Bihar State AIDS Control Society, Patna 17 th August 2016

Bihar State AIDS Control Society, Patna 17 th August 2016

Content of Presentation HIV Prevalence in India and Bihar & Factors HIV and Transmission Prevention of Parent to Child Transmission (PPTCT) Early Infant Diagnosis (EID)

History of HIV & AIDS 1981: First AIDS case detected in USA 1983: HIV identified by Luc Montaigner and Robert Gallo 1986: First HIV +ve case identified in India in Chennai by CMC, Vellore 1992 : First AIDS case detected in Nawada Dist. in Bihar 6

National response to HIV/AIDS in india 1986: First case of HIV detected in Chennai 1990: HIV/AIDS Cell set up in MoHFW 1992: National AIDS Control Organisation (NACO) established within MoHFW 1994-1999: NACP-I launched 1999-2006: NACP-II 2007-2012: NACP-III 2012-2017: NACP-IV 12

What is HIV? H- Human I- Immunodeficiency V - Virus What is AIDS? A - Acquired I- Immuno D- Deficiency S- Syndrome

HIV infection spreads through the following modes : From an HIV-infected mother to her child during - pregnancy, childbirth or breastfeeding By use of HIV-contaminated syringes, needles Transfusion of untested blood ( HIV-contaminated blood).

HIV does not spread Staying together with HIV positive person in the same house Shaking Hands, Hugging and Sharing clothes with a HIV positive person Sharing bathroom, Using public transport public toilets or Food Eating together or sharing the same utensils Mosquito bite HIV is not transmitted by casual contact or other means.

Adults and children estimated to be living with HIV 2013 North America and Western and Central Europe 2.3 million Eastern Europe & Central Asia 1.1 million Caribbean 250 000 Latin America 1.6 million Middle East & North Africa 230 000 Sub-Saharan Africa 24.7 million Asia and the Pacific 4.8 million Total: 35.0 million [33.2 million 37.2 million]

Estimates 2015: 21 lakh Madhya Pradesh 2% Odisha 3% Punjab 2% Alive in Care : 11.5 Lakh Rajastha Punjab n 2% Delhi 2% 2% Madhya Pradesh 2% Orissa 1% Rajastha n 5% West Bengal 6% Tamil Nadu 7% Others 11% Bihar 7% Andhra Pradesh & Telangan a 19% Maharash tra 14% Karnatak a 9% Gujarat 8% West Bengal 3% Bihar 3% Tamil Nadu 9% Others 8% Karnatak a 13% Andhra Pradesh & Telangan a 23% Maharas htra 22% Uttar Pradesh 7% Annual Review-CST Uttar Pradesh 5% Gujarat 5%

HIV Demographic Indicators of Bihar Routes of HIV Transmission, 2012-13 First case in Bihar identified in 1992 in Nawada district Total Identification HIV Reactive at SA-ICTC till date 83,871 ANC Prevalence : 0.33 Ever registered in HIV care: 58,228 Adult Prevalence 0.25 Ever Initiated on ART i.e CD4>350 37,070 Estimated No. of PLHIV : 1,50,689 Alive and on ART i.e CD4>350 28,088

Challenges of trend of new infections in selected States 70% decline 50 % 19-Aug-16 >100% increas e

HIV Prevalence at ANC Site, India & Bihar, (HSS 2012-13) Nagaland Mizoram Manipur Andhra Pradesh Karnataka Chhattisgarh Maharashtra Delhi Punjab Tamil Nadu India Bihar Rajasthan Odisha Uttarakhand Meghalaya Arunachal Pradesh Goa Uttar Pradesh Jharkhand West Bengal Sikkim Tripura Haryana Assam Madhya Pradesh Daman & Diu Jammu & Kashmir Himachal Pradesh Kerla A & N Island Chandigarh D & N Haveli Puduchery 0 0 0 0 0.07 0.04 0.03 0.2 0.19 0.19 0.19 0.19 0.17 0.16 0.14 0.13 0.27 0.26 0.26 0.25 0.4 0.4 0.37 0.36 0.35 0.33 0.32 0.31 0.53 0.51 0.59 0.68 0.64 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 0.88

What is driving the epidemic 1.20 HIV prevalence among ANC clients by status of spousal migration 1.10 1.08 1.00 0.80 0.60 0.40 0.20 0.00 0.14 0.28 0.44 0.45 0.00 0.20 0.31 0.63 Bihar Chattisgarh Jharkhand Madhya Pradesh HIV Positivity - non-migrant spouses 0.36 0.34 0.16 0.53 Odisha Rajasthan Uttar Pradesh 0.09 0.67 West Bengal 0.27 HIV Positivity - migrant spouses India 0.57 19-Aug-16

HIV prevalence among ANC attendees (< 25 yrs / >25 yrs) 19-Aug-16 Higher prevalence among younger pregnant women indicates new HIV infections.

HIV testing facility establishment at General Health system Public Health Facilities Medical college (8-G & 2- P) Total number HIV Testing facility available Stand Alone ICTC F-ICTC Number of Treatment facility available ART LAC/ LAC+ 10 15 0 7 0 District Hospital 36 72 0 9 24 Sub District Hospital 58 14 0 0 0 Community Health Centres Primary Health Centres 71 6 0 0 0 534 92 250 0 0 Sub Centres 9358 0 0 0 0 Jail/Prison (8-C, 32-D, 17- SD) 57 0 0 0 0 Others (Specify) 15 8 0 0 0 Total 10,139 207 250 16 24

Introduction: PPTCT - MDR

Introduction Transmission from HIV infected mother to baby is the key mode of HIV transmission in children Annually about 14,000 New HIV Infections occur among children in India HIV infection causes about 10,000 deaths annually among children in India But It is possible to prevent HIV infection among children It is also possible to Minimize Mortality if children are infected Early detection and prompt treatment Paediatric HIV is thus amenable to prevention as well as effective management 21

Introduction (2) Currently available Anti-Retroviral drug regimen if given to HIV infected pregnant women can potentially Eliminate Risk of HIV transmission United Nations General Assembly adopted a resolution to work towards elimination of paediatric HIV by 2015 Government of India is committed to this goal 22

PPTCT Services: Evolution in India 2001-02: Feasibility study in 11 COEs, launch of VCT services for pregnant women & SD Nevirapine to infected mother and exposed baby 2004-05: Major expansion of these services in 6 high prevalence states with support from Global Fund (Round-2), and gradually across the country 2006-07: VCT and PPTCT services merged in Integrated Counselling and testing Centre 2007-08: Provider Initiated Testing and Counselling (PITC) strategy adopted for testing of Ante-Natal Cases (ANC) 2009-10: Pilot of Sub-Centre level HIV screening strategy through frontline health workers. Launch of Early Infant Diagnosis services through ICTCs 2012-13: WHO PMTCT Option- B adopted by Department Of AIDS Control and implemented in three high HIV prevalence states May/June 2013: National Strategic Plan for Scale-up of PPTCT services using Multi- Drug ARV regimen (Option-B), developed Jan 2014: ART for all HIV positive pregnant women irrespective of CD4 count / WHO clinical staging adopted by Department Of AIDS Control 23

National Strategic Plan: Vision, Goal and Objectives Vision: Women and children, alive and free from HIV Goal: To work towards elimination of paediatric HIV and improve maternal, newborn and child health and survival in the context of HIV infection Objectives: 1. To detect more than 80% HIV infected pregnant women in India 2. To provide access to comprehensive PPTCT services to more than 90% of the detected pregnant women 3. To provide access to early infant diagnosis to more than 90% HIV exposed infants 4. To ensure access to anti-retroviral drug (ARV) prophylaxis or Anti-Retroviral Therapy (ART) to 100% HIV exposed infants 5. To ensure more than 95% compliance with ARV /ART in HIV infected pregnant women and exposed children 24

Four Prongs of PPTCT Programme

4 prongs for PPTCT Prong 1: Primary preventio n of HIV Prong 2: Prevent unintende d pregnanci es Prong 3: Preventio n of MTCT Prong 4: Care, support and treatme nt HIV Negative i.e. general population, e.g. ARSH HIV +ve Not Pregnant Family Planning counselling in ICTC but more importantly at ART centres HIV +ve & Pregnant HIV +ve Mother & Child 26

Four Prongs of PPTCT Programme Young adult/ adolescent: Primary Prevention of HIV Infection HIV-infected women: Care & Support to Women, Children & Families PPTCT HIV-infected women: Prevention of Unintended Pregnancies HIV-infected women: Prevention of HIV Transmission to Infant

Four Prongs of PPTCT Programme HIV-infected women: Care & Support to Women, Children & Families Young adult/ adolescent: Primary Prevention of HIV Infection 1) Delaying onset of sexual activity, 2) Practise sexual abstinence, 3) Reduce number of sexual partners, 4) using condoms HIV-infected PPTC T women: Prevention of Unintended Pregnancies HIV-infected women: Prevention of HIV Transmissio n to Infant

Four Prongs of PPTCT Programme Young adult/ adolescent: Primary Prevention of HIV Infection HIV-infected women: Care & Support to Women, Children & Families PPTC T HIV-infected women: Prevention of HIV Transmission to Infant HIV-infected women: Prevention of Unintended Pregnancies 1) Access to counselling and referral for Family Planning; 2) Safe, consistent & effective contraception

Four Prongs of PPTCT Programme Young adult/ adolescent: Primary Prevention of HIV Infection HIV-infected women: Care & Support to Women, Children & Families PPTC T HIV-infected women: Prevention of HIV Transmission to Infant 1) Decrease viral load, 2) Monitor & treat infections, 3) Support optimal nutrition, 4) Avoid premature rupture of membranes, invasive delivery techniques & unresolved infections such as STI, 5) Promote safer infant feeding through infant feeding counselling HIV-infected women: Prevention of Unintended Pregnancies

Four Prongs of PPTCT Programme HIV-infected women: Care & Support to Women, Children & Families 1) Prevention & Treatment of OI 2) ARV treatment 3) Palliative & non-arv care 4) Nutritional support 5) Reproductive health care 6) Psychosocial support Young adult/ adolescent: Primary Prevention of HIV Infection PPTCT HIV-infected women: Prevention of HIV Transmission to Infant HIV-infected women: Prevention of Unintended Pregnancies

Mother-to-child transmission Is the main cause of HIV infection in children It can occur during: Pregnancy Labour and delivery Breastfeeding 33

Factors that Increase Transmission of HIV to the child from the mother Maternal Factors during Pregnancy Maternal Factors during Delivery Factors while Breastfeeding

Factors that Increase Transmission of HIV to the child from the mother Maternal Factors during Pregnancy Maternal Factors during Delivery Factors while Breastfeeding High maternal viral load New HIV infection during pregnancy Advanced disease in the mother Viral, bacterial & parasitic placental infection Maternal malnutrition STI

actors that Increase Transmission of HIV to the child rom the mother Maternal Factors during Delivery Maternal Factors during Pregnancy Factors while Breastfeeding New HIV infection Advanced HIV disease/aids in mother High maternal viral load Prolonged labour and rupture of membranes Acute chorionamnionitis Invasive child birth procedures Premature birth of infant First infant in multiple birth

Factors that Increase Transmission of HIV to the child from the mother Maternal Factors during Delivery Maternal Factors during Pregnancy Factors while Breastfeeding New HIV infection during breastfeeding Advanced HIV disease/ AIDS in the mother High maternal viral load Duration of breastfeeding Mixed feeding Breast abscesses, nipple fissures, & mastitis Maternal malnutrition Oral disease in infant

THE Most Important Factor for Transmission of HIV is.. High Viral Load in Mother

India National Technical Resource Group (TRG) recommendation on PPTCT All positive pregnant women including those presenting in labour and breast feeding women with HIV should be initiated on a triple ART irrespective of CD4, for preventing Mother-to-Child Transmission risk and should continue life long ART. The duration of NVP to infant be minimum 6 weeks but more if ART to mother was started in late pregnancy, during or after delivery and has not been on adequate period of ART as to be effective to achieve optimal viral suppression (which is at least 24 weeks), then the infant NVP should be increased to 12 weeks. This recommendation on extended NVP duration applies to infants of breast feeding women only and not those on exclusive replacement feeding 40

Factors that decrease the risk of Mother-to-child transmission Highly efficacious PPTCT Regimen containing three ARVs have the potential to reduce the risk of mother to child transmission to less than 5% in breastfeeding populations and less than 2% in non-breast feeding populations. This is basic principle of new PPTCT guidelines 41

Life Long ART for all HIV Positive Pregnant women to prevent Mother to Child Transmission 42

How do ARV drugs work for PPTCT? Reduction of maternal viral load Loading fetus with ARVs that prevent transmitted virions from replicating 43

ART Eligibility Criteria for HIV positive Pregnant Women Clinical Staging Immune Status Irrespective of WHO Clinical Stage Irrespective of CD4 counts 44

Recommendations for HIV positive pregnant women Pregnant Women who are detected to be HIV infected during antenatal care should be initiated on ART (TDF+3TC+EFV) Tenofovir + Lamivudine + Efavirenz Regardless of clinical stage or CD4 count. But obtain sample for CD4 count before initiating or soon after initiating ART. The initiation of ART should not be delayed for want of CD4 test results.

Infants: ARV prophylaxis for infants born to women presenting in active labour All infants born to HIV positive pregnant women will receive Nevirapine syrup once daily for 6 weeks-irrespective of infant feeding option

Infants: ARV prophylaxis for infants born to women who did not receive any ART (Home Delivery) Infant should be stared on daily NVP prophylaxis at their first encounter with health services Daily infant NVP prophylaxis can be started even if more than 72 hours have passed since birth Daily infant NVP prophylaxis should continue for 6 weeks, by which time the mother should be linked to appropriate ART services The duration of daily infant NVP prophylaxis will depend on whether how long the mother is on lifelong ART

Dosage of NVP (10 mg of Nevirapine in 1ml suspension) Infants Birth Weight (gm) NVP daily dose (mg) NVP daily dose (ml) Duration Birth weight less than 2000 gm Birth weight between 2000 2500 gm Birth weight more than 2500 gm 2 mg /kg. once daily. In consultation with a pediatrician trained in HIV care 0.2 ml /kg. once daily 10 mg. once daily 1 ml once a day 15 mg. once daily 1.5 ml once a day Up to 6 weeks irrespective of exclusive breast feeding or exclusive replacement feeding 49

Infant Feeding Options 50

nfant Morbidity / Mortality? Exclusive Breastfeeding Replacement Feeding 51

Benefits versus Risks Breast & Replacement Feeding Breast feeding Ideal Protect baby from many infections Less mortality, morbidity Increased bonding HIV transmission Replacement feeding Risk of other infections (GI, Respiratory) More mortality, morbidity No HIV transmission risk No prolonged prophylaxis in absence of breastfeeding 52

Infant Feeding Counseling Flow Chart Step 1 : Explain Risks Step 2 : Explain Options Step 3: Home environment Step 4 : Assist Choosing Step 5 : Demo Option Step 6 : Follow Up 53

Counsel and Educate Mother Exclusive breastfeeding EBF for 6 months AVOID MIXED FEEDING! 54

Introduction HIV is a single-stranded RNA virus transmitted mostly through sexual contact, blood transfusion and contaminated hypodermic needles. HIV disease progresses very rapidly in young children, often leading to death. Asymptomatic children <18 months are often missed out on prevention, care, support and treatment. The new guidelines will attempt to ensure that HIV exposed and infected infants and children <18 months of age receive the required national essential package of care and support. The current test of choice in NACO s HIV care & treatment program is the HIV-1 DNA PCR test which detects HIV-1 proviral DNA integrated into the human genome.

Rapid HIV progression and higher risk of death in infected infants Without Anti Retroviral treatment: By age 1, one-third of all HIV-infected children will have died By age 2, half of all HIV-infected children will have died CD4 and viral load are poor predictors of disease progression in infants

HIV DNA PCR Labs National AIDS Research Institute (NARI), Pune. (Maharashtra, Chhattisgarh) National Institute of Mental Health and NIMHANS, Bangalore (Karnataka) Kasturba hospital for infectious diseases, Mumbai (Madhya Pradesh, Mumbai, Goa, Gujrat) Tuberculosis Research Centre (TRC), Chennai. (Andhra Pradesh) Tamilnadu Dr MGR Medical University, Chennai (Tamilnadu, Kerala, Pondicherry) Lady Harding Medical College (LHMC), New Delhi.(Delhi, UP, Haryana, Uttaranchal, Rajasthan, Punjab, Himachal Pradesh, Jammu- Kashmir) National Institute of Cholera and Enteric Diseases (NICED), Kolkata(Imphal, Sikkim, Arunachal Pradesh, Meghalaya, West Bengal,Orissa, Bihar, Jharkhand, Assam, Tripura)

Drawing of Blood Age, Weight Where to draw blood 1-4 months, less than 6 kg Heel 5 10 months, less than 10 Kg Toe Larger than 10 Kg Finger

Invalid DBS specimen: circles not filled clotted/layered Scratched/abraded Not Dried before sending Serum Ring around

Care of HIV Exposed Infants & Children Schedule of visits at ICTC 6 weeks 14 weeks Birth 10 weeks 6 months 9 months 12 months 18 months DNA PCR HIV Antibody test followed by DNA PCR if HIV+ DNA PCR for all HIV exposed infants Final confirmatory Antibody Test for all HIV exposed infants irrespective of earlier testing results / treatment status All HIV infected and/ or symptomatic infants/children are to be referred to ART centre

Algorithm for Diagnosis of HIV Infection < 6 months of age

Objectives of ART Centre The main objective of ART Centre is to provide comprehensive package of Care, Support & Treatment services to People Living With HIV (PLHIV) The specific objectives of an ART centre are to: 1. Register and provide Care, Support & Treatment services to all PLHIV & monitor them regularly in HIV care (Pre-ART) 2. Identify eligible PLHIV requiring ART and initiate First line ART in a timely manner as per the NACO guidelines 3. Provide ART & OI drugs to all eligible PLHIV 4. Provide appropriate counselling services before and during treatment to ensure high levels of drug adherence 3

Functions Of ART Centre Medical Psychological ART Centres Sociological Programmatic 10

Medical Functions To monitor, manage and follow up Pre-ART patients To screen PLHIV for HIV-TB co-infection To diagnose and treat Opportunistic Infections To provide primary & secondary prophylaxis as per guidelines To provide baseline investigations and CD4 cell count To screen PLHIV for clinical eligibility and to initiate ART as per NACO ART guidelines To provide ART to eligible PLHIV and counsel them on 100% adherence to therapy for long term effectiveness of ART To monitor patients on ART and manage side-effects, IRIS Referral and linkages 11

Psychological Functions To provide psychological support to PLHIV accessing the ART centre To provide counselling to "Pre-ART" and "On- ART" patients on regular follow up visits and CD4 Testing To provide counselling for adherence to ARV drugs and issues related to toxicity To educate PLHIV on proper nutrition and measures to prevent further transmission of infection To educate patients on sexual health and positive living To advice for risk reduction behaviour / usage of condoms To encourage, educate, counsel spouses, children & family and to assist in the disclosure of HIV results to their spouses 12

Social Functions To encourage and help PLHIV to access various welfare schemes provided by different of government and accredited social entitlement schemes To facilitate linkages between other service providers and patients like educational help for the children and income generation programmes Helping them in accessing legal help when need arises To facilitate linkages between other Governmental & Non- Governmental Organisations and service providers, like CSC*, STI, DOTS *CSC: Care and Support Centre 13

Programmatic functions To work in close coordination with ICTCs to ensure that all the patients detected positive at ICTC get registered at the ART centres To assess the HIV status of spouses and children through ICTC and link them to CST services Tracking of On-ART MIS / LFU cases in co-ordination with DAPCU / CSC / ICTC / Link Workers / Outreach Workers and NGOs Tracking of Pre-ART LFU It shall be ensured that a line list is maintained for patients who are eligible for ART but not initiated yet 14

Programmatic functions To sensitise the hospital staff on universal work precaution, PEP, ART, medical waste management and other CST services through education and training To work in close coordination with the RNTCP to ensure that all the patients with HIV-TB co infection are registered at the ART centre and started on ART To establish functional linkages with ICTC & PPTCT centres, and respond to the needs to be addressed at ART centre Participation in operational research, mentoring the LAC, plus and other health care facilities LAC 15

CD4 machines Each ART centre shall have access to CD4 tests either by a clear linkage mechanism for conducting regular and uninterrupted CD4 counts at a designated centre directly or The centre must follow the instructions on collection and transport of samples (and not patients) from testing site to the identified site where the test is to be conducted The reagents and other consumables needed for CD4 test procured and supplied by NACO to the centres shall be The machines shall be utilised optimally to ensure that there is minimal waiting period for CD4 test. All PLHIV in "Pre-ART" and "On ART" shall get the CD4 count done at least once in six months & more than one in six months, if required clinically 23

ART Centre: Human Resources ART Team ART Centre Staff Recruitment Process Job Responsibilities Training Additional staff to be provided by Institution (Institutional Nurse, Persons for daily cleaning of ART Centre) 29

ART Team of the Institution A 10 member ART Team shall be constituted in the institution. The members shall be from the Departments of: Medicine Paediatrics Obstetrics & Gynaecology Dermatology (and/or Venereology) TB and Chest Microbiology Psychiatry Surgery Community medicine This team shall be headed by the Medical Superintendent / Dean of the institution 30

PEP Prescription 2-drug Regimen (Basic) Zidovudine (AZT) 300 mg bid (or) Stavudine (d4t) 30 mg bid + Lamivudine (3TC) 150 mg bid 3-drug Regimen (Expanded) Zidovudine (AZT) 300 mg bid (or) Stavudine (d4t) 30 mg bid Lamivudine (3TC) 150 mg bid Third Drug: First Choice: Atazanavir/Ritonavir (ATV/r) 300/100 mg once daily (or) Lopinavir/Ritonavir (LPV/r) 400/100 mg twice daily Third Drug: Second Choice: Nelfinavir (NLF) 1250 mg twice daily (or) 750 mg thrice daily with empty stomach Third Drug: Third Choice: Indinavir (IND) 800 mg eighth hourly Drink > 1.5 litres of water daily If Protease Inhibitor is not available, EFV 600 mg may be considered as an option in the expanded PEP. Monitored for CNS side 21 effect (nightmares, insomnia)