The HIV/AIDS epidemic constitutes one of the most formidable challenges to development and social progress. The epidemic impacts poverty and inequality and increases the burden on the most vulnerable sections in society, i.e. the elderly, the women, children and the poor. Countries that do not respond in time have to bear huge costs as a result of declining productivity, loss of skilled and experienced labour and increased expenditures on treatment and associated costs as the demand for public services increases. Impact will be on virtually every sector of the national economies. The 2013 theme for World AIDS Day is “Shared Responsibility: Strengthening Results for an AIDS-Free Generation.
World Scenario
Even as the war against this dreaded infection continues, new infections among adults and children were estimated at 2.3 million in 2012, a 33% reduction since 2001. New HIV infections among children have come down by 52% since 2001. AIDS-related deaths have also dropped by 30% since the peak in 2005 as access to antiretroviral treatment expands. Significant results have also been achieved towards meeting the needs of tuberculosis (TB) patients living with HIV, as TB-related deaths among people living with HIV have declined by 36% since 2004.
By the end of 2012, some 9.7 million people in low- and middle-income countries were accessing antiretroviral therapy, an increase of nearly 20% in just one year. In 2011, UN Member States agreed to a 2015 target of reaching 15 million people with HIV treatment. However, as countries scaled up their treatment coverage and as new evidence emerged showing the HIV prevention benefits of antiretroviral therapy, the World Health Organization set new HIV treatment guidelines, expanding the total number of people estimated to be in need of treatment by more than 10 million.
Despite a flattening in donor funding for HIV, which has remained around the same as 2008 levels, domestic spending on HIV has increased, accounting for 53% of global HIV resources in 2012. The total global resources available for HIV in 2012 was estimated at US$ 18.9 billion, US$ 3-5 billion short of the US$ 22-24 billion estimated to be needed annually by 2015.
Situation in India
The National AIDS Control Programme continues to make progress toward the Millennium Development Goal of halting and reversing the HIV epidemic. The adult HIV prevalence at national level has continued its steady decline from estimated level of 0.41% in 2001 through 0.35% in 2006 to 0.27% in 2011. National adult (15-49 years) HIV prevalence which was estimated at 0.33% in 2007, has declined to 0.27% in 2011. Declining trends in adult HIV prevalence are sustained in all the high prevalence states namely, Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland and Tamil Nadu and other states such as Mizoram and Goa. However, the low prevalence states of Assam, Arunachal Pradesh, Chandigarh, Chhattisgarh, Delhi, Jharkhand, Meghalaya, Odisha, Punjab, Tripura and Uttarakhand have shown rising trends in adult HIV prevalence.
India has demonstrated an overall reduction of 57% in estimated annual new HIV infections (among adult population) during the last decade from 2.74 lakh in 2000 to 1.16 lakh in 2011. This is important evidence on the impact of the various interventions under National AIDS Control Programme and scaled-up prevention strategies. Major contribution to this reduction comes from the high prevalence states where a reduction of 76% has been noted during the same period. The total number of people living with HIV/AIDS in India is estimated at 21 lakh in 2011. Children (under15 yrs.) account for 7% (1.45 lakh) of all infections, while 86% is in the age – group of 15-49 years. Of all HIV infections, 39% (8.16 lakh) are among women. The estimated number of people living with HIV in India maintains a steady declining trend from 23.2 lakh in 2006 to 21 lakh in 2011.
The programme data indicates that antiretroviral treatment services for adults increased by 30% between 2009- 10 and 2010-11.Wider access to antiretroviral treatment has led to 29% reduction in estimated annual AIDS-related deaths during NACP-III period (2007-2011). Greater declines in estimated annual deaths are noted in states where significant scale up of antiretroviral treatment services has been achieved. In high prevalence states, estimated AIDS-related deaths have decreased by around 42% during 2007 to 2011. As on July 2013, around 6.76 lakh people living with HIV are receiving free antiretroviral treatment across the country.
The coverage of targeted interventions with services for high risk groups has significant improvement. Presently, 84% of female sex workers (FSW), 87% of men-who-have-sex-with-men (MSM) and 84% of injecting drug users (IDU) have access to prevention interventions. An impact evaluation (2011) shows that the progress in the decline of HIV among FSW is attributable to the national programme focus on targeted interventions; with an estimated 3 million HIV infections projected to be averted by the national program by 2015 through targeted prevention interventions alone.
World Bank and NACO
India has been a long-term partner and recipient of World Bank funding, starting with the first National AIDS Control Project in 1991 through to the current phase of National AIDS control programme. In the early 1990s, the NACP focused on blood safety, prevention among high risk groups, raising awareness in general population and improving surveillance. In the second phase of NACP (1999-2006), India continued to expand the programme at state level, with greater emphasis on targeted interventions and involvement of NGOs. In the third phase, India has scaled up targeted HIV prevention interventions for most at risk populations and further expanded the surveillance system. The surveillance and analytical work has helped the government know its heterogeneous epidemic, identify Indian states which were most affected by HIV and population groups which were most at risk
The goals of the fourth phase of the NACP are aligned with the Government of India’s Twelfth Five Year Plan (2012-2017) goals of inclusive growth and development for long term sustainability. The national programme goals are to accelerate reversal of the HIV epidemic and integrate the response over the next five-year phase. The programme aims at reaching out to the hard-to-reach population groups at high risk with targeted prevention interventions through innovative approaches; increasing access to comprehensive care, support and treatment; expanding information, education and communication with a focus on behavior change, demand generation and stigma reduction; further strengthening the institutional capacity and process of integration; and, continuing to innovate across programme components – generating knowledge and lessons learned for India and beyond.
The National AIDS Control Support Project (NACSP) will support the Strategic Plan of the fourth phase of NACP 2012–2017, with a focus on outcomes. The project will support the following three components:
Component 1- Scaling Up Targeted Prevention Interventions (total estimated cost -US$440 million): This component will support the scaling up of TIs with the aim of reaching out to the hard to reach population groups who do not yet access the prevention services of the programme, and saturate coverage among the HRGs. In addition, this component will support the bridge population, i.e. migrants and truckers.
Component 2 - Behaviour Change Communication (total estimated cost US$40 million): This component will include: (i) communication programmes for risk reduction and safe behaviour including advocacy, social mobilization and BCC to integrate PLWHA and HRG into society and to encourage normative changes aimed at reducing stigma and discrimination in society at large, and in health facilities specifically, as well as to increase demand and effective utilization of testing and counselling services; (ii) financing of a research and evaluation agency to assess the cost-effectiveness and program impact of behaviour change
Communication activities; and (iii) establish and evaluate a helpline at the national and state level to further increase access to information and services.
Component 3- Institutional Strengthening (total estimated cost US$30 million):This component will support programme steering, coordination and managerial roles in managing the prevention component of the programme, during the transformational phase of NACP IV. The dissemination of best practices and innovations from the project at the national and state levels through annual knowledge dissemination forum, necessary project audits will also be financed.
The implementation structures and institutional arrangements of NACSP will remain the same as under NACP III, with the programme being managed by the Department of AIDS Control, at the central level, the State AIDS Control Societies (SACS) at state level, and the District AIDS Prevention Control Units (DAPCUs) at the district level. The Technical Support Units (TSUs), that were established during NACP III to oversee the quality, mentoring, handholding and supporting the TIs in the states along with SACS, will continue to play a key technical role to ensure the quality of TIs.
Although the overall HIV prevalence rates among high risk groups are declining, they remain high (2010-11): 7.14% among injecting drug users, 4.43% among men-who-have-sex-with-men and 2.67% among female sex workers, and there are significant variations in states which necessitates scaling up of efforts to reach the hard to reach populations in these areas. The national programme will continue to innovate and generate lessons from its performance management system and disseminate the best practices across the world in sync with 2013 theme for World AIDS Day - Shared Responsibility: Strengthening Results for an AIDS-Free Generation.
