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 SessionXVI International Aids ConferenceToronto, Canada,16th August 2006

Dr. B.B. Rewari WHO National Consultant (ART)

National AIDS Control OrganisationNew Delhi

BBR TORONTO 16-08-06 BBR TORONTO 16-08-06

Pondichery

Gujarat

Karnataka

Goa

Lakshwadeep

Dadra Nagar HaveliMaharashtra

Madhya Pradesh

Kerala

Tamil Nadu

Andhra Pradesh

Punjab

Rajasthan

Daman & Diu

J & K

Haryana

Uttar Pradesh

Himachal Pradesh

Delhi

Chandigarh

Bihar

West Bengal

Orissa

Andaman & Nicobar

Mizoram

Meghalaya

Assam

Sikkim

Manipur

Tripura

Arunachal Pradesh

Nagaland

HIV/AIDS Epidemic in India-2005HIV/AIDS Epidemic in India-2005

>1%in Antenatal mothers

>5% in High Risk Groups

<5% in High risk groups

2

Total: 5.206 m

BBR TORONTO 16-08-06

High Prevalence

Moderate Prevalence

Highly Vulnerable

Vulnerable States

Tamil NaduAndhra PradeshMaharashtraKarnatakaNagaland Manipur

Gujarat GoaPondicherry

AssamBiharDelhiHimachal PradeshKeralaMadhya PradeshPunjabRajasthanUttar PradeshWest BengalChhattisgarhJharkhandOrissaUttranchal

Arunachal PradeshHaryanaJammu & KashmirMeghalayaMizoramSikkimTripuraAndaman & Nicobar IslandsChandigarhDadra & Nagar HaveliDaman & DiuLakshadweep

HIV Prevalence : States Reclassified

•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 Scaling up of ARTof ART

•Workplace interventions

•Inter-ministerial links

•Public Private Partnerships

•Surveillance

•Training

•Monitoring and evaluation

•Technical resource group

•Operations research

•Programme management

•AIDS Vaccine Initiative

Prevention

High risk populations

Low risk populations Care &

supportInter-sectoral

collab.Institutional

Strengthening

CareCollaborate Build capacities


4 Pillars of Management

1. General management

2. Treatment of Opportunistic Infections

3. Chemo-prophylaxis against various O.Is

4. Anti-retroviral therapy (ART).


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…


Benefits of Antiretroviral Therapy

Restores Hope for Both Patients and Health Care Providers!


FOUR CLASSES OF ANTIRETROVIRAL DRUGSFOUR CLASSES OF ANTIRETROVIRAL DRUGS

NNRRTTII

NNNNRRTTII

PPII

Zidovudine(AZT)

Lamivudine (3TC)

Stavudine (d4T)

Didanosine (ddI)

Zalcitabine (ddC)

Abacavir (ABC)

Tenofovir (TFV)

Emtricitabine (FTC)

Nevirapine (NVP)

Efavirenz (EFV)

Delavirdine (DLV)

Indinavir (IDV)

Nelfinavir (NFV)

Saquinavir (SQV)

Ritonavir (RTV)

Amprenavir (APV)

Lopinavir (LPV)

Atazanavir (ATV)

Fusion Inhibitor: Enfuvirtide (T-20)Fusion Inhibitor: Enfuvirtide (T-20)


IMPLEMENTATION OF ART IN INDIA

PRINCIPLES AND GUIDELINES


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


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

EligibilityChildren below 15 yrs of ageWomenPLHA 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)

ART Policy Package

Government commitment

Detection of eligible cases

Standardized combination ARV therapy

Regular, secure supply of ARV drugs

Monitoring system

Regimen Under National Programme

Zidovudine / Lamivudine / NevirapineOr

Stavudine / Lamivudine / Nevirapine

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

Tenofovir under consideration for special situations)

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

.


Number of ART service delivery points (GOI)

8 10

25

40

54

0

10

20

30

40

50

6020

04(A

pri

l)

2004

(No

v)

2005

(Mar

ch)

2005

(O

ct)

2006

(Ju

ne)


ART centres in India

NACO supported existing centres in India(54)

NACO supported new centres in India(46)


Access to ART in IndiaGRAND TOTAL of patients on ART as on 30th June 2006

NACO supported ART Centres(54) 33490

State supported ART Centres(9) 766

NGO supported ART Centres(2) 3004

Intersectoral Partners(4) 2327

Private Partners(2) 2399

GFATM Round II Centres(6) 406

Grand Total 42392


Month-wise distribution of patients on ART(June-06)

4200 53

71 6845

7333 91

68 1025

510

740

1154

912

633

1534

917

999

2378

424

490

2648

528

177

2974

632

744

3349

0

0

5000

10000

15000

20000

25000

30000

35000

40000

Jan

Feb

Mar

Apr

May Jun

July

Aug

Sept Oct

Nov

Dec Ja

nFe

bM

arAp

rM

ay Jun


Distribution of Patients on ART in India

63%

32%

5%

Male

Female

Children


1 - Pre-ARTRegister

4 - Patient Care &

Treatment Record

2 - ARTEnrollment

Register

5 - ARV Drug

Dispensing Register

6 - DrugStock

Register

ART Records Reports

MonthlyMonthly Report

New and continuing patients

Adherence

Drug stocks

NGOs

Quarterly/AnnuallyCohort Report

Survival

3 - ART Registration Card (kept by patient)

Ongoing at Facility Regimens

CD4 counts

Defaulters

NACO Recording and Reporting Tools

Distribution of patients in HIV care and patients started on ART (by age and sex)

Men 57.8%

Women37.1 %

Men 64.2%

Children 5.1 %

Women31.2 %

Children 4.6 %

HIV caren=94,698

Started on ART*n=42,047

*Out of 42,047 patients started on ART, D4T+3TC+NVP was used in 61%


6 months (n=5,241) 12 months (n=2,248) 24 months (n=388)

Treatment outcome of patients at 6, 12 and 24 months after start of treatment

Alive on ART 81%Alive on ART 84% Alive on ART 73%

Died 6% Died

8%Died 13 %

Lost 8%

Lost 13%

Lost 9%

Stopped2%

Stopped1%

Stopped2%


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


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


The value of Adherence

8164

50

256

0

20

40

60

80

100

70% 70-80% 80 - 90% 90 - 95% <95%

Percent adherence to therapy

Unde

tect

able

vir

al lo

ad


Long Term Efficacy of HAARTNo Magic Bullet , No Miracle

Good Attitude, Knowledgeable DoctorsSimplified and potent HAART

Proper MonitoringCommitted Patients

Adherence, adherence, adherence adherence adherence

Ultimate Goal – Long term viral suppression -- Normalized CD4 counts -- Good quality of life


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.


Prevention of emergence of HIV Drug Resistance (HIV DR) is accorded a high priority and is a crucial component of the National ART Programme


HIV DR Activities undertaken

• National workshop on “Accreditation and Drug Resistance monitoring with special reference to ART” – New Delhi, 27 th –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)


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).


• 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

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

Challenges

dr. b.b. rewari who national consultant (art) national aids control organisation new delhi

Documents

guidelinesbbr toronto

states reclassifiedbbr

quality of lifeandbbr

previous employmentbbr

longterm arv therapy

hp states

report treatment outcomes

targeted interventionsstd