X-ray as a diagnostic tool:
● High inter and intra-reader variation
● No shadow is characteristic of TB
● 10–15% culture-positive cases remain undiagnosed (under reading)
● 40% patients diagnosed as having TB by X-ray alone may not have active TB
diseaseover reading).
Sputum smear microscopy is the primary tool for diagnosing TB as it is more specific and has
less inter and intra-reader variability than X-ray.
Methods of Sputum C&DST

• Solid Culture – ( LJ Method) -2-3 months – Used both for diagnosis & follow up
• Liquid Culture: - 2-4 weeks for diagnosis - only used for diagnosis
• LPA – Line Probe Assay (Molecular test) – 3 days for diagnosis – Only used for diagnosis
• CBNAAT (Cartridge Based Nucleic Acid Amplification Test)- can diagnose TB and
Rifampicin resistance within 2 hours
DRUG MANAGEMENT
Daily regimen for previously treated TB cases
• IP will be of 12 weeks, where injection Streptomycin will be stopped after 8 weeks
• The remaining four drugs in daily dosages as per weight band for another 4 weeks
• No need of extension of IP
• At the start of CP, Pyrazinamide will be stopped
• Rest of the drugs will be continued for another 20 weeks as daily dosages.
Daily regimen for new TB cases:

• Treatment in IP will consist of 8 weeks of INH, Rifampicin, Pyrazinamide and
Ethambutol in daily dosages as per four weight bands categories
• There will be no need for extension of IP
• Only Pyrazinamide will be stopped in CP
• Other three drugs will be continued for another 16 weeks as daily dosages
LONG-TERM FOLLOW-UP:
● After completion of treatment, the patient should be followed up at the end of 6, 12,
18 and 24 months
• Any clinical symptoms and/or cough, sputum microscopy and/or culture should be
considered (New addition)
(no provision of long-term follow-up in the previous guidelines)
DRUG-SENSITIVE TB REGIMEN
Previous guidelines:
• Standard intermittent regimen
• Treatment under direct observation of Dots provider (DP)
• Category decided by MO (category I/II)
• Drugs to be taken 3 times a week under direct observation of DP,
1. Intensive phase (IP) for 2–3 months – all doses given under supervision
2. Continuation phase (CP) for 4–5 months – first dose of the week given under
supervision.
DRUG-SENSITIVE TB REGIMEN
New guidelines:
Principle of treatment of TB has been shifted towards daily regimen with administration of daily
fixed dose combination of first-line ATD as per appropriate weight bands.
Multidrug-resistant Tuberculosis (MDR-TB)

MDR-TB is defined as tuberculosis disease where the bacilli is resistant to isoniazid (H) and
rifampicin (R), with or without resistance to other drugs. Irregular consumption and
frequent interruption in taking treatment for TB is the most common cause of acquiring
multidrug resistance. In India, MDR-TB amongst new cases are estimated at 2- 3% and
amongst re-treatment cases at 14-17%.
Extensively Drug Resistant TB (XDR–TB) is a subset of MDR-TB where the bacilli, in addition
to being resistant to R and H, are also resistant to fluoroquinolones and any one of the
second-line injectable drugs (namely Kanamycin, Capreomycin or Amikacin). Although XDR-
TB has been reported in India, its magnitude remains undetermined as yet due to the lack of
laboratories being capable of conducting quality assured second line drug susceptibility
testing.
In India, a great concern is the potential threat of drug resistant TB (DR-TB) with the existing
unregulated availability and injudicious use of first and second line anti-TB drugs in the
country.
Diagnosis of Drug Resistant-TB

Culture of Mycobacterium tuberculosis bacilli is a very sensitive and specific tool. It is the
gold standard for evaluating other tools of diagnosis. It is mainly used for the diagnosis of
drug resistant TB as it is expensive (liquid culture systems) and time consuming (solid
culture). Drug susceptibility testing using the proportion susceptibility method is the
accepted gold standard.
Diagnostic Tools for MDR-TB / XDR TB

Drug resistant TB (MDR/XDR and other types) is a laboratory based diagnosis either
phenotypically i.e., growing the bacteria (culture) and demonstrating the ability of bacteria
to grow in the presence of the anti-TB drugs (drug sensitivity testing - DST) or genotypically
by demonstrating the presence of resistance genes using molecular methods.
The conventional and newer rapid tools used for diagnosis are:
● Solid culture medium - Egg-based Lowenstein Jensen or Agar-based 7H11/10
medium
● Liquid culture medium – Commercial automated MGIT 960.
Newer Rapid Diagnostic Tools include:
● Non-commercial solid culture methods – Nitrate Reductase Assay using the

property of M.Tb to reduce nitrate to nitrite as means of detection of drug
resistance.
● Non-commercial liquid culture methods include – Microscopic observation of drug
susceptibility assay (MODS) using 7H9 medium in microtitre wells and observing
growth using an inverted microscope for both culture and DST.
● Liquid culture system – Mycobacteria growth indicator tube system (MGIT) available
in automated (MGIT-960) and MGIT manual systems. This can detect growth of
mycobacteria as early as 4 days from inoculation and DST will be available in 21-28
days.
● Molecular Assays – PCR based technologies using various modifications are used for
detecting the presence of putative resistance genes (rpoβ for rifampicin, katG and
inhA for INH etc). The most widely evaluated and used assays are Line Probe Assays
(LPA) which are based on in-situ hybridization on nitrocellulose strips of specific
genetic targets for resistance genes. These are now available for RIF and INH
resistance (MDR-TB) and will be shortly available for XDR-TB (resistance to
aminoglycosides, polypeptides, fluoroquinolones and ethambutol).
● Newer tools under evaluation include, Cepheid GeneXpert – a completely closed
automated system using real-time PCR which has a sensitivity of 70-90% even for
smear negative cases and can also detect the presence of rifampicin resistance.
DRUG RESISTANT TB
• Introduction of new ATD under RNTCP - Bedaquiline (BDQ)

• New class of drug, diaryl-quinoline
• MOA = targets MTB-ATP synthase, which is essential for supply of energy to the bacterium
• Has strong bactericidal and sterilizing activities against MTB
Advantages-
1. No cross-resistance with first and second-line ATD
2. Significant benefit in improving the time to culture conversion in MDR-TB patients
• Basic criterion –
1. Adult aged ≥18 years having pulmonary MDR TB
2. Non-pregnant females
Multi-drug resistant tuberculosis and DOTS-Plus

Although the standardized drug regimens used by RNTCP are highly effective, with low
failure rates of around 2% and 6% amongst Category I and II cases respectively, the issue of
the treatment of those pulmonary tuberculosis patients who remain smear-positive
following a fully supervised Cat I, II or III treatment regimen, has previously not been well
addressed by the RNTCP.
Although these cases represent a small minority of the overall caseload of TB patients in
India, they are an important group from epidemiological and human rights viewpoint. Also,
although small in relation to percentages and proportions, these rates translate into large
absolute numbers. Moreover, MDR-TB patients often live a number of years before
succumbing to the disease. Therefore MDR-TB prevalence may be three times greater than
its incidence.
After successfully establishing the DOTS services across the country RNTCP is now
introducing the DOTS Plus services to address the needs of this group of patients.
The RNTCP views the treatment of MDR-TB patients as a “standard of care” issue.
Recognizing that the treatment of MDR-TB cases is very complex, the treatment will follow
the internationally recommended 6 DOTS-Plus guidelines and will be done in designated
RNTCP DOTS-Plus sites.
These sites will be in highly specialized centres (e.g. Medical College hospitals, Chest and
respiratory disease institutes etc.) which will have ready access to an RNTCP accredited
culture and DST laboratory, with qualified staff available to manage patients using
standardized second-line drug regimens given under daily DOT and standardized follow-up
protocols, have systems in place for an initial short period of in-patient care to stabilise the
patient on the second-line drug regimen followed by ambulatory DOT and with a logistics
system and standardized information system in place.
Each DOTS Plus site will cater to approximately 10 million population. However this norm is
neither limiting nor restrictive and will be reviewed and revised periodically. The DOTS-Plus
sites will be initiated in a phased manner similar to that for the establishment of the culture
and DST laboratory network.
RNTCP DOTS Plus vision

It is envisioned that by the year 2010 the DOTS Plus services will be introduced in all the
states across the country. By 2012, it is aimed to extend these services to all smear positive
retreatment cases and new cases who have failed an initial first line drug treatment. And by
2015, these services will be made available to all smear positive pulmonary TB cases
registered under the programme. It is intended to treat at least 30,000 MDR cases annually
by 2012-13.
Special considerations for DOTS-Plus

DOTS-Plus is more complex than the basic DOTS strategy. For DOTS-Plus to be successful,
special attention is needed for the following:
• Quality-assured laboratory capacity (smear, culture and DST);
• Treatment design;
• Adherence to difficult-to-take regimens for long periods;
• Side-effect management;
• Drug procurement
; • Recording and reporting; and
• Human and financial resource constraints.
The method of case finding is designed taking into consideration the resources and technical
capacity available to the RNTCP at this time. Also the DOTS-Plus treatment regimen for
MDR-TB has been tailored to the Indian setting. Many health care providers have little or no
experience with second-line drugs and their side effects, 7 especially in combinations of 4 to
6 at a time. The framework presented in this document is designed to address the
challenges faced by RNTCP in relation to MDR-TB in India.
Patient wise drug boxes

• Drugs are supplied in patient-wise boxes (PWB) containing the full course of treatment,
and packaged in blister packs. The PWB have a color code indicating the two regimen - Red
for “New”, Blue for “Previously Treated”. In each PWB, there are two pouches one for
intensive phase and one for continuous phase.
• In the intensive phase, each blister pack contains one day’s medication. For the
continuation phase, each blister pack contains one week’s supply of medication. The drugs
for extension of the intensive phase (prolongation pouches) are supplied separately.
TB-HIV collaborative activities

Specific TB-HIV collaborative activities undertaken are:
• Establishment/Strengthening NACP-RNTCP coordination mechanisms at national,
state and district level
• Scaling up of intensified TB/HIV package of services across the country
• Joint M&E including standardized reporting shared between the two programmes
• Training of the programme and field staff on HIV/TB
• TB and HIV service delivery co-ordination
• Offer of HIV testing to TB patients
• Intensified TB case finding at ICTCs & ART
• Linking of HIV-infected TB patients to NACP for HIV care and support and to RNTCP
for TB treatment
• Provision of Co-trimoxazole Prophylactic Treatment (CPT)⎫ for HIV infected TB
patients
• Involvement of NGOs/CBOs and affected communitiesè working with NACP and
RNTCP for all activities on TB/HIV collaboration
• Operational research to improve the implementation andè impact of TB/HIV
collaborative activities
NATIONAL FRAMEWORK FOR JOINT HIV/TBCOLLABORATIVE ACTIVITIES
INTRODUCTION
The adult HIV prevalence in India is estimated to be 0.27 % translating into 2.1 million
people living with HIV/AIDS (PLHIV) in 2011. This is third highest burden in the world. On the
other hand, India is highest Tuberculosis (TB) burden country in the world with an estimated
2.2 million new TB cases occurring annually. HIV/TB together is a fatal combination with
extremely high death rates (15 to 18%) reported among HIV-infected TB cases notified
under Revised National TB Control Programme (RNTCP). Early detection of HIV/TB cases and
prompt provision of Anti-Retroviral Treatment (ART) and Anti-TB Treatment (ATT) are key
interventions to reduce mortality rates significantly.
Purpose of National Framework: 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 access to 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 management of HIV and TB together.
Existing HIV/TB Collaborative Activities

1. Strong NACP-RNTCP coordination mechanisms at national, state and district level
2. Joint monitoring and evaluation with standardized reporting shared between NACP and
RNTCP
3. Joint training of key programme and field staff in HIV/TB activities
4. Operational research to strengthen implementation of HIV/TB Collaborative Activities
5. Implementation of basic infection control measures at ART centres e.g. fast tracking
6. Specific service delivery coordination activities are as follows:
Activities to reduce burden of HIV among TB patients:

a) Provider initiated HIV testing and counselling (PITC) among TB patients
b) Provision of co-trimoxazole preventive therapy (CPT) for HIV infected TB patients
c) Provision of Anti-Retroviral Therapy (ART) for HIV infected TB patients
d) Provision of HIV prevention education for patients with presumptive or diagnosed TB
cases
Activities to reduce burden of TB among HIV infected individuals:

a) Intensified (TB) case finding (ICF) at ICTC
b) Intensified (TB) case finding (ICF) at ART centres and Link ART centres
c) Air borne infection control measures for prevention of TB transmission at HIV care
settings
d) Implementation of Isoniazid preventive treatment (IPT) for all PLHIV (On ART + Pre-ART)
What is new in National Framework ?
1. Emphasis on Integrated TB and HIV services e.g. HIV screening at RNTCP DMC
2. Focus on early detection and early care:
a. Early detection of TB in PLHIV:
i). Early suspicion of TB–symptoms of any duration among PLHIV
ii). Use of an expanded clinical algorithm for TB screening that relies on presence of four
clinical symptoms (current cough, weight loss, fever or night sweats) instead of only cough,
to identify patients with presumptive TB
iii). Strengthen ICF at ART, Link ART centre (LAC) and Targeted intervention projects (TI) for
High Risk Group (HRG) specially Injection Drug Users (IDU)
b. Early detection HIV/TB:
i). Enhance HIV testing facilities in settings with lack of co-located HIV and TB testing
facilities, by establishing HIV screening services using whole blood finger prick test (WBT)
ii). Strengthen HIV testing of TB patients in high HIV prevalent settings by promoting
establishment of Facility Integrated Counselling and Testing Centre(F-ICTC) where DMC
exists
iii). PITC among patients being evaluated by diagnostic smear microscopy presumptive TB
cases in high HIV prevalent settings
c. Early Care:
i. Strengthened linkage of HIV/TB patients to ART centres through travel support by RNTCP
as per NSP (2012-2017) etc.
ii. ART for HIV infected TB cases irrespective of CD4 count
iii. Prompt ART initiation- within first 8 weeks of commencing Anti-TB treatment.
iv. Monitoring of timeliness of ART initiation through expanded ART reporting formats
3. Early detection and care of HIV infected Drug Resistant TB patients (DR-TB/HIV):
i. Strengthen HIV testing in presumptive DR-TB cases (Criteria C)
ii. Ensure access to culture and drug susceptibility testing for HIV infected TB patients
iii. Prompt linkage of HIV infected DR-TB cases to ART centres
iv. Prompt initiation of ART in HIV infected DR-TB cases
4. Prevention of TB among HIV infected adults and children:
i. Implementation of IPT for all PLHIV (On ART + Pre-ART)
ii. Strengthen implementation of air borne infection control strategies.
5. Strengthen HIV/TB activities among children and pregnant women
6. Promotion of participation of private, NGO, CBO health facilities and affected
communities working with NACP and RNTCP to strengthen HIV/TB Collaborative Activities.
INTESIFIED TB CASE FINDING AT ART CENTRES

The ART centers Medical officer should have high index of suspicion for TB and ensure
that TB disease in clients attending ART centre is not missed.This provisional guidance is
intended to define the minimum standard for TB disease screening among clients
attending ART centers. This guidance expected to evolve, as ongoing and planned
operational research will clarify the optimum screening and diagnostic procedures for
TB.
Counselors & Other Para-medical stair of ART Center: Screen all patients (even if no
complain) for the following signs and symptoms of TB.
If symptoms are suspicious for TB disease are present:

ART Centre health staff to refer patient to ART MO far clinical evaluation
ART Centre medical officer to refer patient the same day for:
1. Sputum microscopy to the institutional Designated Microscopy Centre
2. Chest X Ray, if indicatcd as per NACO ART guidelines
3. F0r additional investigations as clinically indicated in ART guidelines like FNAC,
Ultrasound
All patients encounter at ART centre following:
● Pre-ART registrations and follow up visits.
● ART initiation
● Monthly visit to ART centre
● Unscheduled follow up visits
TB diagnosis and treatment
● It should be based on diagnostic algorithm
● All patients diagnosed with TB should be initiated on RNTCP DOTS as quickly as
possible and referred to DOTS centre near their residence.
● Feedback need to be provided to ART centre
REVISED SCHEMES FOR NGOS AND PRIVATE PROVIDERS
RNTCP recognizes the need for involvement of all sectors-public and private : to create an
epidemiological impact of Tuberculosis controlThe NGOs and private providers are
considered closer to and more trusted by patients and perform an active role in health
promotion in the community.
There are 2500 NGOs, 25000 PPs; 260 Medical colleges and I5O corporate houses. which are
providing DOT services.
Following areas are identified for collaboration with NGO:
1. TB advocacy, communication and social mobilization scheme
2. Sputum collection scheme
3. Sputum pickup and transportation scheme
4. Designated Microscopy Centre Scheme
5. Laboratory Technician Scheme
6. Culture-DST scheme
7. Treatment adherence centre
8. Urban slum scheme
9. Scheme for tuberculosis unit
10. TB-HIV scheme
RNTCP has interacted with other major organization like Confederation of Indian
Indutries, World Economic Forum, Bharat Heavy Electrical Limited.
TB SURVEILLANCE
● This ICT (information communication technology) application (Nikshay) was
launched on 15th May 2012 by NIC (National informatics centre) (HQ) and central TB
division.
● The data entry of the individual TB cases is being done at the block level DEO’S (data
entry operator) of NHM.
● The system has been extended to include drug resistant TB cases, online referral and
transfer of patients.
● Govt of india had declared TB as a notifiable disease on 7th May 2012. All public and
private health providers shall notify TB cases diagnosed and or treated by them to
the nodal officers for the TB notifications.
Objectives of Nikshay:
a) Short term:
1. To improve Tuberculosis surveillance in the country.

2. To facilitate individual patient wise monitoring & tracking of TB treatment.
3. To automate reporting, once the case wise data is regularly entered and update.
4. To facilitate online referral/transfer mechanism with real time information transmission

to prevent patient loss.
5. To monitoring of TB Treatment saving the lead time in hard copy updating in TB register,
6. To make available of real time data at block & district for prioritized, focused supervision.
7. To create electronic Database of all TB patient details for further in depth analysis.
8. Effective Programme management (e.g. e HRD, e procurement e-supply chain, e~cash

transfer).
b) Long term:
1. Linking the TB Database with UID (2016-17) for extending social welfare schemes
2. Disease trend & pattern studies for geographical understanding for epi-foci, using GIS for
a. Contact tracing
b. Identification of local / focal epidemics of MDRTB,

c. Outbreaks investigation of XDR-TB
The Users of Nikshay is National (CTD), State (State TB Cell, State TB Demonstration Centre),
District (District TB Cell), Tuberculosis Unit, Culture and Drug Sensitivity Laboratory, DR-TB
Centre, State Drug Store. Details entered in this software are TB patient registration,
diagnosis, treatment details, DOT provider details, follow-up smear examination details,
treatment adherence details, HIV details, chemoprophylaxis details, health Establishment
registration, TB patient notification entry, contractual staff details.
Facilities provided by the Government for general public and TB patients:

● Diagnosis of TB with advanced technologies free of cost.
● Free- of- Cost treatment of all forms of TB.
● TB patients notified to RNTCP get Rs 500 per month through Direct Benefit Transfer
in their bank account. This is applicable to patients registered on or after 1st April
2018. It is required to provide bank account number for transfer of amount.
● Travel support of Rs 750/- to TB patients belonging to Scheduled Tribal Areas.
Financial Incentives for treatment supporters:

● New Case for Private Providers - Rs. 500 for notification and Rs. 500 for treatment
completion (total Rs. 1000).
● Incentives for Treatment Supporter –
a.) Rs. 500 for notification and Rs. 500 for treatment completion (total Rs. 1000).
b.) Multi-drug Resistant/Rifampicin Resistant TB - Rs. 2000 at the end of intensive phase and
Rs. 3000 at completion of treatment.
National strategic plan (2017-25)
GOALS AND OBJECTIVES

• The goal of the national strategic plan is to achieve universal access of quality of TB diagnosis and
treatment of all TB patients in the community.
The objectives are:

1. 90% notification rate for all cases
2. 90% success rate for all new and 85% for re-treatment cases
3. To significantly improve the successful outcome of treatment for DRTB cases
4. To achieve decreased morbidity and mortality for HIV-associated TB cases
5. To improve the outcome of TB care in the private sectors
Aim is to :
• Bring about changes in Incidence, prevalence and mortality of TB
• Attain Global End TB targets five years ahead of SDGs
• RNTCP has been further strengthened including improvement in DOTS services

• Establishment of sub district level management unit with health system under NHM
• Improvement in diagnostics at field level
• Engagement of all care providers
• Improvement in rapid diagnostics
• Strengthening of urban TB control
• Expanding diagnosis and treatment of DR TB
• GoaI aims to eliminate TB by 2025
• Using 4 strategic pillars
VISION: TB-Free India with zero deaths, disease and poverty due to TB
GOAL: to achieve a rapidly decline in TB, morbidity and mortality while working towards elimination
STRATEGY PILLAR
Detect:
The first objective of NSP is to find all drug sensitive TB cases (DS-TB) and drug resistant TB
cases (DRTB) with an emphasis on reaching TB patients seeking care from private providers and
undiagnosed TB cases in high-risk populations (such as prisoners, migrant workers, people living
with HIV/AIDS, contacts etc.).
Early diagnosis and treatment of TB cases in the community is an important step in TB
elimination, which will help in decreasing the risk of transmission of disease to others, poor
health outcomes, and social and economic hardships of the patient and their family.
Notification of TB cases: Notification of all TB patients from all health care providers is

made mandatory by Ministry of Health and Family Welfare, Government of India since 2012. All
health care providers (clinical establishments run or managed by government (including local
authorities), private, or NGO sectors, and /or individual practitioners) should notify every TB case
to local health authorities (district health officer, chief medical officer of a district, and municipal
health officer of a municipal corporation/ municipality) every month. With its amendment in 2015,
all laboratories are also included to notify TB cases.
Till now, only medical practitioners, hospitals and laboratories were notifying TB patients to
government health system, now according to ‘Mandatory TB notification Gazette for private
practitioners, chemists and public health staff’ March 2018, all chemists will also inform about TB
patients for whom they have dispensed the TB drugs. TB patients themselves are also
encouraged to notify themselves. Every TB patient will be attempted to reach out by the local
public health authority, namely, District Health Officer or Chief Medical Officer of a District and
Municipal Health Officer of urban local bodies, so that the incentives and support to patients,
families and communities can be properly extended.
NIKSHAY: To facilitate TB notification, RNTCP has developed a case-based web-based TB

surveillance system called “NIKSHAY” (https://nikshay.gov.in ) for both government and private
health care facilities. Future enhancements under NIKSHAY are for patients support, logistics
management, direct data transfers, adherence support and to support interface agencies which
are supporting programme to expand the reach.
Public private partnership: For promotion of public-private mix (PPM) in TB prevention and

care, private providers are provided incentives for TB case notification, and for ensuring
treatment adherence and treatment completion. The incentives are provided through direct
beneficiary transfer.
The incentives to the Private Sector TB Care Provider are as follows :
 Rs 250/- on notification of a TB case diagnosed as per Standards for TB Care in India

(STCI)
 Rs 250/- on completion of every month of treatment
 Rs 500/- on completion of entire course of TB treatment
 Rs 2750/ for notification and management of a drug-sensitive patient over 6-9 months as
per STCI
 Rs 6750/-for notification and correct management of a drug-resistant case over 24
months as per STCI
Free drugs and diagnostic tests to TB patients in private sector- Free drugs and
diagnostic tests are provided to TB patients seeking treatment from private health sector. There
are two approaches for ensuring access to free drugs and diagnostic tests to TB patients in
private sector, first is access to programme- provided drugs and diagnostics through attractive
linkages; and second is reimbursement of market- available drugs and diagnostics.
Significant cost reduction of select diagnostics is achieved by ‘Initiative for Promoting Affordable
and Quality TB Tests’ (IPAQT). 131 private sector labs networked to provide four quality tests for
TB at or below the ‘ceiling prices.
For TB diagnosis more than 14,000 designated microscopy centres spread across the country.
Cartridge Based Nucleic Acid Amplification Tests (CBNAAT) / Line Probe Assay (LPA) have
been established at district levels for decentralised molecular testing for drug resistant TB.
Reference laboratories have been established at state and national levels which provide culture
and dug sensitivity test (DST) services as well as molecular diagnosis.
Treat:
Next step under the programme is initiation and sustaining all TB patients on appropriate anti-TB
treatment wherever they seek care, with patient friendly system and social support. Provision of
free TB drugs in the form of daily fixed dose combinations (FDCs) for all TB cases is advised with
the support of directly observed treatment (DOT).
(DOT is a specific strategy, to improve adherence by any person observing the patient taking
medications in real time. The treatment observer does not need to be a health-care worker, but
could be a friend, a relative or a lay person who works as a treatment supervisor or supporter. If
treatment is incomplete, patients may not be cured and drug resistance may develop).
Screening of all patients for rifampicin resistance (and for additional drugs wherever indicated) is
done. For drug sensitive TB, daily fixed dose combinations (FDCs) of first-line anti-tuberculosis
drugs in appropriate weight bands for all forms of TB and in all ages should be given. First line
treatment of drug-sensitive TB consists of a two-months (8weeks) intensive phase with four drug
FDCs followed by a continuation phase of four months (16 Weeks) with three drug FDCs.
For new TB cases, the treatment in intensive phase (IP) consists of eight weeks of Isoniazid
(INH), Rifampicin, Pyrazinamide and Ethambutol (HRZE) in daily doses as per four weight band
categories and in continuation phase three drug FDCs- Rifampicin, Isoniazid, and Ethambutol
(HRE) are continued for 16 weeks.
For previously treated cases of TB , the Intensive Phase is of 12 weeks, where injection
streptomycin is given for 8 weeks along with four drugs (INH, Rifampicin, Pyrazinamide and
Ethambutol) and after 8 weeks the four drugs (INH, Rifampicin, Pyrazinamide and Ethambutol) in
daily doses as per weight bands are continued for another four weeks. In continuation phase
Rifampicin, INH, and Ethambutol are continued for another 20 weeks as daily doses.
The continuation phase in both new and previously treated cases may be extended by 12-24
weeks in certain forms of TB like skeletal, disseminated TB based on clinical decision of the
treating physician.
Patients eligible for retreatment should be referred for a rapid molecular test or drug susceptibility
testing to determine at least rifampicin resistance, and preferably also isoniazid resistance status.
On the basis of the drug susceptibility profile, a standard first-line treatment regimen
(2HRZE/4HR) can be repeated if no resistance is documented; and if rifampicin resistance is
present, shorter regimen for MDR-TB (multi drug resistant TB) regimen should be prescribed
according to WHO’s recent drug resistant TB treatment guidelines.
RNTCP has introduced Bedaquiline CAP for MDR-TB under conditional access programme in
2016 across six sites, with a country wide scale up plan in 2017-2020.
Nikshya poshak yozana: It is centrally sponsored scheme under National Health Mission
(NHM), financial incentive of Rs.500/- per month is provided for nutritional support to each
notified TB patient for duration for which the patient is on anti-TB treatment. Incentives are
delivered through Direct benefit transfer (DBT) scheme to bank accounts of beneficiary*.
Expending options for ICT based treatment adherence support mechanisms:
 Mobile based “Pill-in-Hand” adherence monitoring tool
 Interactive Voice Response (IVR), SMS reminders.

 Specially designed electronic pill boxes or strips with GSM connection and pressure
sensor
 Patient Compliance toolkit: a mobile app for patients to report treatment compliance
using video, audio or text message
 Automated pill loading system
 innovatively designed ICT enabled smart cards SMS gateway
Intensifying TB control activities in following key populations is addressed in

NSP:
 TB-HIV
 Diabetics, Tobacco use and Alcohol dependence
 Poor, undernourished, economically and socially backward communities

 TB control in hilly and difficult terrains
 Substance dependence and sexual minorities
 TB and pregnancy
 Paediatric population
 Prison Inmates and staff of prisons/jails
 management of extra pulmonary TB
Prevent:
With the objective to prevent emergence of TB in susceptible population various measures are
indicated as:
 Scale up air-borne infection control measures at health care facilities
 Treatment for latent TB infection in contacts of bacteriologically-confirmed cases

 Address social determinants of TB through intersectoral approach.
a) Air borne infection control measures-TB infection control is a combination of

measures aimed at minimizing the risk of TB transmission within population and hospital and
other settings. The foundation of such infection control is:
 Early diagnosis, and proper management of TB patients.

 Health education about cough etiquettes and proper disposal of sputum by patient.
Cough etiquette means covering nose and mouth when coughing or sneezing. This can
be done with a tissue, or if the person doesn’t have a tissue they can cough or sneeze
into their upper sleeve or elbow, but they should not cough or sneeze into their hands.
The tissue should then be safely disposed of.
 Houses should be adequately ventilated.
 Proper use of air borne infection control measures in health care facilities and other
settings
b) Contact tracing-Since transmission can occur from index case to the contact any time
(before diagnosis or during treatment) all contacts of TB patients must be evaluated. These
groups include:
 All close contacts, especially household contacts

 In case of paediatric TB patients, reverse contact tracing for search of any active TB case
in the household of the child must be undertaken.
 Particular attention will be paid to contacts with the highest susceptibility to TB infection
c) Isoniazid Preventive Therapy (IPT)- Preventive therapy is recommended to Children <
6 years of age, who are close contacts of a TB patient. Children will be evaluated for active TB
by a medical officer/ pediatrician and after excluding active TB he/she will be given INH
preventive therapy
In addition to above, INH preventive therapy will be considered in following situation:
 For all HIV infected children who either had a known exposure to an infectious TB case
or are Tuberculin skin test (TST) positive (>=5mm induration) but have no active TB
disease.
 All TST positive children who are receiving immunosuppressive therapy (e.g. Children
with nephrotic syndrome, acute leukemia, etc.).
 A child born to mother who was diagnosed to have TB in pregnancy will receive
prophylaxis for 6 months, provided congenital TB has been ruled out. BCG vaccination
can be given at birth even if INH preventive therapy is planned.
Close contacts of index cases with proven DR-TB (drug resistant-TB) will be monitored closely
for signs and symptoms of active TB as isoniazid may not be prophylactic in these cases.
d) BCG vaccination- It is provided at birth or as early as possible till one year of age. BCG
vaccine has a protective effect against meningitis and disseminated TB in children.
e) Addressing social determinants of TB like poverty, malnutrition, urbanization, indoor

air pollution, etc. require inter departmental/ ministerial coordinated activities and the programme
is proactively facilitating this coordination.
Build:
Health system strengthening for TB control under the National Strategic Plan 2017-2025 is
recommended in the form of building and strengthening enabling policies, empowering
institutions and human resources with enhanced capacities.
TB Notification
Tuberculosis has been declared a notifiable disease in India on 7th May 2012, with an
objective to improve diagnosis and case
management, to sccelente reduction of TB transmission and to prevent further drug

resistance.
99 DOTST
It was initially started in 2015 as an ICT-enabled system to improve compliance to
medication in patients receiving daily fixed dose combination (FDC) medications in high
bunden ART centers for HIV-TB coinfected patients. In 2016, it expanded to include all HIV
TB patients at all ART Centers in India. The blister pack of FDC-antituberculosis therapy (ATT)
contains hidden toll-free numbers which are revealed once the patient takes the tablets.
Once the patient takes a tablet he calls the toil free number from any phone as evidence
that he has consumed the medicine. The number sequence for every patient is unique and
can be used to track the treatment adherence of the patient from the platform by any
healthcare worker
Standards for TB Care
The International Standards for Tuberculosis Care, fremulated in 2009, is a set of 21

standards to monitor TB diagnosis, treatment, public health and prevention. Similarly
Standards for TB Care in India were released in 2014, which is a set of 27 standards that
govern the diagnosis and treatment of both PTB and EPTB and HIV-TB coinfection and other
comorbid conditions, public health, and prevention.
ACCORDING TO ANNUAL REPORT:

Dr Harsh Vardhan releases Annual TB Report 2020
24.04 lakh TB patients notified in 2019; 14% rise over 2018
Number of missing cases reduced to 2.9 lakh cases
HIV testing for all notified TB patients increased to 81% (2019) from 67%
(2018)
We need to come together to fight against TB and the stigma surrounding it:
Dr. Harsh Vardhan
Posted On: 24 JUN 2020 4:48PM by PIB Delhi
Dr Harsh Vardhan, Union Minister for Health and Family Welfare released the annual TB
Report 2020, in the presence of Shri Ashiwni Kumar Choubey, MOS (HFW), through a
virtual event. They also released a Joint Monitoring Mission (JMM) report, a manual on
Direct Benefit Transfer (DBT) to TB patients under NIKSHAY system, a Training Module,
and the quarterly newsletter NIKSHAY Patrika.
The key achievements listed in the Report include:
 Around 24.04 Lakh TB patients have been notified in 2019. This amounts to a 14%
increase in TB notification as compared to the year 2018.
 Achieving near-complete on-line notification of TB patients through the NIKSHAY
system.
 Reduction in the number of missing cases to 2.9 lakh cases as against more than 10
lakhs in 2017.
 Private sector notifications increased by 35% with 6.78 lakh TB patients notified.
 Due to easy availability of molecular diagnostics, the proportion of children
diagnosed with TB increased to 8% in 2019 compared to 6% in 2018.
 Provision of HIV testing for all notified TB patients increased from 67% in 2018 to
81% in 2019.
 Expansion of treatment services has resulted in a 12% improvement in the treatment
success rate of notified patients. For 2019 it is 81% compared to 69% in 2018.
 More than 4.5 lakh DOT Centers provide treatment covering almost every village
across the country.
 NIKSHAY also expanded the provision of four Direct Benefit Transfers (DBT) schemes
of the programme –
I. Nikshay Poshan Yojana (NPY) to TB patients
II. The incentive to Treatment Supporters
III. Incentive to Private Providers and
IV. Transport incentive to TB patients in the notified tribal areas
ROLE OF NURSE
• Planning and policy development
• Contact investigation
• Clinical and diagnostic services for patients with TB and their contacts
• Training and education
• Surveillance data and information management
• Monitoring and evaluation.
Planning and Policy Development

including a responsible case manager for each suspected and verified case of TB disease
• Provide provisions for expert consultation and oversight for TB-related matters to
• Provide special guidance to local laboratories that process TB-related samples
• Assist local authorities in conducting contact or outbreak investigations and directly
observed therapy (DOT); and
Clinical and diagnostic services for patients with TB and

their contacts
• nurse should ensure that patients with suspected or confirmed TB disease have
ready access to diagnostic and treatment services that meet national standards.
maintain close working relationships with
2. Pharmacies


prevention and control of TB. TB patients often receive care in a variety of settings,
including
2. Hospitals
3. HIV clinics
6. Nursing homes.
Training and Education TB control programs
aspects of TB to all program staff.

Surveillance and Information Management

intervals.


of DOT, and drug-drug interactions.

treatment plans.
Monitoring and Evaluation

• The systematic monitoring and evaluation of TB program activities is a critical factor
in enhancing program performance.
• Evaluation techniques provide TB programs with an evidence-based means of

assessing and improving their TB-control strategies by helping them understand


7. • Recognizing achievemen
Conclusion:
to eliminate TB in India by 2025, five years ahead of the global target, a framework to guide
the activities of all stakeholders including the national and state governments, development
partners, civil society organizations, international agencies, research institutions, private
sector, and many others whose work is relevant to TB elimination in India is formulated by
RNTCP as National Strategic Plan for Tuberculosis Elimination 2017-2025.
References
https://tbcindia.gov.in/showfile.php?lid=3322
https://tbcindia.gov.in/WriteReadData/NSP%20Draft%2020.02.2017%201.pdf
https://www.tbcindia.gov.in/WriteReadData/l892s/8337437943TOG-Chapter%204-Treatment
%20of%20TB%20Part%201.pdf
http://www.who.int/tb/careproviders/ppm/IPAQT.pdf
https://tbcindia.gov.in/showfile.php?lid=3314
https://www.tbfacts.org/wp-content/uploads/2017/12/NSP-2012-2017.pdf
*https://tbcindia.gov.in/showfile.php?lid=3319
RAJ KUMARI AMRIT KAUR COLLEGE
OF NURSING,LAJPAT NAGAR
PRESENTATION ON
REVISED NATIONAL
TUBERCULOSIS CONTROL
PROGRAMME
SUBMITTED TO SUBMITTED BY
MRS.SARITA SHOKANDA VAISHALI
ASST. PROFESSOR M.Sc. NURSING(F)
RAKCON RAKCON

NATIONAL AIDS CONTROL PROGRAMME 3rd Sem

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NATIONAL AIDS CONTROL

 According to UNAIDS/WHO estimates, 11 men, women and children were infected

The milestones of the programme are summarized as follows :

HIGH RISK GROUP

PREVELANCE IN INDIAN STATES

1. WHO clinical staging of HIV disease in adults, adolescents and children

Adults and adolescents Children

Pulmonary tuberculosis Oral hairy leukoplakia

Severe bacterial infections (such as Lymph node tuberculosis

Key Strategies under NACP-IV

3) Expanding IEC services

NATIONAL STRATEGIC PLAN FOR HIV/AIDS AND SEXUALLY

Based on the recommendations of a mid-term appraisal of NACP-IV held in 2016, the

Paving the way for an AIDS free India.

Managing Community Health in India

Table: Objectives and outcomes of NACP under NSP 2017-24

Facilitate sustainable NACP i. Integration of identified components of

• Accelerating HIV prevention in "at risk group" and key population.

Elimination of mother to child transmission of HIV and syphilis.

• Addressing the critical enablers in HIV programming.

Package of Services Under NACP IV¹9

Kit no. Syndrome Color Contents

KIT 2 Vaginitis/VD Green Tab. secnidazole 2 g

Kit 3 GUD/NH White Inj. benzathine

KIT 4 GUD-NH (for patient White Tab. doxycycline

KIT 5 GUD-H Blue Tab. acyclovir 400

KIT 7 IB Black Tab. doxycycline

Eliminate parent-to-child transmission of HIV and syphilis (e-PTCT)

Guidelines for diagnosis have been given along with

Management of sexual violence:

Postexposure prophylaxis against STI

HIV counseling and testing services (HCTS):

Integrated counseling and testing centers:

Prevention of parent-to-child transmission of HIV:

Prong 1: Primary Prong 2: Preventing

HIV/TB Collaborative activities:

Step 2: Establish eligibility for PEP

Depending upon the nature of exposure and status of source patient.

Step 3: Counseling for PEP

Explain risks and benefits of PEP and seek informed consent.

Step 4: Prescribe PEP

Iformation, Education and Communication (IEC)

Care, Support, and Treatment Services

Service delivery mechanism

ICTC Integrated counselling and testing center

WHO GUIDELINES FORTREATMENT:

Highly Active Anti Retroviral Therapy (HAART)

• ART at any CD4 count in PLHIV

When to start ART in people living with HIV:

1) Adults and adolescents (≥10 years):

Initiate ART if CD4 cell count ≤500 cells/mm3

Regardless of WHO clinical stage and CD4

2) Infants <1 year old

3) Children < 5 yrs old

Services offered under the Targeted Intervention Programme:

BLOOD TRANSFUSION SERVICE

IEC AND MAINSTREAMING

Behavior Change Communication