NACP III Executive Summary

The number of people living with HIV/AIDS (PLHA) in India is estimated to be 5.2 million (0.88%), the second largest in the world. Over the years the virus has moved from urban to rural and from high risk to general population disproportionately affecting women and the youth. The main transmission route continues to be sexual (86%). After the discovery of the first HIV infection in 1986, the Government of India initiated programmes of prevention and raising awareness under the Medium Term Plan (1990-92), the first plan (NACP-I, 1992-99) and the second plan (NACP-II, 1999-2006). The HIV sentinel surveillance data for the last three years suggests that these initiatives have started showing results with signs of stabilization in some parts of the country.

With the growing complexity of the epidemic, there have been changes in policy frameworks and approaches of the NACP. Focus has shifted from raising awareness to behaviour change, from a national response to a decentralized response and an increasing engagement of NGOs and networks of people living with HIV/AIDS. The National AIDS Prevention and Control Policy and the National Council on AIDS (NCA), chaired by the Prime Minister, provide policy guidelines and political leadership to the response.

Based on the lessons learnt and achievements made in Phase I and II, India has now developed the Third National AIDS Programme Implementation Plan (20076-20121). This has evolved through a year-long preparatory process that included wide-ranging consultations through 14 working groups, e-forums, civil society organisations, PLHA networks, NGOs/CBOs, national expert groups, development partners and the World Bank led pre-appraisal team. It has also incorporated inputs from various assessments and studies. All this has led to a consensus about the goals, objectives and overall framework of the NACP-III.

India is committed to achieving Millennium Development Goals (MDGs). Keeping this in view, the primary goal of NACP-III is to halt and reverse the epidemic in India over the next 5 years by integrating programmes for prevention, care, support and treatment. This will be achieved through four stages, namely: 

1.  Prevention of new infections in high risk groups and general population through: 

1.  Saturation of coverage of high risk groups with targeted interventions (TIs), and
   1.  Scaled up interventions in the general population 

1.  Providing greater care, support and treatment to a larger number of people living with HIV/AIDS.
2.  Strengthening the infrastructure, systems and human resources in prevention, care, support and treatment programmes at the district, state and national levels. 

1.  Strengthening a nation-wide Strategic Information Management System. 

The specific objective of the above strategy is to reduce new infections as estimated in year 1 of the programme by: 

•  Sixty per cent (60%) in high prevalence states so as to obtain the reversal of the epidemic; and
•  Forty per cent (40%) in the vulnerable states so as to stabilize the epidemic. 

Guiding principles include the Three Ones, equity, legal, ethical and human rights, PLHA and civil society participation. 

NACP-III seeks to learn from the lessons of the previous two phases of programme implementation and build on the strengths thereof.  Its priorities and thrust areas have been drawn up accordingly and include the following:
 

Prevention 

The mainstay of the NACP Strategy will continue to be prevention since more than 99% of the people are HIV negative. The programme will focus on saturating the estimated 4 million high risk groups (commercial sex workers, IDUs and MSM), an estimated 12 million highly vulnerable populations, namely migrants and truckers and the large number of young women and men in the general community who constitute almost 40% of the country's population, with prevention messages. Accordingly, it is planned to set up 2100 TI sites to cover 80% of HRGs with primary prevention services: treatment for STI, condoms, BCC and enabling environment. 95% of the young people will be accessed by collaborating with the ministries of Youth Affairs, Human Resource Development (HRD), Women and Child Development (W&CD) and Ministry of Social Justice and Empowerment (MSJE), among others, volunteer networks and youth friendly information centres. 

To create a non stigmatizing environment and enhance access to services, a well coordinated communication strategy will be put in place which will focus on value based lifestyle at one level and at another, reduce vulnerabilities and break the silence surrounding issues related to sexuality. It will also generate the need to reduce risky behaviour and rountinize the use of condoms as the only prophylaxis against sexually transmitted infections and unwanted pregnancies. Campaigns aimed at very quickly upscaling voluntary testing to reach atleast 21 million tests per year at the end of the project period by establishing an estimated 5000 testing centres in the public sector and another 21 million tests by encouraging the private sector to routinely provide HIV testing. 

With the constitution of the NCA, there is now an opportunity to upscale the dissemination of HIV prevention messages by mainstreaming them into all government offices, organized private sector and civil society organisations. Socio-economic determinants that increase vulnerabilities to HIV will receive special attention and the related ministries will be assisted to establish a HIV unit within their departments to integrate HIV prevention into their ongoing activities. Innovation in forging public private partnerships and effective convergence with the Reproductive and Child Health (RCH) Programme particularly in the three key programme areas of access to safe blood, treatment for sexually transmitted diseases, ANC for screening the estimated 150,000 HIV pregnant women for providing the prophylaxis under the PPTCT programme, Revised National Tuberculosis Control Programme (RNTCP) and the National Rural Health Mission (NRHM). 

Given the importance of prevention to our strategy, an amount of Rs. 7,786 crore (67.2% of total project outlay) is proposed to be allocated for these wide ranging set of activities.

Care, Support and Treatment 

NACP-III seeks to implement the principle of a continuum of care. Accordingly, prevention will go hand in hand with access to prophylaxis, management of opportunistic infections and ART. Given the low levels of coverage, focus will also be on assuring universal access to first line ARV drugs in the first instance. To ensure drug adherence, the Community Care Centres will be reconfigured to be a bridge between the patient and the ART centres and provide psycho-social support, counselling through strong outreach services, referrals and palliative care. Home based care will be an integral part of this strategy. 

Care, support and treatment services will include management of opportunistic infections including control of TB in PLHA, anti-retroviral treatment (ART), safety measures, positive prevention and impact mitigation.  By 2011, the programme will be able to treat 3.2 lakh OI episodes in a year, provide TB referrals to 28 lakh PLHA and ART treatment to 3 lakh PLHA, including 0.39 lakh children. The component related to Care, Support and Treatment is proposed to be allocated an amount of Rs. 1953 crore accounting for 16.9% of the total project outlay.   

Impact Mitigation 

NACP will also make efforts to address the needs of persons infected and affected by HIV, especially children.  This will be done through the sectors and agencies involved in child protection and welfare.  Impact of HIV on others will also be mitigated through other welfare agencies providing nutritional support, opportunities for income generation and other welfare services. 

More importantly, to promote an enabling environment, NACP-III will encourage review and reform of structural constraints, legal procedures and policies that impede interventions aimed at marginalized populations. It will promote Greater Involvement of People living with HIV/AIDS (GIPA) and facilitate establishment of PLHA networks and civil society forums in each district by 2010. Attempt to bring in non-stigmatizing legislation will be made and capacity developed at all levels for effective advocacy against discrimination and a rights based approach to the HIV mitigation programme. 

Decentralization of Implementation
 

Given the spread of HIV infection into rural areas, NACP-III will further decentralize its organizational structure to implement programmes at the district level. The basic unit of implementation will now be the district. Accordingly, based on the epidemiological and vulnerability criteria, all the 611 districts in the country have been classified into four categories: Category A-163 districts - high prevalence; Category B-59 districts - concentrated epidemic; Category C-278 districts - increased presence of vulnerable population and Category D-111 districts - low/unknown vulnerability. 

The categorization of districts based on vulnerability is useful for enabling us to prepare plans that are need based. Accordingly, differential packages of services have been developed for each category of districts. Institutional arrangements and capacities of the SACS as well as the proposed District AIDS Prevention and Control Units (DAPCUs) will be strengthened. To address special vulnerabilities of the North-Eastern States, a Regional AIDS Control Unit (RACU) will be established as a sub-office of NACO but embedded in the governance structure of NRHM. NACP-III has also developed an HRD plan to continuously update and improve the competency and skills of the programme personnel. 

Monitoring & Evaluation 

A list of 140 indicators to measure outcomes have been identified, a manual developed and a logframe designed to monitor the achievement of these indicators. To integrate the needs of the NACP-III, the existing CMIS will be revamped. A Strategic Information Management Systems (SIMS) unit will be set up at national and state levels to address issues relating to planning, monitoring, evaluation, surveillance and research. The allocation of funds for SIMS will be about 5% of the total budget. The proposed surveillance system will focus on tracking the epidemic, identifying pockets of infection and estimating the burden of infection. Two types of Behavioural Surveillance Survey (BSS) will be conducted: (a) for annual risk assessment at the district level, and (b) methodologically rigorous at national/state level once in three years. A Multi-disciplinary Advisory Committee will be constituted to implement and guide the research agenda to be monitored by the research division at NACO. Regional centres of excellence will be identified to provide the needed technical support while Technical Support Units (TSUs) will be expanded to cover all states. 

In order to implement wide range of interventions indicated above, a financial resource plan has been worked out. Resources required for NACP-III are estimated to be Rs. 11,585 crore as under:

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