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1 LOK SABHA SECRETARIAT PARLIAMENT LIBRARY AND REFERENCE, RESEARCH, DOCUMENTATION AND INFORMATION SERVICE (LARRDIS) MEMBERS REFERENCE SERVICE REFERENCE NOTE . No. 31/RN/Ref./2014 For the use of Members of Parliament Not for Publication HIV/AIDS CONTROL The reference material is for personal use of the Members in the discharge of their Parliamentary duties, and is not for publication. This Service is not to be quoted as the source of the information as it is based on the sources indicated at the end/in the text. This Service does not accept any responsibility for the accuracy or veracity of the information or views contained in the note/collection.

2 HIV/AIDS CONTROL INTRODUCTION Human Immunodeficiency Virus (HIV) is a lenti virus that belongs to the retroviruses group may cause HIV infection/ Acquired Immunodefienciey Syndrome (AIDS). Among the many health targets in the Millennium Development Goals (MDGs), MDG 6 calls for unprecedented action to halt and begin to reverse the AIDS epidemic. As the United Nations Member States implicitly recognized when they endorsed the Millennium Declaration, the persistent burden associated with communicable diseases undermines efforts to reduce poverty, prevent hunger and preserve human potential in the worlds most resource-limited settings. AIDS remains an unfinished MDG, underscoring the need for continued and strengthened international solidarity and determination to address this most serious of contemporary health challenges. The latest Global Report highlights continued progress towards the Global Vision of zero new HIV infections, zero discrimination and zero AIDS-related deaths. The annual number of new HIV infections continues to decline, with especially sharp reductions in the number of children newly infected with HIV. More people than ever are now receiving life-saving antiretroviral therapy, contributing to steady declines in the number of AIDS-related deaths and further buttressing efforts to prevent new infections1. INDIA AND HIV/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 region2. 1 UNAIDS Report on the Global AIDS Epidemic 2013, GLOBAL REPORT, p. 2 2 http://nihfw.nic.in/ndc-nihfw/html/Programmes/NationalAidsControlProgramme.htm

3 -2- India has the third highest number of estimated people living with HIV in the world. According to the HIV Estimations 2012, the estimated number of people living with HIV/AIDS in India was 20.89 lakh, with an estimated adult (15-49 age group) HIV prevalence of 0.27% in 2011. India has demonstrated an overall reduction of 57% in the annual new HIV infections among adult population from 2.74 lakh in 2000 to 1.16 lakh in 2011, reflecting the impact of various interventions and scaled-up prevention strategies under the National AIDS Control Programme (NACP). The trend of annual AIDS deaths is showing a steady decline since roll out of the free Anti-Retroviral Therapy (ART) programme in India in 2004. It is estimated that around 1.5 lakh lives have been saved due to ART till 2011. The detailed list of number of HIV/AIDS patients and the growth and decline in their number are given at Annexure-I and II. The HIV epidemic continues to be heterogenic in geographical spread and across different typologies. Reiterating Indias success story on HIV/AIDS control, the HIV prevalence trend has witnessed significant decline among antenatal clinic attendees considered proxy for general population (0.49% in 2007 to 0.35% in 2012- 2013), Female Sex Workers (5.06% in 2007 to 2.67% in 2011) and Men who have Sex with Men (7.41% in 2007 to 4.43% in 2011), and stable trends have been recorded among Injecting Drug Users (7.23% in 2007 to 7.14% in 2011) at the national level3. In the past few years, the decline in HIV prevalence has been more substantial in erstwhile high prevalence States, where long-standing prevention and treatment interventions have effected behaviour change with increasing condom use, etc. It is noteworthy that newer pockets of high HIV prevalence among different risk groups in low prevalence States have emerged over the past decade. Transgenders are emerging as a risk group with high vulnerability and high levels of HIV. Also, in certain regions of the country, evidence indicates the possible role of bridge population including high-risk migrants and long distance truckers in fuelling the HIV epidemic. NATIONAL AIDS CONTROL PROGRAMME (NACP) India had responded promptly to the HIV/ AIDS challenge at the initial stage itself by setting up an AIDS Task Force under the Indian Council of Medical Research and a National AIDS Committee headed by the Secretary, Ministry of Health & Family Welfare. In 1990, a 3 India, Department of AIDS Control, Annual Report 2013-14, p. ix

4 -3- Medium Term Plan (1990-1992) was launched in four States - Tamil Nadu, Maharashtra, West Bengal and Manipur, and four metropolitan cities - Chennai, Kolkata, Mumbai and Delhi. The plan facilitated targeted Information, Education and Communication (IEC) campaigns, establishment of surveillance system and safe blood supply4. The key achievements made under the programme during the financial year 2012-13 is given at Annexure-III. NACP-I: In 1992, the Government of India launched the first National AIDS Control Programme (NACP-I) as a comprehensive programme for prevention and control of HIV/AIDS in India. The programme, implemented during 1992-1999 with an IDA Credit of USD 84 million, had the objective of slowing down the spread of HIV infections so as to reduce morbidity, mortality and impact of AIDS in the country. To strengthen the management capacity, a National AIDS Control Board (NACB) was constituted and an autonomous National AIDS Control Organisation (NACO) set up for project implementation. The National AIDS Control Organisation is a division of the Ministry of Health and Family Welfare that provides leadership to HIV/AIDS Control Programme in India NACP-II: In November 1999, the second National AIDS Control Programme (NACP-II) was launched with World Bank credit support of USD 191 million. Based on the experience gained in Tamil Nadu and a few other States, along with the evolving trends of the HIV/AIDS epidemic, the focus shifted from raising awareness to changing behaviour, decentralisation of programme implementation to the State level and greater involvement of Non-Government Organisations (NGOs). NACP-III: The third phase of National AIDS Control Programme (NACP-III), implemented during 2007-2012, was a scientifically well-evolved programme, with strong structure of Policies, programmes, schemes, operational guidelines, rules and norms. The NACP-III aimed at halting and reversing the HIV epidemic in India by scaling-up prevention NACP-IV: The fourth phase of National AIDS Control Programme (NACP-IV) under the Department of AIDS Control aims to accelerate the process of epidemic reversal and further strengthen the epidemic response in India through a cautious and well-defined integration process over the period 2012-2017. The NACP-IV will focus on intensifying and consolidating 4 Ibid, p. 1

5 -4- prevention services with a focus on High Risk Groups (HRG) and vulnerable population, increasing access, and promoting comprehensive care, support and treatment services. The objectives of NACP-IV are to reduce new infections and provide comprehensive care and support to all PLHIV and treatment services for all those who require it. The five cross-cutting themes that are being focused under NACP-IV are quality, innovation, integration, leveraging partnerships, and stigma and discrimination5. The package of Services under NACP-IV are given at Annexure-IV. The new initiatives under the fourth phase of the National Aids Control Programme (NACP-IV) are as follows: Differential strategies for districts based on data triangulation with due weightage to vulnerabilities; Scale-up of programmes to target key vulnerabilities; Scale-up of Opioid Substitution Therapy for IDUs; Scale-up and strengthening of Migrant Interventions at Source, Transit & Destinations; Female Condom Programme; Multi-Drug Regimen for PPTCT in keeping with international protocols; Social protection for marginalized populations through earmarking budgets for HIV among concerned government departments; Establishment of Metro Blood Banks and Plasma Fractionation Centres; Demand promotion strategies specially using mid-media, e.g. National Folk Media Campaign & Red Ribbon Express (in convergence with NRHM); and Scale-up of second-line ART6. DEPARTMENT OF AIDS CONTROL For prevention and control of HIV/AIDS the Department of AIDS Control has formulated policies and developed standards, guidelines and norms. Prevention measures for those who 5 Ibid, p. 5 6 Ibid, p. 6

6 -5- are not infected and care, support & treatment services for the infected and affected, formed the two key pillars of all the AIDS control efforts in India. The National AIDS Control and Prevention Policy, 2002 The National AIDS Control and Prevention Policy principally aims at the following strategy for prevention and control of the disease:- 1. Prevention of further spread of the disease by (i). Making the people aware of its implications and provide them with the necessary tools for protecting themselves. (ii). Controlling STDs among vulnerable sections together with promotion of condom use as a preventive measure (iii). Ensuring availability of safe blood and blood products; and (iv). Reinforcing the traditional Indian moral values among youth and other impressionable groups of population. 2. To create an enabling socio-economic environment so that all sections of population can protect themselves from the infection and families and communities can provide care and support to people living with HIV/AIDS. 3. Improving services for the care of people living with AIDS in times of sickness both in hospitals and at homes through community healthcare7. Measures taken for HIV/AIDS awareness and prevention Multimedia campaigns are implemented for behavior change on mass media supported by outdoor media such as hoardings, bus panels, information kiosks, folk performances and exhibition vans for creating awareness and demand generation at service centres/facilities across the country among general population on services being provided by the Department of AIDS control like Integrated Counseling and Testing Centre (ICTC), Prevention of Parent to Child Transmission Sexually Transmitted Infections (PPTCT), Sexually Transmitted Infections (STI) etc. Vulnerabilities of High Risk Groups including Commercial Sex Workers (CSW) , Men having Sex with Men(MSM), Injecting Drug Users (IDU) and also truck drivers and migrants are specifically addressed through inter personal programmes, trainings and sensitization 7 http://www,hsph.harvard.edu/poplation/aids/india.aids.02.pdf

7 -6- programmes by involving Self-Help Groups, Anganwadi workers, ASHA, members of Panchayati Raj Institutions (PRIs) and other key stakeholders. The preventive services include Behaviour Change Communication, Free condom distribution, Free Needles and Syringe distribution Program, STI treatment, Abscess management, Counseling, referral and linkages etc. Consistent condom use has been one of the most critical aspects of the DACs prevention strategy for HIV / AIDS control. Through these services, the Department of AIDS Control (DAC) is able to bring down the HIV prevalence among High Risk Groups (HRG) as follows Typology Prevalence of Prevalence of HIV in 2007 HIV in 2011 Female Sex Workers 5.06% 2.67% Men Who have Sex with Men (MSM) 7.41% 4.43% Injecting Drug Users (IDU) 7.23% 7.14% 789 targeted interventions were implementing HIV prevention program among High Risk Groups in 2007 which have been scaled up to 1873 in 2014. The Department of AIDS Control is also implementing Adolescence Education Programme (AEP), a key intervention to build like skills of the young people and empower adolescence cope with negative peer pressure, develop positive behaviors, improve sexual health, substance dependence and prevent HIV infections8. The Department of AIDS Control is engaging with Insurance Regulatory Development Authority (IRDA), and the Ministry of Finance to bring HIV/AIDS patients under the insurance coverage. HIV/AIDS patients who are Below the Poverty line (BPL) are eligible to Rashtriya Swasthaya Bima Yojana(RSBY), run by the Government of India, but most other life and insurance schemes exclude insurance coverage for HIV/AIDS and related ailments. 8 Lok Sabha Unstarred Question No. 3294 dated 1.8.2014

8 -7- The testing facilities in the country have diagnosed like 2,85,152 positive cases in year 2011-2012; 2,45,859 positive cases in year 2012-13; 2,39,763 positive cases in year 2013-14; and 35,436 cases in April and May 20149. 'RED RIBBON EXPRESS' PROJECT The Red Ribbon Express (RRE) was launched at New Delhis Safdarjung Railway Station, on the World AIDS Day, 1 December in the year 2007. The Red Ribbon Express, a specially designed seven-coach train, endeavoured to generate a national movement against the HIV epidemic. The following objectives of Red Ribbon Express were successfully met: i. Disseminating information regarding prevention and services; ii. Developing an understanding about the infection to reduce stigma and discrimination against People Living with HIV/AIDS; iii. Strengthening peoples knowledge about the measures to be taken to prevent HIV/AIDS; and iv. Adopting preventive health habits and life style. Red Ribbon Express covered 22 states and 1 Union Territory. The State/UT wise breakup of railway stations covered during the year 2012-13 of Red Ribbon Express is given at Annexure III10 The list of Railway Stations covered by the Red Ribbon Express is given at Annexure-V. THE HIV/AIDS (PREVENTION AND CONTROL) BILL 2014 The HIV/AIDS (Prevention & Control) Bill 2014 has been introduced in the Parliament (Rajya Sabha) on 11 February 2014. The Bill sought to prevent and control the spread of HIV and AIDs, prohibits discrimination against persons with HIV and AIDs, provides for informed consent and confidentiality with regard to their treatment, places obligations on establishments to safeguard their rights, and creates mechanism for addressing their complaints 11. The Bill has been referred to the Department- related Parliamentary Standing Committee. 9 Lok Sabha Unstarred Question No. 2442 dated 25.7.2014 10 Ibid 11 http://164.100.47.4/Bill.Texts/RSBillTexts/asintroduced/11120/4ERS.pdf

9 -8- UNICEF INDIA AND HIV/AIDS The UNICEF supports the Government in its effort to halt and reverse the HIV/AIDS epidemic in India, and mitigate its impact on affected children and women. UNICEF is also assisting the Government to further expand and enhance the quality of programmes to reduce the transmission of HIV from infected mothers to their children and to increase the access of these mothers and their children to treatment in various ways, viz. by providing strategic supplies of drugs and commodities; improving the capacity of staff; by developing innovative communication approaches for prevention and care; helping to improve monitoring and reporting systems. UNICEF supports efforts to reduce the stigma and discrimination against children and people affected by HIV and for commitment on ensuring their equal access to essential health, social welfare and educational services12. CONCLUSION The Department of AIDS Control has been directed to work with renewed, vigor, freshness and innovative strategies for HIV/AIDS awareness and prevention. It has decided to provide nationwide the multi drug ARV drugs to Prevent Women infected with HIV, irrespective of Cluster of Differentiation 4 (CD4) count, w.e.f. 1 January 2014. Indias AIDS response has also been a fountainhead of innovative service delivery models with rich civil society involvement. The Department of AIDS Control has taken cognizance of the emerging challenges and is focusing on region-specific strategies and evidence-based scale up of the prevention as well as treatment interventions13. 12 http://www.unicef.org/india.hiv.aids.html 13 Statement containing Brief Activities of the Department of AIDS Control in 2013, p. 16

10 -9- ANNEXURE- I State/UT Wise Details of Numbers of HIV/AIDS Patients Sr. No. State Adult Children Total (Above 15 years) (Below 15 years) 1 Andhra Pradesh 163895 7091 170986 2 Arunachal Pradesh 39 4 43 3 Assam 2756 137 2893 4 Bihar 18925 1087 20012 5 Chandigarh 3165 301 3466 6 Chhattisgarh 4999 386 5385 7 Delhi 15494 1041 16535 8 Goa 1917 148 2065 9 Gujarat 37995 2126 40121 10 Haryana 5022 247 5269 11 HP 2439 243 2682 12 J&K 1298 98 1396 13 Jharkhand 4649 348 4997 14 Karnataka 100913 6751 107664 15 Kerala 8455 442 8897 16 Maharashtra 134299 9279 143578 17 Mumbai 30743 2027 32770 18 Manipur 8787 675 9462 19 Mizoram 2755 192 2947 20 Meghalaya 465 29 494 21 MP 11001 743 11744 22 Nagaland 4596 226 4822 23 Odisha 8258 469 8727 24 Pondicherry 930 73 1003 25 Punjab 13286 711 13997 26 Rajasthan 19091 1240 20331 27 SIKKIM 94 6 100 28 Tamil Nadu 76731 3954 80685 29 Tripura 440 13 453 30 Uttaranchal 1868 133 2001 31 Uttar Pradesh 31437 1986 33423 32 West Bengal 17526 1011 18537 Total 734268 43217 777485 Source: Lok Sabha Unstarred Question No. 2442 dated 25.7.2014

11 -10- ANNEXURE II The growth/decline in number of people suffering from HIV/AIDS detected through ICTC (Integrated Counselling and Testing Centres) during the last three years and the current year, State/UT-wise Sl.No Name of State/Uts 2011-12 2012-13 2013-14 2014-15 (April 14- May 14) 1 Andaman & Nicobar Islands 38 29 29 6 2 Andhra Pradesh 65060 58686 56730 5499 3 Arunachal Pradesh 17 21 4 2 4 Assam 1306 1280 1161 174 5 Bihar 9370 8323 9323 1966 6 Chandigarh 954 836 813 167 7 Chhattisgarh 3023 2430 3009 416 8 Dadra & Nagar Haveli 97 91 88 16 9 Daman & Diu 68 67 93 18 10 Delhi 7700 7274 6855 1433 11 Goa 639 515 529 87 12 Gujarat 14056 11746 13676 1723 13 Haryana 4091 4299 4372 902 14 Himachal Pradesh* 853 739 526 0 15 Jammu & Kashmir 423 403 340 70 16 Jharkhand 2197 2228 1813 317 17 Karnataka 41643 35838 30906 5116 18 Kerala 1988 1916 1660 303 19 Madhya Pradesh 4972 5072 4978 993 20 Maharashtra 57035 44389 43550 6772 21 Manipur 2247 1910 1660 294 22 Meghalaya 364 367 459 99 23 Mizoram 1440 1180 1160 68 24 Nagaland 1787 1684 1672 325 25 Odisha 3933 3815 3467 620 26 Puducherry 716 699 635 123 27 Punjab 5386 4863 4537 1041 28 Rajasthan 8455 6665 7871 1592 29 Sikkim 32 49 31 5 30 Tamil Nadu 21562 16053 16653 1452 31 Tripura 195 197 225 25 32 Uttar Pradesh 14741 13977 12954 2388 33 Uttarakhand 835 876 786 187 34 West Bengal 7929 7342 7198 1237 All India 285152 245859 239763 35436 * Reported in SIMS is 431.Yet to be verified by SACS Source: Lok Sabha Unstarred Question No. 2442 dated 25.7.2014

12 -11- ANNEXURE III Progress in Achievement of Physical Targets during 2012-2013 and 2013-2014 Source: India, Department of AIDS Control, Annual Report 2013-14, p. 7

13 -12- ANNEXURE IV Source: India, Department of AIDS Control, Annual Report 2013-14, p. 6

14 -13- ANNEXURE V List of Railway Stations Covered by the Red Ribbon Express Sl. No. Name of Stations Sl. No. Name of Stations Delhi 27 Amgaon 1 Delhi Safdarjang 28 Jalgaon 2 PragatiMaidan 29 C.S.T Mumbai Rajasthan 30 Bhivandi Road 3 Sadulpur 31 Ahmadnagar 4 Hanumangarh 32 Latur 5 Bhagatkikothi 33 Solapur 6 Jaisalmer 34 Khadki 7 Durgapura Jaipur 35 Sangli Madhya Pradesh 36 Miraj 8 Saugar Goa 9 KatangiKhurd 37 Madgaon 10 Katni Karnataka 11 MadanMahal 38 Belgaum 12 Amla 39 Harihar 13 Itarsi 40 Dharwad 14 LaxmiBai Nagar 41 Gadag 15 Ujjain 42 Bidar 16 Nagda 43 Bangalore Cantt. 17 Ratlam 44 Ashokapuram Gujarat 45 Kolar 18 Vadodra Kerala 19 Patan 46 Palakkad 20 Surender Nagar 47 Kannur 21 Hapa 48 Kozhikode 22 Bhavnagar 49 Thrisur 23 Ahmadabad 50 Ernakulam 24 Valsad 51 Alappuzha Maharashtra 52 Kollam 25 Murtazapur 53 Thiruvananthpuram 26 Nagpur Source: Lok Sabha Unstarred Question No. 2442 dated 25.7.2014

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