OU Executive Summary India has the third largest HIV epidemic in the world. According to the 2007 Government of India (GOI) national estimates, there are 2.31 million people living with HIV/AIDS (PLHIV). However, because India is such a large country, the estimated adult HIV prevalence is a mere 0.34% of the population. This low prevalence rate is misleading given that nominal elevations in the HIV/AIDS rates in India have global ramifications. Fortunately, since 1990 the Government of India has been dedicated to combating the HIV/AIDS epidemic through a series of progressively stronger national programs. The most recent National AIDS Control Program, Phase III (NACP III) has increased efforts to expand services and tailor interventions to the unique dynamics of the epidemic in India. Given NACP III’s current momentum and significant advances in scale-up and capacity development, at the central and state level, reversing the epidemic is within reach over the next five to ten years.
India’s success influences the global HIV/AIDS pandemic reaching the Millennium Development Goals and meeting UNAIDS principles of the “Three Ones.” Working in close cooperation with the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and international partners, India is implementing “One” HIV/AIDS action framework, NACPIII, with “One” national AIDS coordinating authority, the National AIDS Control Organization (NACO). Now India is working towards unifying the country-level monitoring and evaluation (M&E) systems under “One” authority. PEPFAR/India is successfully implementing an aggressive transition from direct services to technical assistance. This fits well with the large scale $2.5 billion NACP III. The USG is strategically focusing on addressing the capacity gaps and TA needs at the national and state level in India to enhance GOI efforts to effectively combat HIV/AIDS.
The HIV/AIDS Epidemic in India
India has a concentrated epidemic with the highest prevalence among Most at Risk Populations (MARPs): female sex workers (FSW), men who have unprotected sex with men (MSM) and injection drug users (IDU). USG support predominately focuses on these MARPs along with bridge populations, pregnant women and Orphans and Vulnerable Children (OVC). HIV prevalence among men continues to be higher (0.45%) than females (0.27%). Out of the total estimated number of PLHIV, 39% are females and 3.5% are children. India has 3-4 million children affected by AIDS, out of which 95,000 children are living with HIV. Out of an estimated 27 million annual deliveries in India, approximately 85,000 infected women become pregnant and give birth to 25,000 infected babies each year. In 2008, 4.15 million pregnant women (15.3% of all pregnancies) received PMTCT services of which 19,986 tested HIV positive.
HIV estimates for India (2007)
Number of people living with HIV (adults and children)
Source: HIV Sentinel Surveillance and estimation is conducted annually by NACO. The latest report available is HIV data 2007. The HIV Sentinel Surveillance data 2008 is expected by November 2009.
While India’s national HIV prevalence appears to be declining with an estimated 0.36% in 2006 to 0.34% in 2007, this national statistic masks the more complex variation in state and district-level prevalence throughout the south and north east. In fact, there are several states and districts where prevalence appears to be rising. A third of FSW sentinel sites have >5% prevalence, with the highest rates in Mumbai (42%) and Pune (59%). Similarly 50% of MSM sentinel sites have >5% prevalence.
USG Focus Groups
HIV Prevalence 2007
(defined as temporary change of residence)
(defined as mobile populations)
Antenatal Clinic Attendees
(based on public sector registration)
3-4 million (currently being estimated)
Source: HIV Sentinel Surveillance and estimation is conducted annually by NACO. The latest report available is HIV data 2007. The HIV Sentinel Surveillance data 2008 is expected by November 2009.
The USG is focused on five high burden areas: Tamil Nadu, Karnataka, Andhra Pradesh, Maharashtra and the North East region.
Distribution of PLWHA among high burden states:
Rest of the states
The GOI and USG Response
The GOI is now implementing the third phase of a $2.5 billion NACP-III, 2007-2012, a plan developed with input from the donor community, including critical support from the USG. This GOI strategy outlines a decentralized response to the epidemic to deliver expanded prevention, treatment and care services, with the goal of integrating HIV/AIDS services within the National Rural Health Mission (a national Primary Health Care (PHC) strategy reaching about two-thirds of India’s population) by 2012. The integration of HIV/AIDS services will strengthen routine health and public health services in India.
NACP III has four primary objectives:
Prevent infections through saturation of coverage of high-risk groups with targeted interventions and scaled up interventions in the general population.
Provide greater care, support and treatment to larger numbers of PLWHA.
Strengthen the infrastructure, systems and human resources in prevention, care, support and treatment Program at district, state and national levels.
Strengthen the nationwide strategic information management system.
With strong GOI leadership under the National AIDS Control Organization (NACO), and strategic USG support, there has been a swift roll-out of the third phase of NACP III, significantly increasing India’s response to the HIV epidemic. NACP III outlines an ambitious time-line to deliver large-scale outcomes. For example, NACP III has set targets to scale-up prevention interventions at over 2,000 sites MARPs across 31 states; antiretroviral therapy (ART) in more than 200 centers; and the provision of counseling and testing (CT) services in nearly 5,000 centers.
The USG has a vital role to play supporting NACO’s implementation of large-scale, multi-faceted HIV/AIDS program. Leveraging relatively modest resources, $30 million annually, in FY 2010 the USG will continue to meet NACO’s critical need for technical assistance and capacity building at the national and state levels in select priority regions primarily: Tamil Nadu, Maharashtra, Andhra Pradesh, Karnataka and the North East (in Nagaland and Manipur). Transitioning to targeted technical assistance, the USG has dramatically reduced the number of districts receiving direct service provision. For example in Tamil Nadu the USG moved from working in 23 to 7 districts. The planned transition has allowed the GOI at all levels to support and maintain those services previously supplied by the USG. In line with NACP III and PEPFAR priorities, the USG will continue to increase the amount of TA through a mix of technical expertise and capacity building for NACO and State AIDS Control Society (SACS) to manage MARP interventions, care and support demonstration projects, OVC programming, laboratory strengthening and strategic information (SI) support. PEPFAR/India has established good working relations with each of the SACS in the focus states, and has supported effective partners on the ground.
USG efforts have recently resulted in a number of sustainable HIV/AIDS prevention, counseling and testing, treatment and SI programs. Maintaining a focus on sustainability, PEPFAR/India has established a four pillar approach including: capacity building at all levels of government; an ambitious transition from direct services to technical assistance, demonstration or pilot programs to test effective interventions and private sector expansion to guide India’s NACP III. In FY 2010, PEPFAR/India will develop an innovative four-year HIV/AIDS Partnership Framework to better support the TA needs of a reinvigorated national program currently implemented with strong national leadership and formidable resources to carry out its mandate to reverse the HIV/AIDS epidemic in India.
Program Areas: Strengths, Weaknesses and Opportunities: Program Area: Prevention: PMTCT/Sexual Prevention/ Biomedical Prevention/ Testing and Counseling
The NACO has a well-articulated, decentralized strategy. Dedicated HIV/AIDS efforts have led to a platform of data to support evidence based programming. Continued emphasis on prevention with set targets for saturating coverage of MARPs has maintained the momentum of HIV/AIDS efforts throughout the country. India has high quality behavioral and sentinel surveillance data on MARPs. In addition, migration patterns and MARPs hot spots have been mapped throughout the country to promote prevention and effective treatment programs.
In FY 2010 the USG will continue to be a primary source of TA and capacity building at all levels of the Indian government. At NACO’s request the USG has established a critical mechanism for on-going technical support that is the Technical Support Units (TSU) to strengthen the capacity of SACS, with a priority on strengthening Targeted Interventions (TIs) for MARPs. NACO’s annual evaluation of the TSUs revealed that the seven USG-supported TSUs were among the better-performing TSUs in terms of scaling-up and monitoring activities. These temporary TSUs are an excellent conduit to provide state level technical assistance and capacity building. Next year, the USG will continue to work to promote evidence based planning at the state and district levels to promote strategic MARPs interventions.
USG support has led to the GOI’s adoption of a number of policies, protocols and demonstration models. USG programs have pioneered prevention interventions among rural MARPs which have been adopted by NACO. For example, USG programs have successfully demonstrated sexual prevention interventions in selected sites which have resulted in scaling-up coverage, improving quality and beginning to stabilize the epidemic. Current interventions with MARP primarily focus on condom promotion. The provision of comprehensive package of services, including positive-prevention counselling, reduction of the number of sexual partners, increased access to STI treatment, HIV counselling and testing, care, support and treatment services, is being piloted by PEPFAR/India. USG programs have demonstrated systems for NGOs/Community Based Organizations (CBO) identification, capacity building and monitoring which are now replicated by SACS and NACO. In addition, the Ministry of Labor and Employment has endorsed a nationwide HIV/AIDS workplace policy based on over 400 workplace programs throughout the country.
India is actively expanding counseling and testing (CT) and PMTCT services. NACP III significantly scaled-up CT services by establishing 6,300 centers across the country and plans to expand to 10,200 centers by 2015. The increase CT service coverage specifically targets MARPs. To reach this goal, NACO is supporting CT services placed in the private sector and initiating demand generation programs to increase the uptake of services. The USG will continue to support NACO in scaling up and rolling out the effective implementation of comprehensive package of services in both the public and private sectors. At the Government of India’s request, in FY 2010 there will be a special focus on Andra Pradesh as interventions have yet to penetrate the HIV epidemic in many districts in that state.
Rapid scale-up of CT services was not complemented by comprehensive, MARPs tailored demand generation programs to increase the uptake of services. Stigma, inconsistent quality, and limited private sector regulation/collaboration have impeded the full scale-up and utilization of MARPs services and support. Solid demonstration of community-based and private sector approaches will inform focus states enhancing MARPs counseling, testing and treatment. In FY 2010 USG will provide technical support in developing demand generation campaigns for increasing uptake of CT services among MARPs; developing operation research studies on community led CT approaches and addressing gender concerns in CT programs.
The most recent data from 2008 reveals that 4.15 million pregnant women (15.3% of all pregnancies) received PMTCT services and 19,986 tested HIV positive. However, of the identified positive pregnant women, only 51% of the mother-baby pairs received Single Dose Nevirapine (SD NVP). Unfortunately, many HIV positive pregnant women remain unidentified and similar to the Maternal Child Health (MCH) sector, poor care seeking behavior and low hospital utilization remain significant barriers to reaching pregnant women. Even when women are identified, there is a major service gap in follow-up with positive pregnant women after delivery. In addition, there is no male involvement in PMTCT services. In the next year PEPFAR/India will explore the possibility of completing a gender analysis examining the role men have in promoting PMTCT. Significant support from the Global Fund, Round 2, is supporting both PMTCT and ART treatment scale-up in public and private sectors. Considering that almost 50% of total institutional deliveries take place in private hospitals, collaboration with the private sector will significantly expand the GOI’s out-reach to positive pregnant women and families. In FY 2010 USAID will continue support to three private sector PMTCT sites to explore opportunities for NACO. NACO and the USG will promote integrating HIV/AIDS into MCH services which would improve NACO’s ability to reach and support positive pregnant women and their families.
The GOI is scaling up Oral Substitution Therapy (OST) to IDUs resulting in the accreditation of 27 OST centers. Strong coordination between NACO and the Ministry of Social Justice and Empowerment has resulted in 200+ NGO managed counseling de-addiction and rehabilitation centers. However, with the exception of the North East region, most SACS have not considered IDU interventions as a priority mainly due to their limited capabilities to address IDU needs. Furthermore providing comprehensive services to female IDUs is even more challenging. The USG will continue to support improved IDU HIV/AIDS programs in NACO and SACS through TSUs and focus on bringing international and regional experts to develop more responsive IDU programs.
Program Area: Treatment: Adult/ Pediatric and Lab Infrastructure
National Government commitment for scale-up and support from GF Rounds four and six, have resulted in greater access to treatment and support services for both adults and children infected with HIV. NACO launched the free public ART program in April, 2004 in eight government hospitals located in six high HIV prevalence states. Today services are provided in 217 fully functional ART Centers. ART Technical Guidelines for Adults (both first line and second line) were developed and distributed to all ART Centers. NACP III plans to provide free ART services to 300,000 adults through 250 ART centers and 650 Link ART centers by 2012. Link ART centers (LAC) have been established in existing health facilities at district and sub-district level to make the treatment services more accessible and facilitate delivery of ARVs to PLHIV. Currently 577,011 PLHIV are registered in 217 ART centers and 223,000 are on ARVs. Of the total PLIV on ARVs, 39% are female. Over 53,000 of HIV infected children have been registered in ART centers and 14,474 children are on ARVs (39% or ARV care is provided to girls). An estimated 40,000 PLHIV seek ART services from the private sector.
Patient compliance and ARV drug adherence is poor. Late stage initiation of ARVs, and therefore management of AIDS, is more difficult resulting in high morbidity and mortality. Only 50% of the PLHIV tested positive at Integrated Counseling and Testing Centers (ICTC) are successfully referred to and registered at the ART centers. Nearly 25% of PLHIV enrolled at the ART centers have a CD4 count of less than 50cells/cmm resulting in high mortality rates despite being on ARVs. The follow-up of pre-ART patients is poor with few PLHIV receiving cotrimoxazole (CTX) prophylaxes. Lack of availability of drugs for Opportunistic Infections (OI) at the ART centers hampers the timely treatment of infections. There are also low rates of drug adherence. The USG has focused on home based care and support with ARV with three pilots to improve future treatment efforts.
While MARP interventions are expanding, working with MARPs remains challenging. Only 53% of FSWs and 77% MSM are currently reached in India. There are inconsistent levels of quality of MARP interventions throughout the country. Limited documentation of success stories and best practices in prevention programs has limited the positive influences to developing high quality programs. Moreover the MARPs high risk behavioral characteristics are evolving. For example, recently the dynamics of sex work have moved from predominately street and hotel operations to more underground venues such as private houses and lodges. This rapidly changing environment further complicates efforts to reach MARPs.
In order to effectively reach MARPs our understanding of MARPs behavior, situation and specific needs to deepen. There is a gap in specific data on MARPs’ access to counseling, testing, care, support and treatment services in India. Given the success of NGO/CBO prevention programs to reach evasive MARPs there is an opportunity to work through NGO/CBOs to connect MARPs to much needed services. The USG will work to address the gaps in our understanding of MARP interaction with services and establish better linkages between prevention programs and counseling and testing, care, support and treatment programs.
The USG leads the national efforts to strengthen the 13 National and 117 State Reference Laboratories to improve quality of diagnostics and testing. India has a well laid out laboratory infrastructure with one 1 Apex lab, the National AIDS Research Laboratory (NARI), 12 National Reference Laboratories (NRLs) and 117 State Reference Laboratories (SRLs). There are approximately 5000 ICTCs for service delivery and 150 CD4 Laboratories providing support to ART Centers. However there remains an overall lack of quality laboratory testing services in the State Reference Labs and ICTCs. India does not have an active laboratory regulatory body and current Laboratory Management Information Systems (LMIS) are immature. PEPFAR/India support contributed to strengthening of the laboratories of the Indian Armed Forces Medical Services (AFMS). The USG-supported state-of-the-art laboratory at the Government Hospital for Thoracic Medicine at Tambaram (GHTM), Chennai is recognized as one of the centers of excellence (COE) by NACO.
Recently the NRLs have been assessed and NACO is working to accredit these labs by a government recognized body, i.e., the National Accreditation Board of Laboratories, Dept of Science and Technology Government of India. CDC will continue to work with NACO strengthening SRL performance through assessments, feedback and technical assistance on laboratory management. A major objective of the laboratory strengthening efforts is to have all national and state reference laboratories accredited by the National Accreditation Board of Laboratories. A mature LMIS will be supported to facilitate quality systems. Finally rolling out rolling out of early infant diagnosis (EID) has major implications for the follow-up and treatment of positive women and their infants at the earliest stages.
Program Area: Care: TB/HIV and OVC
In 2009, USG PEPFAR supported a demonstration project providing mobile counseling and testing vans in remote rural areas for follow up of Direct Observes Therapy, Short Course (DOTS) treatment for co-infected persons. Counselors from various USG-supported projects have supported government DOTS centers to ensure smooth referrals and counseling of TB-HIV patients. The USG also developed the capacity of a wide range of health providers in HIV programs, including counselors, peer educators, HIV-positive network persons and men who have sex with men, to serve as DOTS providers.
The USG provided technical assistance to revise the TB-HIV providers’ curriculum to improve treatment in both national programs. The USG-supported WHO technical advisor provides critical policy and technical inputs on TB-HIV issues at the national level. This advisor has worked closely with the GOI on policy development and program implementation, especially in the areas of TB/HIV surveillance, provider-initiated counseling and testing, and TB/HIV coordination. The USG, along with DFID, World Bank and WHO were involved in a series of Joint Monitoring Missions (JMM) to review progress in the implementation of the India Revised National Tuberculosis Control Program (RNTCP) and TB-HIV collaborative initiatives.
USG PEPFAR has worked with the USAID TB Control activities in Karnataka to strengthen the TB-HIV referral complex to ensure treatment adherence for both TB and ART through a comprehensive care, support and treatment program in 15 districts. Similar efforts are ongoing in five coastal districts of AP as well.
USG advocacy efforts for a stronger focus on OVC have resulted in the adoption of a national policy to support OVC treatment, care, and support. In addition, a national pilot to field-test new operational guidelines developed by the USG has been approved. However OVC implementation has been delayed due to a lack of true government commitment to OVC. In FY2010 the USG will continue to promote NACO efforts to support OVC and advocate for program implementation.
Other: Strategic Information/ Health Systems Strengthening/ Human Resources for Health and Gender
Strengthening SI systems is one of the four overarching objectives under NACP III, revealing NACO’s commitment to improving SI systems, data collection and utilization to inform and effectively combat HIV in India. NACP III lays out a robust M&E framework along with performance measures, and benchmarks (annual core indicators and dashboard indicators) are reviewed every six months.
Currently multiple Management Information Systems generate program data. There is a program to integrate these systems into a Strategic Information Management System (SIMS) to form one comprehensive data reservoir.
However, there is no single national SI body to oversee the utilization of data for program enhancement, due, in part, to the limited SI capacities at all levels of government. While data are generated, usage is still limited. In addition, poor data quality plagues the SI system. High staff attrition rates further complicate the SI objective, making it difficult to maintain a trained workforce.
The NACP III Midterm Review (MTR) will be a key SI driver, as it will encompass several important SI studies, including: Behavioral Sentinel Surveillance among MARPS; triangulation and validation of different data sets to identify hotspots that need renewed attention; and expenditure and resource allocation analysis. Results from these studies will be vital for a mid-course correction re-invigorating SI in the latter half of NACP III implementation. The process is already increasing interest in using available data. A well-functioning Strategic Information Management System at the state and national level will bring financial and programmatic data under the same umbrella to promote data for effective and efficient program implementation.
Presently, the health budget of state and central government combined to support clinical delivery of care is very low, at less than one percent of India’s GDP. With the decentralization of health services, states now manage their programs, and they contribute approximately 80% to public health expenditures. In the states with low per capita incomes and with a high concentration of poverty, per capita public expenditure on health and family welfare remains very low.
The USG has a well respected track record of providing critical technical assistance and capacity development to support NACO, SACS, the Ministry of Labor and Employment and the Indian Armed Forces Medical Services’ individual and institutional capacity development. In the coming years, the USG will focus on promoting convergence and integration with other sectors such as MCH, reproductive health (RH) and Primary Health Care (PHC) system strengthening. There are also opportunities for Public Private Partnerships that will be pursued by the USG in the coming years, while district level institutional strengthening will enable better outreach and interventions for MARPs.
The USG has taken the lead in supporting Health System Strengthening (HSS) initiatives to carry out NACP III in a wide range of program areas including: lab strengthening, human resource development, institutional capacity building of state and national governments. In particular the USG has emphasized neglected areas such as: communications, strategic information skills and systems, program management, prevention, and work with OVC. Efforts in HSS and Human Resource Health (HRH) have been scaled up with PEPFAR’s mandate to transition to targeted technical assistance to enhance the scale-up and impact of NACP III.
Central to the USG led mentoring and human capacity development for NACO and SACS is government ownership. This has resulted in an intensive capacity building plan built into the NACP III program, such as the temporary TSUs shadowing SACS, and national and state reference lab initiatives promoting quality and performance monitoring systems.
While intense USG supported HSS and HRH initiatives are underway, there are challenges to effectively implement plans to improve HIV/AIDS competencies. Current barriers include: frequent changes in leadership of SACS project directors; poor quality of services due to the rapid service scale-up; duplication between functions and functionaries of the rural PHC system (NRHM) and NACO; the absence of a solid integration plan to promote high-impact HIV/AIDS outcomes; lack of a phase-out plan in place for temporary TSUs; lack of technically competent professionals in key NACO and SACS positions; absence of a coordinated, data driven system to identify the specific training needs of various cadres of HIV/AIDS program and service staff; and inadequate donor coordination with local institutions to develop and implement training programs.
Women living with HIV face special challenges in accessing services since they may not be able to leave their villages to seek treatment due to routine family responsibilities or care-giving responsibilities. The cross cutting issue of gender will be addressed by the USG in all program areas. While it is part of the NACP III, gender is not a prevailing priority therefore the USG will continue to support deeper gender analysis, data collection disaggregated by sex and incorporating gender considerations in all aspects of NACP III implementation. It is well documented that considering gender will enhance program impact.
Integration of gender into USG programming increased since the last COP, but is still in the early formative stage. The recently formed USG Gender Technical Working Group (TWG) focuses on ensuring the India/USG team and partners address gender issues and that both PEPFAR and NACO gender guidelines are integrated and used in all the supported programs. In FY 2010 the TWG will be the focal point for addressing gender programming in HIV and mainstreaming gender with other programs. TA at the state, district levels and below, through partners and the USG supported TSUs in six states, includes addressing gender inequities in care, treatment, and prevention services, and reducing vulnerability and risk for MARPs and women.
FSW, MSM, and transgendered are highly vulnerable to both HIV and sexual violence. The risk of violence for young men and women is linked to early socialization of gender norms that implicitly sanction this mode of social control. USG partners are actively involved in group education interventions to promote more equitable gender norms and these activities will continue in FY2010.
In FY2010 USG partners will work to ensure that HIV-positive women have access to rights and entitlements. The USG will work with several state and district level PLHA networks and legal coalitions, such as the Women's Lawyers’ Collective, to address the concerns of HIV-positive women. Referral systems will be strengthened so that health care providers will refer women to legal services to ensure property inheritance, widows’ pensions, housing, and ration cards.
Since male risk behaviors are the single most important driver of the epidemic in India, shifting social norms for acceptable male behavior is critical to the success and sustainability of HIV prevention efforts. USG partners support such normative change through targeted interventions promoting mutual fidelity and partner reduction, and consistent condom use with non-regular partners. In four states, risk reduction interventions will continue to target short-term male migrants in urban areas. These interventions also protect their spouses, who often remain in their home villages. The USG-funded Positive Prevention Counseling Toolkit seeks to reduce risk behavior among HIV-positive men.
Targeted USG support, coupled with strong NACO leadership and significant NACP III resources, has fostered many sustainable achievements, especially: successful pilot or demonstration site scale-up, better functioning government bodies at the national, state and district levels and private sector engagement to expand HIV/AIDS efforts. In addition to the examples of sustainability already mentioned, a few highlights include:
GOI Adoption of USG Demonstration Site Projects:
NACO has scaled-up many USG supported implementation models developed in demonstration sites or pilot programs.
The USG’s model program piloting task-shifting through the nurse-practitioners (NP) expanded to 266 facilities.
Several USG MARPs interventions, such as work with trucker and migrant populations, are now completely supported by state governments.
USG efforts in Tamil Nadu (TN) such as Women’s Self-Help Groups (SHG) and Youth Red Ribbon Clubs (RRC) are now funded and maintained by the TN state government.
In Karnataka, USG partners pioneered the concept of reaching rural MARPs through Link Workers, a model now recognized by NACO and scaled-up nationally through the support of the GFATM.
Communication materials developed by USG partners for MARPs and bridge populations have also been adopted and disseminated by SACS and NACO.
An assessment tool for prioritizing industries based on risk developed by a USG partner in Andhra Pradesh is now being used by other agencies.
The Ministry of Labor and Employment is about to launch a nationwide HIV/AIDS workplace policy developed by the USG based on work in over 400 workplace programs throughout the country.
The Indian Armed Forces now fully maintains and properly utilizes laboratories with appropriate equipment to diagnose, treat and support military personnel and their families infected and affected by the HIV epidemic.
Better functioning government bodies at the National, State and District levels:
Since late 2007, NACO led a Joint Implementation Review (JIR) every six months. The JIR is a self-governed, multi-sectoral review involving NACO, SACS, donors, and local experts. NACO and SACS receive strategic recommendations from the JIR to improve their HIV/AIDS programs.
The newly formed TSUs are a team of professionals assisting SACS with strategic planning, capacity building, targeted interventions, public-private partnerships (PPP) and mainstreaming HIV/AIDS priorities with non-health ministries. With the TSUs in place SACS increased program management capacity. For example, many SACS are now, for the first time, preparing evidence-based annual action plans that are expanding the scale and quality of state programs. Some HIV/AIDS program state expenditures have almost doubled in the last year. In Uttar Pradesh, the SACS increased tailored MARPS interventions from about 55 to over 100 specific interventions.
With USG support a number of government bodies have either been developed or reinvigorated to address HIV/AIDS through NACP III. These include:
District AIDS Prevention and Control Units (the nodal agency for implementation and monitoring of HIV programs and services at district level)
State Training Resource Centers (local institutions such as academic universities and medical colleges identified as the state-level nodal agency responsible for training and capacity building activities related to HIV prevention programs for MARPs)
The National Institute of Biology (the equivalent of U.S. National Institutes of Health – to support state of the art diagnostics)
The National Centers for Disease Control (the newly designated institute modeled on the USG CDC)
The Indian Network of Positive Persons (actively engaging in innovative positive prevention approaches)
USG TA for communication at NACO and SACS built strategic health communication leadership and facilitated NACO’s development of thematic communication strategies tailored to specific populations.
Private Sector Expansion:
The USG initiated India’s first private sector insurance scheme for PLHIVs. This privately financed insurance scheme is attracting a number of insurance companies that previously excluded HIV positive clients from their insurance plans. This ground breaking initiative has tremendous potential to facilitate PLHIVs’ access to quality care and support services while also reducing the financial burden for families and communities affected by the epidemic.
A help-line for PLHIVs was launched with USG support and significant support from Tata, a major Indian corporation. Now the GOI is also supporting Tata to scale-up this highly utilized communication tool to additional states.
USG support for innovative work place policy programs has resulted in active work place programs financed and maintained by over 200 companies throughout the country.
NACO signed a Memorandum of Understanding (MOU) with leading private sector companies /business corporations (Bajaj, Reliance and Godrej) to establish ten ART Centers in the private sector to provide treatment to more than 3,000 PLHIV.
These are exciting, sustainable achievements that go beyond direct service delivery to the more complex and intensive efforts of fostering the systems and government commitment to implement and maintain proven HIV/AIDS models well after USG support has graduated.
Confirmation of GOI Commitment to HIV/AIDS
Over the last year there have been several important developments indicative of the GOI’s commitment to combating HIV/AIDS in India:
a) The historic judgement by the Delhi High Court legalising consensual adult male homosexual relations and overturning the Indian Penal Code Section 377. This change in the legal code is widely seen as an important step to create a more enabling environment for programs seeking to reach marginalized MSM with HIV services.
b) Multiple bi-lateral and multi-lateral donors have been invited to participate in an intensive Mid-Term Review (MTR) of NACP III programs. The MTR will assess the progress of NACP-III against plans; provide insight on factors facilitating/hindering progress; ascertain the effectiveness of technical strategies; and review resource commitments and gaps. The MTR reveals the GOI’s true commitment to transparency, program effectiveness and collaboration to improve its already well functioning national program.
c) Nationally 1,513 TI projects were implemented, an increase of almost 80% from last year. NACO also rolled-out the Link Worker Program in 90 out of 187 high HIV prevalence districts to ensure TIs reach rural MARPs. USG prime partners in Tamil Nadu and Maharashtra have leveraged resources from NACO to implement the Link Worker Program in their high-prevalence districts.
With the implementation of NACP III and the strong leadership of NACO, India now has a well functioning vertical program that has rapidly advanced India’s response to HIV/AIDS. This year it became increasingly evident that a major boundary to NACP III progress is the serious stigma and discrimination against PLHIVs and the poor integration of HIV/AIDS programs with other services, manifesting in a general inability to effectively reach MARPS with services and support. NACP III introduced a decentralization plan transferring services and oversight to the states. While the decentralization will help integration of services in the long term and routinizing HIV/AIDS services may decrease stigma, in the short term it has revealed poor capacity by the SACS to use data or resources to efficiently execute MARPs focused programs.
In FY 2010
The USG will continue to play a critical role in India’s fight against HIV/AIDS as the GOI continues to provide a strong leadership and commitment to addressing the enormous challenges of the HIV/AIDS epidemic in the world’s largest democracy. The PEPFAR/India program has closely aligned with the national program, established good working relations with each of the SACS in the focus regions, and supported effective partners on the ground. The long-term focus of USG is on strategic provision of TA and strengthening the quality of service delivery through strategic partnerships that leverage public and private resources. This will be pivotal year for the USG to promote innovative MARPS interventions, support the fight against stigma, and capitalize on opportunities for integration and continued capacity building at all levels of government. President Obama’s Global Health Initiative will open up new opportunities for PEPFAR to promote HIV/AIDS integration in MCH, RH and HSS initiatives accelerating India’s progress in combating HIV.
Relevant demographic and HIV/AIDS data:
Source of Data
Year of Estimate
Total population (all ages)
Women 60 years & above
Women 15 -59 years
Men 60 years & above
Men 15 -59 years
Girls 0 – 14 years
Boys 0 – 14 years
Age not stated
Note: Census of India data is published by Office of Registrar General of India, Govt of India, Ministry of Home Affairs. The last Census was conducted in 2001. The next census is planned in 2010.
Life expectancy at birth : 68years
Infant mortality 57/1000 (NFHS 2006)
Peri-natal mortality 49/1000 (NFHS 2006)
Maternal mortality ratio : 300/100,000 (SRS 2007)
Percentage of safe deliveries : 47%
Percentage of underweight children: 43%
Birth rate 23.1/1000 ( SRS 2008)
Crude death rate ; 7.4/1000 (SRS 2008)
Total Fertility rate :2.7
Socio Economic indicators:
Adult Literacy (Male) : 78% ( NFHS 2005- 2006)
Adult Literacy (Female): 55% (NFHS 2005-2006)
Human Development Index : 0.62 ( Human Development Report 2008)
Access to an improved water source (rural) : 82% ( World Bank 2005)
Access to improved water source (urban) : 96% ( WB 2005)
Access to improved sanitation facilities (rural ): 18% (WB 2005)
Access to improved sanitation facilities(urban): 58% (WB 2005)
Unemployment rate : 7.2% (2008)
Percentage of women employed :43%
Percentage of men employed :87%
Median age at marriage : 17.2 years (NFHS 2006)
Source of Data
Year of Estimate
Number of people living with the disease (all ages)
HIV Sentinel Surveillance and HIV Estimation 2007: A Technical Brief (Annex 22)
Injecting drug users/ HIV +
156,300 Estimates may be revised based on Mapping of HRG carried out in 2008-09.
7.2% HIV positive (2007 HSS)
Report of Expert Group on size estimation of population with high risk behavior for NACP-III Planning