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Dr. B.B. Rewari WHO National Consultant (ART) National AIDS Control Organisation New Delhi

Overcoming Barriers: Road Map for Universal Access to Care, Support and Treatment in India Satellite Session XVI International Aids Conference Toronto, Canada,16 th August 2006. Dr. B.B. Rewari WHO National Consultant (ART) National AIDS Control Organisation New Delhi.

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Dr. B.B. Rewari WHO National Consultant (ART) National AIDS Control Organisation New Delhi

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  1. Overcoming Barriers:Road Map for Universal Access to Care, Support and Treatment in IndiaSatellite SessionXVI International Aids ConferenceToronto, Canada,16th August 2006 Dr. B.B. Rewari WHO National Consultant (ART) National AIDS Control Organisation New Delhi

  2. HIV/AIDS Epidemic in India-2005 Total: 5.206 m J & K Himachal Pradesh Punjab Chandigarh Delhi Haryana Arunachal Pradesh Sikkim Rajasthan Assam Uttar Pradesh Nagaland Meghalaya Bihar Manipur Tripura Mizoram Madhya Pradesh Gujarat West Bengal Daman & Diu Dadra Nagar Haveli Orissa Maharashtra >1%in Antenatal mothers >5% in High Risk Groups Andhra Pradesh <5% in High risk groups Goa Pondichery Karnataka Andaman & Nicobar Tamil Nadu Lakshwadeep Kerala BBR TORONTO 16-08-06 BBR TORONTO 16-08-06 2

  3. HIV Prevalence : States Reclassified BBR TORONTO 16-08-06

  4. Prevention Care Collaborate Build capacities Low risk populations High risk populations Care & support Inter-sectoral collab. Institutional Strengthening • Surveillance • Training • Monitoring and evaluation • Technical resource group • Operations research • Programme management • AIDS Vaccine Initiative • Targeted interventions • STD care and condom programming • Blood safety • Voluntary counselling and testing • Adolescents • IEC and social mobilisation • PPTCT • Community Care • Treatment of Opportunistic Infections • Prevention of Occupation Exposure • Scaling up of ART • Workplace interventions • Inter-ministerial links • Public Private Partnerships

  5. 4 Pillars of Management • 1. General management • 2. Treatment of Opportunistic Infections • 3. Chemo-prophylaxis against various O.Is • 4. Anti-retroviral therapy (ART). BBR TORONTO 16-08-06

  6. Benefits of Antiretroviral Therapy • Delays disease progression • Prevents severe OIs • Decreases rates of hospitalization • Decreases transmission of HIV • Increases survival and quality of life And… BBR TORONTO 16-08-06

  7. Benefits of Antiretroviral Therapy Restores Hope for Both Patients and Health Care Providers! BBR TORONTO 16-08-06

  8. FOUR CLASSES OF ANTIRETROVIRAL DRUGS Fusion Inhibitor: Enfuvirtide (T-20) BBR TORONTO 16-08-06

  9. IMPLEMENTATION OF ART IN INDIA PRINCIPLES AND GUIDELINES BBR TORONTO 16-08-06

  10. Objectives and Targets of National ART Programme: • To provide long-term ARV therapy to eligible patients • To monitor and report treatment outcomes on a quarterly basis • To attain individual drug adherence rates of 95% or more • To increase life span so that 50% of patients on ARV are alive 3 years after starting ARV • To ensure that 50% of patients on ARV therapy are engaged in their previous employment BBR TORONTO 16-08-06

  11. Details of the ART Initiative • Provide free access to ART for 100,000 PLHA by 2007;188,000 by 2010 in 6 HP states and Delhi and 300,000 by 2011all over the country • Eligibility • Children below 15 yrs of age • Women • PLHA with full blown AIDS • Access in phases, initially through 25 identified medical institutions, 54 at present,100 by July 2007, 250 by 2011(188 in 6 HP states and Delhi) BBR TORONTO 16-08-06

  12. ART Policy Package • Government commitment • Detection of eligible cases • Standardized combination ARV therapy • Regular, secure supply of ARV drugs • Monitoring system

  13. Regimen Under National Programme Zidovudine / Lamivudine / Nevirapine Or Stavudine / Lamivudine / Nevirapine ( Efavirenz in place of Nevarapine if coinfected with TB or side effects with NVP, Tenofovir under consideration for special situations)

  14. Relative Proportions of different Regimen Under National Programme The relative proportion of ZDV vs STV based combinations is 60:40. The relative proportion of STV 30 mg and 40 mg based combinations is 90:10 The relative proportion of NVP vs EFV is 80:20 .

  15. Number of ART service delivery points (GOI) BBR TORONTO 16-08-06

  16. ART centres in India NACO supported existing centres in India(54) NACO supported new centres in India(46) BBR TORONTO 16-08-06

  17. Access to ART in India BBR TORONTO 16-08-06

  18. Month-wise distribution of patients on ART(June-06) BBR TORONTO 16-08-06

  19. Distribution of Patients on ART in India BBR TORONTO 16-08-06

  20. NACO Recording and Reporting Tools ART Records Reports • Ongoing at Facility • Regimens • CD4 counts • Defaulters 3 - ART Registration Card (kept by patient) • Monthly • Monthly Report • New and continuing patients • Adherence • Drug stocks • NGOs 4 - Patient Care & Treatment Record 1 - Pre-ART Register 2 - ART Enrollment Register 5 - ARV Drug Dispensing Register 6 - Drug Stock Register • Quarterly/Annually • Cohort Report • Survival BBR TORONTO 16-08-06

  21. Distribution of patients in HIV care and patients started on ART (by age and sex) Children 4.6 % Children 5.1 % Women 37.1 % Women 31.2 % Men 64.2% Men 57.8% Started on ART* n=42,047 HIV care n=94,698 *Out of 42,047 patients started on ART, D4T+3TC+NVP was used in 61%

  22. Treatment outcome of patients at 6, 12 and 24 months after start of treatment 24 months (n=388) 6 months (n=5,241) 12 months (n=2,248) Stopped 1% Stopped 2% Stopped 2% Lost 8% Lost 9% Lost 13% Died 6% Died 8% Died 13 % Alive on ART 81% Alive on ART 73% Alive on ART 84% BBR TORONTO 16-08-06

  23. Initiating ART: Patient education • It is not curative, but prolongs life • Treatment is lifelong, expensive • High level of adherence is critical (>95%) • Short and long term adverse events • Drug interactions • Safer sex still essential • Do not share drugs with friends , family members Start ART when patient is ready BBR TORONTO 16-08-06

  24. Role of PLWHA Groups/NGOs in ART programme • In providing psycho-social support • In providing treatment literacy to HIV infected persons • In supporting drug adherence through peer counselling • Advocacy • Devising strategies to deliver care at each level of health care BBR TORONTO 16-08-06

  25. The value of Adherence BBR TORONTO 16-08-06

  26. Long Term Efficacy of HAARTNo Magic Bullet , No Miracle Adherence, adherence, adherence adherence adherence Good Attitude, Knowledgeable Doctors Simplified and potent HAART Proper Monitoring Committed Patients Ultimate Goal – Long term viral suppression -- Normalized CD4 counts -- Good quality of life BBR TORONTO 16-08-06

  27. Steps being taken to prevent emergence of Drug Resistance • Simple ART implementation guidelines. • Patient education & counselling on ensuring maximum levels of adherence. • Ensuring uninterrupted supply of ARV drugs. • NGOs linkages with all ART centres. • ART Centres to be Family counselling centres as well. BBR TORONTO 16-08-06

  28. Prevention of emergence of HIV Drug Resistance (HIV DR) is accorded a high priority and is a crucial component of the National ART Programme BBR TORONTO 16-08-06

  29. HIV DR Activities undertaken • National workshop on “Accreditation and Drug Resistance monitoring with special reference to ART” – New Delhi, 27th –28th Jan., 2005. • Expert Group meeting at National AIDS Research Institute, Pune; 28th – 29th March, 2005. • Preparation of HIV DR strategy with WHO assistance (Dr. Don Sutherland), New Delhi – May, 2005. • National consultation on “HIV DR Surveillance & Monitoring meeting”, Chennai – June 2005 (a WHO supported activity) BBR TORONTO 16-08-06

  30. ARV Drugs • Presently only first-line ARV drugs being procured under the NACP. • Issue of second-line drugs being examined, expert group meeting held in November, 05. • Cost of first-line ARV drugs is Rs.550/- per month, while second-line drugs will cost Rs.8,000/- per month(16 times more). BBR TORONTO 16-08-06

  31. Challenges • Infrastructure including laboratory services strengthening • Training of Health Care providers • Assuring 95% adherence • Country wide provision of ART and continuity of drugs supply • Drug Resistance Surveillance BBR TORONTO 16-08-06

  32. Challenges • Community mobilization and strengthening Network of People Living with HIV/AIDS • Capacity for Home based care • Co ordination of HIV-TB activities • Additional facilities for admission of people on ART with adverse effects • Pediatric Formulations and second line drugs BBR TORONTO 16-08-06

  33. Thank You BBR TORONTO 16-08-06

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