CHAPTER-I

HIV/AIDS- AN INTRODUCTION

Acquired Immunodeficiency Syndrome (AIDS) has become the most serious

and deadly disease of the millennium that mankind has ever faced. More than 37.7
million people have been affected worldwide. It is a disease caused by the retrovirus
known as Human Immunodeficiency Virus (HIV) which attacks the immune system.
An advanced stage of HIV infection is when the HIV positive individual develops
opportunistic infections like tuberculosis, meningitis, oral esophagus candidacies,
pneumonia and certain types of cancer or the CD4 cells fall below 200 cells/mm3 is
referred as AIDS (UNAIDS, 2015a).

The epidemic of HIV/AIDS has devastated the lives of millions of people

throughout the world since its out break into human society. The deadly, catastrophe
that grabbed the entire human society was accentuated by the misconceptions,
triggered anxieties and fear about people living with HIV/AIDS (PLHA), which
paved way for mayhem in the social order. Unlike any other disease, living with
HIV/AIDS itself is a social challenge rather than biological existence. The societal
implication of this epidemic was kept at abeyance by the increased demand for
HIV/AIDS vaccine and other related bio medical questions, which consumed the
human intelligentsia during the 1980s. But by the thoughtful interventions of
International agencies particularly UNAIDS and other non- governmental
organizations (NGOs) some light had been shed upon the hidden social dimensions of
HIV/AIDS from the early twenties.

These HIV/AIDS pose a threat to the lives of people at high risk groups
(HRGs) worldwide, depending on their level of disruption, literacy and awareness.
Some infections, such as STDs and AIDS, are transmitted through sex workers, men
through sexual contact, drug abuse, blood transfusions, transplants, and organ
transplants. It reflects a negative opinion on social behavior as well as on the victims.
It is very disturbing that the social life of the respondents in most societies. The
malignancy of this disease causes a kind of social disorder, which is triggered by
institutional and familial disorder as a personal problem. The disease is affecting or
taking a toll on human lives, in the African Sahara region it has shaken up social

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viability by eradicating adult generations and children. It has brought about a society
of missing generations that is in danger of wiping out humans in its progress.
Human Immunodeficiency Virus (HIV)
Human Immunodeficiency Virus weakens the immune system or the body’s
own defense system. This process is slow and usually takes years after the infection
for a person to notice she/he has been infected. The main components are, the white
blood cells present in the blood and lymphatic system including the lymph glands,
HIV virus enters the white blood cell. Upon entry, it hijacks the genetic constitution
and partly replaces it is by own sensitive information and then multiplies. These cells
now attack other white blood cells. Slowly the number of white blood cells in the
body is reduced and immune system is paralyzed. The person, who has the virus and
is harboring HIV infection, is identified as a sero- positive individual. When a person
is infected with HIV, nothing is visible on the exterior but the person infects others.

According to this definition of HIV-positive individual with a CD4+ cell count

of 200 or less or whose CD4+ cells represented less than 14 per cent of all
lymphocytes are called AIDS people. Two additional illnesses are also included in the
case definition that is AIDS-defining in children but not in adults [Theresa et al.,
1998].

The person with HIV may initially be perfectly healthy but will eventually
develop AIDS with HIV is called “Having AIDS”, when his immune system is
totally broken down and does not respond to treatment, there is profound immune
suppression and opportunistic infections may prone to fatal out this stage. The CD4
(Cluster Designated) count is usually less than 200 cells and progressively falls.
Infections with HIV, is lifelong. Severe immune deficiency develops in infected
persons within 10-12 years on an average. It is estimated that one person is infected
with the HIV is every eight seconds, equivalent to 11,000 infections worldwide every
day. Severe immune deficiency develops immune damage, susceptibility to
opportunistic infections and cancers act as surrogate clinical indications of AIDS.

Acquired Immunodeficiency Syndrome (AIDS)

AIDS stands for Acquired Immunodeficiency Syndrome. AIDS is the final
stage of HIV infection. It can take years for a person infected with HIV, even without
treatment, to reach this stage. Having AIDS means that the virus has weakened the

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immune system to the point at which the body has a difficult time fighting infections.
When someone has one or more of these infections and a low number of T cells,
she/he has AIDS. Electron microscope of HIV is seen as small sphere on the surface
of white blood cells [AIDS.gov, 2014].

AIDS is a syndrome caused by the HIV virus. It is when a person’s immune

system is too weak to fight off many infections, and develops when the HIV infection
is very advanced. This is the last stage of HIV infection where the body can no longer
defend itself and may develop various diseases, infections and if left untreated, death.
However, among the right way of treatment and support systems, respondents can live
long and healthy lives with HIV/AIDS [AIDS.gov, 2014].

HIV gradually attacks immune system cells. As HIV progressively damages

these cells, body becomes more vulnerable to various infections, which it will have
difficulty in fighting off. It is at the point of very advanced HIV infection that a
person is said to have AIDS. It can be years before HIV has damaged the immune
system enough for AIDS to develop [UNAIDS 2008].

HIV/AIDS: Mode of Transmission

The HIV care or awareness can be transmitted through many channels.
Explaining the mechanism of transmission of HIV, medicine states that all people
infected with HIV have HIV in their blood and genital secretions, regardless of
whether they have symptoms or not. HIV is spread through contact with tissues such
as the vagina, anal area, mouth or eyes (the mucous membranes) or when the skin is
broken, either through a needle or through a puncture. The most common ways HIV is
spread worldwide are through sexual contact, needle sharing and transmission through
infected mothers to their newborns during pregnancy, childbirth or breastfeeding. It
also states that kissing is generally not considered a risk factor for HIV transmission
unless there are scores or blood in the mouth. This is because saliva, in contrast to
genital secretions, has been shown to have very little HIV. It is still argued that the
theoretical dangers of sharing toothbrushes and having razors are bleeding and that it
is the cause of transmission because there is a large amount of HIV in the blood.

The British Medical Association Illustrated Medical Dictionary (2002:16) also

notes that “HIV is transmitted in body fluids, including semen, blood, vaginal

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secretions and breast milk. The major methods of transmission are sexual contact
(vaginal, anal, or oral), blood to blood (via transfusions or needle-sharing in drug
users) and mother to fetus”. HIV infected Mother is more than high risk for the
transmission of HIV/AIDS occur during pregnancy, time of delivery and as a result of
breast feeding. The presence of Sexual Transmitted Diseases (STD) increases to risk
of HIV transmission because of more mucous membrane is exposed to the virus.
Other practices that have been associated with HIV transmission include practices like
ear, nose and eyelid piercing, circumcision and other body marks that involve sharing
of instrument without adequate sterilization (Ogbu:2006). However, the most
common form of HIV transmission is through sexual intercourse and from who have
sexual contact by infected blood, semen, or cervical and vaginal fluids transmitted to
any infected person to his or her sexual partner whether it be man to woman, man to
man, or woman to woman. Sexual transmission of HIV can occur virginally, orally
and anally (WHO 2000:12-2).

According to Gracious Thomas et al (1997:26) the HIV can pass on to an

individual mainly through the following three routes:
Sexual exposure: The spread of HIV is most commonly transmitted through sexual
contact between men and women, from women to men, and between men who want
to be men.

Parent to Child: This is called the ore-natal transmission. Before delivery, it spreads
to the developing fetus through the placenta. During childbirth, the virus is
transmitted to the baby through the mother's blood or body fluids.
Contact with contaminated blood and blood products: It can also be transmitted
through the blood of an HIV-infected person. People became infected through this
blood transfusion, sharing infected blood products and syringes and hypodermic
needles, including donated organs. In many parts of the world, donated blood is now
being tested for antibodies to HIV, making this type of transmission very rare.
However, in areas where blood has not been systematically tested and circulating in
this way may still be normal.
Inject drugs: Sharing drug-taking devices with each other, especially using non-
sterilized needles, increases the risk of HIV infection. There is an increased risk of
HIV infection when medications are taken by means other than this injection, but

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people infected with the drugs have the highest risk. The nature of injecting drugs
creates barriers to accessing adequate HIV prevention, testing and treatment services,
making it even more vulnerable for people who inject drugs to become infected with
HIV and its effects.
Piercing/Tattoos: If the equipment has not been sterilized before having a tattoo or
piercing, there could be a significant risk of exposure of the person before was HIV
positive [Meenu Sharma, 2006].
HIV/AIDS Transmission: HIV is transmitted when a person comes in contact with
specific body fluids of another person who is HIV positive.
Body fluids that can contain and transmit HIV include:
 Blood and Blood products
 Breast milk
 Semen
 Vaginal and creviced secretions
 Wound discharge or pus
Body fluids that contain and transmit HIV which medical staff may contact
include:
 Fluid surrounding an unborn baby
 Fluid surrounding bone joints
 Fluid surrounding the brain and spinal cord
HIV/AIDS are primarily transmitted in the following ways
 Sexual transmission
 Blood transmission
 Sharing needles or using syringes and razor blades
 Mother to child transmission
HIV is not acquired through the following:
 Touch and hugging
 Kissing
 Living in the same place with people who have HIV/AIDS
 Shared food, utensils, caps or dishes
 Shared swimming pools or pools or bathing facilities
 Bites from mosquitoes or other insects
 Sneezes or coughs [WHO, 1986].

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The Groups Vulnerable to HIV Infection

The through everyone is under the risk of acquiring HIV infection, certain
groups are more vulnerable to HIV based on their life on high risk situation. These
groups are called high risk groups. The high risk groups identified by the UNAIDS
are past and present intravenous of drug users, prostitutes and their sexual partners,
homosexual and bisexual men, Eunuchs involves in sexual activities particularly with
homosexual men, prison inmates involved in homosexuality, multi-sexual partners,
drug addicts, street children involved in sex and drug abuse, truck drivers who
involved in sexual activity in the highway. Defense personal who are engaged in sex
with prostitutes, children of HIV positive women, sexual partners of HIV infected
people, thalassemia people who often receive blood from the donors, migrants who
are away from their home for a long time and are involved in extra marital sex,
construction workers etc [Thomas et al.,1997].

Symptoms of HIV/AIDS
Just because a person has HIV/AIDS does not mean that they are the only
ones. A person can only be diagnosed with a blood test to find out if he or she is
infected with HIV. An HIV- infected person may look very healthy and feel good, but
they can still transmit the virus to others. Once a person is infected with HIV it is as if
their body has been infected with HIV for the rest of his / her life. Antiretroviral drugs
are used to treat this HIV infection. They react differently to HIV infection by
slowing down the Facsimile of HIV in the body. The right combination of
antiretroviral drugs can slow the damage caused by HIV to the immune system and
delay the onset of AIDS, thereby prolonging the life of people living with HIV/AIDS
(PLHA).
The Symptoms of HIV/AIDS:
 Fever for longer than one month, intermittent or continuous.
 Persistent cough for longer than one month.
 Weight loss greater than 10 per cent of body weight.
 General itchy dermatitis or skin irritation
 Recurrent herpes zoster (painful patches on the skin)
 Fungus infection in the mouth/throat
 Swelling of lymph glands
 Chronic diarrhea for longer than one month, intermittent or constant.

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The virus weakens the immune system of an HIV-infected person so that they
are more vulnerable to opportunistic infections. These infections are caused by germs
around us, but can usually be fought by a healthy immune system. Once HIV breaks
down the body's defenses, such infections can have a wide variety of symptoms and
some of them can be very serious. Some cancers also become common when the
immune system is weakened.

HIV Tests
The standard of HIV test is the Antibody Screening Test (Immunoassay),
which tests for the antibodies that body makes against HIV. The immunoassay may be
conducted in a lab or as a rapid test at the testing site. Because the level of antibody in
oral fluid is lower than it is in blood, blood tests tend to find infection faster after
exposure than do oral fluid tests. In addition most blood-based lab tests find infection
sooner after exposure than rapid HIV tests [AIDS Govt.].

Several tests are being used more commonly that can detect antibodies and
antigen. These tests can find recent infection earlier than tests detect only antibodies.
These antigen/antibody combination tests can find HIV as soon as 3 weeks after
exposure to the virus, but they are only available for testing blood, not oral fluid. Not
all testing sites offer this test by default if you believe you have been recently exposed
to HIV be sure to let your provider know and ask if this type of test is available.
[AIDS Govt.]

The rapid test is an immunoassay used for screening and it produces quick
results in 30 minutes or less. Rapid tests use blood or oral fluid to look for antibodies
to HIV. If an immunoassay is conducted during the window period the test may not
find antibodies and may give a false- negative result. All immunoassay that are
positive need a follow-up test to confirm the result [AIDS Govt.]

Follow-up diagnostic testing is performed if the first immunoassay result is

positive. Follow-up tests include an antibody differentiation test which distinguishes
HIV-1 from HIV-2 an HIV-1 Nucleic Acid Test which looks for virus directly, or the
Western blot or indirect Immune fluorescence assay, which detect antibodies. Immune
as says are generally very accurate but the follow-up testing allows you and your
health care status is provides to be sure to the diagnosis is right way of better results.

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If you first attempt for test is a rapid test and you get positive, you will be directed to
the medical setting to get follow-up to testing and counseling for the better way of
living. If your first test is a lab test and it is positive the lab will conduct follow-up
testing usually on the same blood specimen as the first test [AIDS Govt.].

Accuracy of the HIV Tests

The standard of HIV antibody (ELISA) tests are at least 99.5 per cent accurate
when it comes to detecting the presence of HIV antibodies. This high level of
sensitivity however means that their specificity (Ability to distinguish HIV antibodies
from other antibodies) is slightly lowered. Once an individual is out of the window
period, it is more likely that they will receive a false positive result than a false
negative. Any HIV positive result given by an ELISA test must therefore be
confirmed using a second test. Secondary tests include: [National AIDS Trust, 2014].
Western Blot Assays- One of the oldest but most accurate confirmatory antibody
tests, it is complex to administer and may produce indeterminate results if a person
have a transitory infection with another virus.
Line Immunoassay- Commonly used in Europe. Reduces chance of sample
contamination and is as accurate as the Western Blot.
Indirect Immune fluorescence Assay- Like the Western blots, but uses a micro
scope to detect HIV antibodies.
Second ELISA– In resource- poor settings with relatively high prevalence, a second
ELISA test may be used to confirm a diagnosis. The second test will usually be a
different commercial brand and will use a different method of detection to the first.
When two tests are combined, the chance of getting an inaccurate result is 0.1 per cent
[V. Ramamurthy, 2004].

Course of HIV Infection

This HIV infects cells in the central nervous system in the immune system.
The major type of HIV- infected cell is T helper lymphocyte. These cells play a key
role in the immune system by coordinating the actions of other immune system cells.
A large reduction in the number of T helper cells can severely weaken the immune
system. This HIV T-infected cell is infected because the protein CD4 on its surface is
used to attach to the cell before it enters HIV. Hence the T helper cell is sometimes
referred to as CD4+ lymphocyte. Once it enters a cell, HIV produces new copies of it

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that infect other cells. Over time, HIV infection can lead to a drastic reduction in the
number of helper cells that can help fight disease. The process usually takes several
years.
HIV infection can generally be broken down into four distinct stages namely:
1. Acute primary infection
2. The Symptomatic Stage
3. Symptomatic of HIV Infection
4. Progression from HIV to AIDS
1. Acute primary Infection
The around one to four weeks after becoming infected with HIV, some people
will experience symptoms that can feel a lot like flu. This may not last long (a week
or two) and may only get some of the flu symptoms or none at all. Experiencing these
symptoms alone is not a reliable way of diagnosing HIV. Should always visit doctor if
are worried have been at the risk of HIV infection and subsequent to that even if do
not feel sick for then you have any of the follow symptoms. You can position to have
an HIV testing. [NHS, Choices, 2014].
HIV Symptoms
Fever: The Symptoms of an HIV positive person include feverish body temperature
and high sweating.
Body rash: It is also a factor in the increase in body rash among the symptoms of
HIV respondents.
Sore throat infection: The pain in this infection is increasing in the throat of a
positive person.
Swollen glands: These swollen glands are then a factor in the risks that those who are
HIV positive may have.
Having a Headache: Then come up to the health problems caused by headaches in
the positives.
Upset to the stomach: Their digestive system is not functioning properly due to
damage to the immune system.
Joint Aches: Loss of stamina and fitness of positivity.
Muscle pain: The muscle aches in positives can have health problems.
Positive person’s health can react to the HIV symptoms. Cells that are
contaminated with HIV are circulating all over blood system, so immune system then
tries to harass the virus by producing HIV antibodies. This process is called sero-
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conversion, and it frequently happens within 45 days of infectivity and can acquire up
to a few months to complete. It important that always use a condom when having sex,
especially if think has been exposed to HIV. It may be too early to get an accurate
HIV test result at this stage (this can take anything from a few weeks to a month’s),
but the levels of virus in blood system are very high at this stage. [Net Doctor, 2015].

2. The Symptomatic Stage

Many people start to feel better. In fact, the HIV virus may not reveal any
other symptoms for many years. Health professionals say this could be around 10
years. However, the virus will still be active, infecting new cells and making copies.
Over time this will cause a lot of damage to immune system [Terrence Higgins Trust,
2014].

3. Symptomatic HIV Infection

During the third stage of HIV infection there is usually a lot of damage to
immune system, are more likely to get serious infections or bacterial and fungal
diseases that otherwise would be able to fight off. These infections are referred to as
‘opportunistic infections’. If a person is experiencing opportunistic infections they are
now said to have AIDS [AIDS Govt. 2017].
Symptoms can include
 Loss of the Weight
 Chronic diarrhea
 Night sweats
 A fever
 A persistent cough
 Mouth and skin problems
 Regular infections
 Serious illnesses or diseases
It isn’t a test for AIDS and one cannot inherit it. AIDS is a syndrome, and this
means it is diagnosed from a set of symptoms that happen when you become very ill
from a serious infection or disease. Taking treatment on a daily basis can be difficult
to get used to, especially if are suffering from any side effects, so it’s important to
access support from health professionals when need it. AIDS also does not mean will

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die from an AIDS- relate illness but getting the right treatment is really important at
this point [AIDS, Avert 2016].

4. Progression from HIV/AIDS

The immune system becomes more and more spoiled the illnesses so as to
transpire turn into extra and additional cruel foremost ultimately to an AIDS
diagnosis. At presents in the UK an AIDS diagnosis is confirmed if a person with HIV
develops one or more of a specific number of severe opportunistic infections or
cancers. In the US, someone may also be diagnosed with AIDS if they have a very
low count of T helper cells in their blood. It is possible for someone to be very ill with
HIV but not have an AIDS diagnosis [WHO 2010 and avert. org, 2016].

Cure for the AIDS

There is still no way to cure AIDS and the only way to be safe at present is to
avoid getting infected with the disease. The surveys show that many people think
there is a 'cure' for AIDS- but it makes them feel safer and probably takes risks they
should not. There are antiretroviral drugs that slow the progression from HIV to AIDS
and this keeps some people healthy for many years. In some cases, antiretroviral
drugs stop working after a few years, while in other cases people can recover from
AIDS and live with HIV for a longer period of time. But they have to take powerful
medicines every day in their life, sometimes suffering from very unpleasant side
effects.

The HIV virus lasts a lifetime. However, with proper treatment, people can
live a good life for a long time. This Anti Retroviral Therapy (ART), if taken at the
right time, can effectively suppress regeneration. Successful viral suppression restores
the immune system and stops the onset and progression of the disease as well as
reduces the chances of opportunistic infections (OI), thus ART is intended to work.
This drug thus enhances both quality of life and longevity. ART is initiated depending
on the stage of infection. PLHIV (blood cells/mm3 if present) less than 200 CD4
require treatment regardless of clinical stage. For PLHIV containing 200-350 CD4,
ART is provided for symptomatic individuals. Of those with more than 350 CD4,
treatment may be postponed for asymptomatic individuals.

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Adherence to ART regimen is therefore very vital in this treatment. Any

irregularity in following the prescribed regimen can lead to resistance to HIV drugs,
and therefore can weaken or negate its effect. ART is now available free to all those
who need it. Public health facilities are mandated to ensure that ART is provided to
people living with HIV/AIDS (PLHIV). Special emphasis is given to the treatment of
sero-positive women and infected children [Radhika Ramasubban & Bhanwar
Rishyasirnga, 2010].

There are 519 functional ART Centers transversely the country seeing that of
September 2015. It be moreover observed to just about 20 per cent of PLHIV arrive at
ART Centers by a very late stage (CD4 count <50), when the risk of mortality is
nearly 2-3 times higher. The total number of On ART at 9.02 lakhs Nearly 77,729
children living with HIV/AIDS are active in HIV care at ART centres and of whom,
49,909 care receiving free ART, pediatric formulation of ARV drugs are available at
all ART centres. ART accessible ART centers are located in medical colleges, district
hospitals and Sub-district and area hospitals providing Care and Support Centres
provide expanded and holistic Care & Support Services for People living with HIV
(PLHIV). 350 Care and Support Centres are functional and a number of 8, 31,821
PLHIV have received services. A PLHIV network person at each of the ART centre
facilitates access to Care and Support Services at these centres. ART centres also
provide counseling and follow up on treatment adherence and support through
community care centres. The primary goal of pediatric prevention, Care and Support
programme is to prevent HIV infection to newborns through Prevention of Parent to
Child Transmission (PPTCT) and provide treatment and care to all women infected by
HIV [NACO, 2016-17].

HIV and Antiretroviral Drug Treatment

There is currently no vaccine or cure for HIV or AIDS. The only known
methods of prevention are based on avoiding exposure to the virus or failing that an
antiretroviral treatment directly after a highly significant exposure, called Post-
Exposure Prophylaxis (PEP). PEP has a very demanding four week schedule of
dosage. It also has very unpleasant side effects including diarrhea malaise, nausea and
fatigue. Antiretroviral Therapy (ART) is the make use of HIV medicines to care for
HIV infection. People on ART receive a permutation of HIV medicines (Called an

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HIV regimen) every day. ART is recommended for everyone infected with HIV.
People infected with HIV be supposed to start ART as in a little whereas as potential.
ART can’t cure HIV, but HIV medicines assist community of HIV conduction.
Potential risks of ART include unwanted side effects from HIV medicines and drug
interactions between HIV medicines every day and exactly as person are taking
[AIDS Info, 2016].

Anti Retroviral therapy is the only effective way to control HIV infection.
This treatment reduces the amount of virus in the body to very low levels, allowing
the immune system to recover its strength. Current guidelines recommend starting
antiretroviral therapy at a relatively advanced stage of disease, usually several years
after becoming infected. HIV is highly adept at developing resistance to medications.
To prevent this happening, it is essential that the drugs be taken every day in the
correct way, and that people undergo regular monitoring. If resistance does emerge
then the drug combination must usually be changed. Antiretroviral therapy has
transformed HIV infection in rich countries from a death sentence to a chronic illness
that people may live with for decades. But in many parts of the world Access To Anti
Retroviral Treatment remains scarce, mainly because of inadequate resources. Almost
all developing countries have only a small range of available drugs, so there are few
options for those who must change treatment because of resistance or side effects
[AIDS Info, 2016].

It is primarily an important treatment for HIV or AIDS. It may not be make

well, but it can stop you from getting sick for many years. Treatment consists of these
drugs intended to be taken daily by a person for the rest of his life. The goal of this
antiretroviral treatment is to keep the amount of HIV in the body to a minimum. It
stops any weakening of the immune system and allows HIV to recover from any
damage it has already caused. Medications are often prescribed:
 Antiretroviral
 Anti-HIV or Anti-AIDS Drugs
 HIV Antiviral Drugs

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HIV/AIDS Drugs
These are more than 20 approved antiretroviral drugs, but not all are licensed
or available in every country. There are basically five groups of these antiretroviral
drugs. Each of these groups pollutes HIV in a different way.

Combination Therapy
This combination therapy involves taking two or more antiretroviral drugs at
the same time. Taking a combination of three or more Anti-HIV drugs at once is
sometimes referred to as 'Highly Active Antiretroviral Therapy' (HAART). If only
one drug is taken, HIV can be tolerated quickly and the drug stops working. Taking
two or more antiretroviral at the same time greatly reduces the rate at which resistance
develops, making treatment more effective in the long run.

Two NRTIs are combined with an NNRTI or "boosted" protein inhibitor in the
most common combination of drugs given to first aid beginners. Ritonavir (in small
doses) is commonly used as a booster; it enhances the effects of other protein
inhibitors so they can be given in small doses. Two NRTIs, zidovudine, lamivudine,
and NNRTI, are examples of a common antiretroviral combination. Some
antiretroviral drugs are combined into one pill, called a 'fixed dose combination'. This
reduces the number of pills to be taken each day.

Many people living with HIV in developing countries still have very limited
access to antiretroviral treatment and are often treated only for diseases that occur as a
result of a weakened immune system. Such treatment has only short-term benefits
because it does not address the underlying immune defect.

First and Second line Therapy

At the beginning of treatment, the combination of drugs that a person is given
is called first line therapy. If after a while HIV becomes resistant to this combination,
or if side effects are particularly bad, then a change to second line therapy is usually
recommended. In Second line therapy will ideally include a minimum of three new
drugs, with at least one starting a newest group, contained by regulate to increase the
possibility of therapeutic success. [Avert 2011].

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HIV/AIDS Treatment and Care

The people living with HIV (PLHIV) have different needs depending on their
individual conditions and stages of infection. These forms of HIV treatment and care
are generally classified into three broad categories according to when they are first
needed. The comprehensive package of care covers the entire journey from diagnosis
to death, with many decades of antiretroviral treatment.
 Early stage
 Later stage
 End of life stage
1. Early Stage
HIV Testing:-
Most people remain without major symptoms for many years after being
infected with HIV. However HIV testing provides a gateway to access other services;
A person living with HIV will not receive any care until they are diagnosed. This
traditional model ICTC (Integrated Counseling and Testing Center), people should
come forward to test. The campaign for general exams has also increased in recent
years. Under this procedure, everyone who attends certain health care facilities- for
example antenatal clinics, sexual health clinics or physician surgeries - is routinely
tested for HIV unless they refuse.

Early diagnosis allows for more effective treatment and care. If HIV infection
is detected early in the late stages, more complex care is needed and treatment is less
likely to work. Early diagnosis also reduces the risk of subsequent transmission; once
someone finds out they have HIV they are more likely to take precautions against
infecting others.

Psychosocial Support
The receiving this HIV positive test result can be painful. Non- psychosocial
support is aimed at helping HIV- positive individuals and their caregivers cope with
traumatic stress, change and resume normal life. With this good quality counseling
PLHIV is less likely to develop serious mental health problems. Health workers
should be able to provide psychosocial assistance and receive additional care from
trained volunteers or AIDS service organizations. Support is also crucial to the
success of any medical treatment. People need to understand why and how to treat

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HIV- Related diseases and what types of treatment and care are available locally and
how to access them. Malnutrition accelerates progression from HIV infection to AIDS
and death. Nutritional counseling allows people to stay healthy longer, delaying the
time they need to start antiretroviral therapy.

Prevention of onward Transmission

The HIV- positive individuals should be counseled to prevent other adults
from becoming infected with HIV. This mainly means promoting safer sex through
condom use, fidelity and voluntary abstinence. Counselors should ask about partners
at risk for HIV infection and discuss how these partners can be informed. Some
sexually transmitted infections, especially genital herpes, increase the risk of HIV
transmission. Therefore it is important for people living with HIV to seek treatment
for any other sexually transmitted infections. HIV can be transmitted from mother to
child during pregnancy, childbirth and through breastfeeding. These antiretroviral
drugs and safe feeding of infants can greatly reduce the risk of infection in the infant.
Pregnant women with HIV should be diagnosed in advance to gain maximum benefit,
including education and counseling on prevention methods.

Protection from Stigma and Discrimination

The stigma and discrimination are caused by a number of factors such as lack
of awareness about the disease, myths about how HIV is transmitted, bias, lack of
proper treatment and social fears. These negative attitudes can prevent HIV-infected
people from being tested, infecting others and preventing them from receiving proper
care and treatment. Involvement of people living with HIV/AIDS (PLHA) is essential
in activities that reduce stigma and discrimination. People talking openly about their
HIV status is one of the first steps they need to take in combating stigma and
discrimination. This allows people to realize that HIV is part of their community and
is just "someone else's problem". In addition, the role of HIV- negative individuals
should not be underestimated. Talking about HIV/AIDS can help in providing broader
support to those infected with HIV.

2. Later Stages
The progress from this HIV infection to AIDS is the gradual deterioration of a
person’s health; these symptoms intensify over time but the pattern varies from person
to person.

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 HIV/AIDS- An Introduction

Prevention and Treatment for Opportunistic Infections

The opportunistic infections occur when the body's defenses against HIV are
weakened. Common examples are tuberculosis, pneumonia and candidacies.
Providing prevention and treatment for these infections will not only help the victims,
but also prevent the disease from spreading further.

Even in areas with the best resources, opportunistic infections need treatment,
especially those that have not yet begun or have recently started antiretroviral therapy.
For young children and people with weakened immune systems, medications such as
cotrimoxazole may be recommended to prevent opportunistic infections.

Managing Nutritional Effects

As the immune system weakens, people living with HIV/AIDS (PLHIV)
become more vulnerable to weight loss and malnutrition. Weight loss and
malnutrition can worsen disease progression. In addition, people are less likely to
benefit from antiretroviral treatment if they are malnourished. It is therefore important
that people receive the help they require to maintain a healthy diet. Emergency food
provision may be appropriate for those in direst need [NACO, 2017].

3. End of life Stage: Lifelong care is required when antiretroviral treatment is not
available, when it is rejected, or when it does not work due to drug resistance.

End of life Care

The goal of lifelong care is to provide comfort and assistance to people
suffering from this terminal illness and to eventually make them die with dignity. It
can help control pain, treat symptoms such as diarrhea, vomiting and provide relief
from mental or spiritual distress, and support families and caregivers. It is estimated
that at least half of people with HIV will experience severe pain during their illness
and may therefore need stronger painkillers such as morphine. Health workers are
advised not to discontinue painkillers as they are concerned that people will become
addicted to drugs. Pain medications should be reviewed frequently and increased as
needed and pain should be controlled in a way that keeps people as alert and active as
possible.

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 HIV/AIDS- An Introduction

Preparing for Death

It is often believed that it is inappropriate to talk about the fact that someone is
going to die and that mentioning death will speed it up in some way. However, for
those who want to discuss death, ideally from an early diagnosis, open discussion can
help people who are dying feel that their concerns are being heard, that their desires
are being pursued, and that they are not alone. One big concern is what happens after
the dependents die. Where possible, plans should be made for dependent individuals
and partners. While discussing these issues can be painful, making plans can reduce
anxiety. Making a will can also prevent family conflict and make partners and
children homeless.

Support for Surviving Family and Orphans

Family members, partners and friends, looking after someone with HIV can be
very daunting. And the need to offer counseling to partners and families following the
death of a family member or friend is often overlooked, particularly in resource poor
countries. Counseling can help a person to discuss their loss. The family members
may have unresolved fears about HIV infection for them, and can be helped to come
to decisions about HIV testing. The process of grieving to may last many months and
possibly even few years. However, for some people a single counseling session may
be sufficient to clarify their thoughts and feelings and to reassure them that they are
coping as best as they can under the circumstances. Other people may need several
sessions, and some people never completely come to terms with a loss, particularly
that of a child [NACO, 2017].

HIV/AIDS in India
India is one of the few countries in the world that is filled to capacity with
responsibility for treating or educating the immense majority of HIV/AIDS patients. It
first took place in Chennai, Tamil Nadu in 1986, making the first sero-logical
diagnosis of HIV infection in India. A second case was registered in Mumbai. Since
then, the HIV epidemic has spread to all the states and union territories of the country.
Sub-groups at risk of contracting HIV include Female Sex Workers (FSW), Injection
Drug Users (IDUs) and Men Who Have Sex with Men (MSM), long-distance truckers
and single male migrants. The last two sub- groups of people are called bridge
populations.

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 HIV/AIDS- An Introduction

The number of people infected with HIV is very supportive of the assumptions
based on the estimates because most of them have not been tested for the virus. The
Third National Family Health Survey (NFHS-3) was the first proper survey in 2005-
06 to provide credible data on what is happening here at the general community level
and contradict international agencies' claims regarding statistical levels. There is a
need to come up with appropriate statistics and pictures on the prevalence of
HIV/AIDS in the country. It accounts for 25 per cent of the world's total health care
for HIV treatment, but accounts for 3.7 percent of global deaths. It also accounts for a
large proportion of domestic spending on the disease, which generally exceeds the
domestic health budget (Rupa Chinai, 2009).

According to National Family Health Survey (NFHS-3), the HIV rate of

prevalence in the age group of 15-49 years was 0.28 per cent in the country. This
approximately translates into 1.7 million people with HIV positive status in the age
group of 15-49 in the country in April 2006, the midpoint of the NFHS-3. The rate of
HIV prevalence in the age group of 15-49 stood at 0.22 per cent for women as against
0.36 per cent for men. The rate of prevalence of HIV for the four states in the country
with the highest number of HIV/AIDS patients was as follows: Manipur 1.13 per cent,
Andhra Pradesh 0.97 per cent, Karnataka 0.69 per cent, Maharashtra 0.62 per cent
(NFHS-3).

According to NACO's 2009 estimates, the number of people living with

HIV/AIDS (PLHA) is 2.39 million. Males constitute 1.46 million (61.24%) and 0.92
million (38.66%) surrounded by the People Living with HIV/AIDS (GOI, 2012).
From 2.7 million in 2000 to nearly 1.2 million new cases of HIV infection in 2009, it
served as a pointer to the impact of various intervention programmes, including
scaled-up prevention strategies under the National AIDS Control Programme.

According to the India HIV Estimation 2019 report, the prevalence of HIV in
India in 2019 was estimated at 0.22 per cent along with adults (15–49 years), which is
higher in males (0.25 per cent) than in females (0.19 per cent). Nationally, the
prevalence of adult HIV has declined from 0.38 per cent in 2001-03 to 0.34 per cent
in 2007, 0.28 per cent in 2012, 0.26 per cent in 2017 and 0.22 per cent in 2019.

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 HIV/AIDS- An Introduction

India is expected to have approximately 69,220 new cases of HIV infection in

2019, down from 86 per cent in 1997 and 37 per cent from 2010. In 2019, 44 per cent
of all new HIV infections were reported annually. Outbreaks appear to be exacerbated
during the last seven years in Nagaland, Manipur, Assam, Mizoram and Meghalaya,
as well as Nagaland and Manipur Will is registered Delhi, Chhattisgarh and Jammu
&Kashmir. Telangana, Bihar, West Bengal, Uttar Pradesh, Andhra Pradesh,
Maharashtra, Karnataka, Gujarat, Tamil Nadu and Delhi: 71 per cent of the total
annual new HIV infections are in just ten states.

In view of the fact that 2005, the figure of AIDS-Related Deaths (ARD) has
begun to decline steadily, with the annual AIDS-related number of deaths as per year
falling by 71 per cent in 2019, according to the report. It is estimated that 69,110
people died of AIDS-2017 related causes in my country. AIDS-related deaths are
declining in all states/UTs in India except Assam, Bihar, Jharkhand, Haryana, Delhi
and Uttarakhand.

It is estimated that out of 22,677 HIV positive babies born in India in 2019,
only were women. The need for Mother-To-Child Transmission Control (PMTCT) is
defined as HIV-positive women who give birth within a year to prevent their child
from becoming infected with HIV.

HIV/AIDS Situation in Different States

Table-1.1 presents a state-wide précis of the HIV/AIDS pandemic of
according to 2019 statistics. Table 4.1 shows that Mizoram has the highest
predominance of HIV at 2.04 per cent among adolescents (15-49 years), followed by
Manipur (1.43 per cent), Nagaland (1.15 per cent) and Telangana (0.70 per cent).
Andhra Pradesh (0.63 per cent). Among those states, Karnataka (0.47 per cent), Goa
(0.42 per cent), Maharashtra (0.33 per cent) and Delhi (0.30 per cent) are estimated to
have higher prevalence of adult HIV than the countrywide frequency (0.22 per cent),
while Tamil Nadu (0.22 per cent) matched. All other states/UTs have an HIV
prevalence of less than 0.22 per cent in adulthood. Maharashtra has the highest
PLHIV number followed by Andhra Pradesh, Karnataka and Telangana. The state of
Telangana has the highest number of new HIV infections, followed by Bihar, West
Bengal and Andhra Pradesh. Telangana tops the list in terms of AIDS- related deaths,
followed by Maharashtra, Andhra Pradesh and Karnataka. As far as PMTCT

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 HIV/AIDS- An Introduction

requirement is concerned, the state-wise requirement of PMTCT is highest in

Maharashtra, followed by Uttar Pradesh, Bihar and Andhra Pradesh.

Routes of Transmission
The major prevalence of HIV transmission in the country is through
heterosexual procedure, which accounts for approximately 88.2 per cent of all
identified cases of HIV. The subsequent transmission of HIV is transmitted from
mother to child, accounting for approximately 5.0 per cent of all HIV cases. Unclean
syringe and needle transmission causes 1.7 per cent of infections, while
homosexuality leads to 1.5 per cent of transmissions and, finally, untested or
contaminated blood and blood products lead to 1.0 per cent of HIV infections in the
year of 2011.

The main cause of HIV infection is the most prevalent form of transmission
of sex by commercial sex workers or female sex workers (FSWs) who engage in sex,
and the majority of the population infected with HIV through this commercial method
or group of sex workers is concentrated, grouped. More than 50 million of high-risk
spouses are also at risk as a result of this commercial sex practice (Ranjita Biswas,
2010). The infection is mostly concentrated in commercial sex workers and injecting
drug users (Marcus Hacker 2004).

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 HIV/AIDS- An Introduction

Table- 1.1
State-Wise Summary of HIV/AIDS Epidemic (2019 Estimates)
Adult New HIV AIDS related
PLHIV PMTCT
State/UT Prevalence Infections death (in
(in lakhs) need
(in percent) (in Thousands) thousands)
Andhra Pradesh 0.63 2.700 6.55 8.46 1,960
Arunachal Pradesh 0.06 0.006 0.08 0.02 12
Assam 0.06 0.135 1.39 0.27 238
Bihar 0.16 1.154 8.85 3.30 2,090
Chhattisgarh 0.13 0.262 1.55 0.87 346
Delhi 0.30 0.457 3.10 0.58 533
Goa 0.42 0.059 0.21 0.31 38
Gujarat 0.19 0.918 4.52 2.12 1,297
Himachal Pradesh 0.05 0.031 0.09 0.03 29
Haryana 0.18 0.363 2.48 1.31 446
Jharkhand 0.14 0.334 2.60 1.33 632
Jammu & Kashmir 0.03 0.030 0.21 0.03 37
Karnataka 0.47 2.474 5.01 8.45 1,951
Kerala 0.08 0.228 0.88 0.75 176
Meghalaya 0.11 0.021 0.19 0.02 51
Maharashtra 0.33 3.297 5.95 10.1 2,406
Manipur 1.43 0.315 1.61 1.62 382
Madhya Pradesh 0.09 0.512 2.39 1.85 723
Mizoram 2.04 0.168 1.50 0.47 259
Nagaland 1.15 0.170 1.23 0.54 237
Odessa 0.13 0.414 2.42 1.39 603
Punjab 0.18 0.406 1.90 0.76 406
Rajasthan 0.10 0.547 2.75 0.9 959
Sikkim 0.05 0.002 0.02 0.002 6
Tamil Nadu 0.22 1.419 3.63 2.80 1,167
Telangana 0.70 2.037 9.32 10.16 1,737
Tripura 0.09 0.027 0.21 0.07 38
Uttarakhand 0.11 0.080 0.73 0.21 106
Uttar Pradesh 0.09 1.340 7.06 3.82 2,286
West Bengal 0.20 1.439 8.61 6.47 1,453
Andaman & Nicobar 0.14 0.004 0.06 0.02 9
Islands
Chandigarh 0.20 0.021 0.24 0.05 20
Dadra & Nagar Haveli 0.17 0.005 0.06 0.01 11
Daman & Diu 0.17 0.004 0.04 0.01 8
Pondicherry 0.15 0.018 0.17 0.02 25
India 0.22 21.40 87.58 69.11 22,677

Source: India HIV Estimations 2019 - Technical Report.

The National AIDS Control Organization of India (NACO), which is
currently responsible for controlling the HIV/AIDS epidemic, estimates that 84 per
cent of new infections are due to sexual contact each year 2000. (Mead over et al
2004).

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 HIV/AIDS- An Introduction

India has one of the largest road transport systems in the world and the
longest and widest roads in the country. It is estimated that there are 2.4 million truck
drivers and their assistants driving their trucks on this road transport. As a result, they
spend most of their time traveling away from their families, and for their sexual
needs, they come into contact with hoteliers or FSWs on the roadsides. Therefore, this
segment of the population, truck drivers, played a vital role in the spread of HIV and
STI across the country (Karthikeyan S et al, 2007).

In similarly, the migrant workers are playing a key role in the spread of HIV
across the country for the sake of migration. A huge figure of poor people is going to
different urban areas of the country in search of work. There are approximately 2.58
million poor migrant workers in India and it is estimated that many of them are
migrating from one place to another for livelihood. Numerous studies have been
conducted worldwide, and there is ample evidence that migration leads to multiple
sexual partners and as a result many are more susceptible to HIV transmission.
Several studies have revealed that mobile individuals and migrant workers have
proven to be the bridge population to transmit HIV to high-risk groups and from
urban to rural areas, mostly through High Risk Groups. The being away from home
for work, being away from a spouse for work for long periods of time, and the
movement of individuals in those areas increase the likelihood that a person will have
normal sexual contact with FSWs, resulting in an increased risk of HIV infection. In
many cases, immigration does not lead to a change in personal sexual behavior, but
rather to the transition of their settled social behavior to areas where HIV is highly
prevalent. Therefore, the risk of HIV infection may not be the same for all
immigrants.

In 2009-10 depicts the worst-case scenario of infection in India as a whole

with different HIV prevalence among different population groups, with the highest
prevalence among high-risk groups - Female Sex Workers (4.94 per cent), male (7.3
per cent), Injection Drug Users (9.19 Per cent) and Sexually Transmitted Diseases
(STD) Clinic Attendance (2.46 per cent), and ANC low prevalence (0.48 per cent).
Numerous studies have been conducted on high risk groups (HRGs) to determine the
vulnerability of those infected with HIV/AIDS. Many interrelated factors such as low
levels of literacy, unemployment, poverty, lack of employment opportunities,

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 HIV/AIDS- An Introduction

migration for livelihood, mobility, economic and labor exploitation in their lives often
lead them from poverty to poverty and into a vicious circle that makes them more
vulnerable and raises the dilemma. They become infected with HIV, leading to poor
health, loneliness, fear of humiliation, financial loss and eventual death. Stress is
exacerbated and complicated by a number of problems due to their lack of proper
understanding of the disease and indifference to it (Meenu Sharma, 2006).

HIV/AIDS Knowledge of Sexual Behaviour

The Third National Family Survey statement to (NFHS-3, 2008) states that
consciousness of HIV/AIDS along with people in both rural and an urban area has
greater than before significantly. Nevertheless, responsiveness is still low among
people who are not properly open to the elements to the media, folks belonging to
Scheduled Tribes, those who are uneducated, those who live in areas with low living
standards and some people in rural areas. The knowledge of methods for preventing
HIV/AIDS varies between men and women aged 15-49 years. With the increasing
wealth and education of the people, the knowledge will increase significantly through
prevention methods and measures. Men and women who are regularly exposed to the
mass media are more likely to know the prevention methods of the disease compared
to adults who are not exposed to or accessible to the current mass media.

At the even among current pregnant women, there is very little awareness and
knowledge about HIV transmission from a pregnant woman to her child. It has been
observed that only 40 per cent of pregnant women are currently aware of the risk of
HIV transmission from mother to child if one in a thousand mothers has HIV
infection. Only about 15 per cent of current pregnant women find that they can
significantly prevent HIV transmission from mother to child by taking certain
antiretroviral drugs. Awareness beliefs and knowledge about HIV/AIDS affect how
the general public deals with the people living with HIV/AIDS.

In addition, according to the NFHS-3 report, three out of every four men and
women in their own home are willing to take appropriate care of a more and more
sick relative who is living with HIV/AIDS. Although the prevalence of polygamous
partners is very low, a comprehensive survey has found that the proportion of men
and women who have sex with someone other than their partner is slightly higher.
Men who had sex with a partner and extramarital partner who had not been cohabiting

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 HIV/AIDS- An Introduction

for one year prior to the survey were more than twice as likely as women to report
condom use in such normal sex (38 per cent). Women who had sex on average
reported having only 1.02 lifetime sex partners, while men who had sex reported that
they had only 1.49 lifetime sex partners on average. The use of condoms during paid
sex with most FSWs is higher for men who have read class ten and above and for men
with the highest wealth.

Economic Cost of the Epidemic

HIV/AIDS is mainly affect to develop and developing countries. Nearly half
of the budgets allocated to health care in these countries are spent on surveillance and
care and assistance programmes launched in many countries to provide assistance to
people affected by this infection. Therapeutic indirect costs and direct costs of the
disease have been proven to outweigh the costs, as the epidemic mainly affects
adolescents and middle- aged people who are engaged in social and economic
activities that promote the well-being of the individual, the well-being of the family,
the well- being and well-being of the nation. Therefore, HIV/AIDS has caused
damage to national incomes as well as the incomes of families and individuals.
Several international studies conducted to assess the damage caused by this disease
have come to the conclusion that the indirect costs of this disease are about 50-60
times higher than the direct costs. It is estimated that it will reverse the annual
economic growth of the country’s most severely affected or worst affected by
HIV/AIDS worldwide by up to two percent. According to World Bank estimates, its
prevalence rate is still declining at 0.4 per cent of gross domestic product (GDP), up
to 8 per cent compared to the non-AIDS scenario. According to 2009 estimates, the
prevalence of HIV in India is 0.31 per cent.

The direct impact of HIV/AIDS is on the economy or the collapse of the

economic development angle leading to an increase in the mortality rate and
consequently a decline in the life expectancy of individuals. In some countries
affected by HIV/AIDS, the life expectancy of individuals is said to be less than 20
years. The Human Development Index, compiled by the United Nations Development
Programme, indicates that HIV/AIDS is the single most important factor influencing
development in recent decades (Kenneth A. et al., 2009).

25
 HIV/AIDS- An Introduction

The evidence for the macroeconomic consequences of HIV/AIDS is not very

clear. There is a widespread consensus that gross domestic product (GDP) growth will
also slow as a result of HIV/AIDS, in the face of declining population growth at
working age. Studies applying the neo-classical growth model have shown that
HIV/AIDS reduces productivity per worker due to declining productivity and
declining per capita worker productivity due to declining worker health. In addition,
health-related costs for HIV/AIDS treatment also reduce national savings and
investment rates. These effects are at least partially offset by the increased mortality
rate on the capital-labor ratio. However, if investment flows are sensitive to changes
in the rate of return on capital then the latter effect is partially dissipated (Kenneth A.
et al., 2009).

With regard to the micro-economic level, the disease is associated with

income losses for individuals and households because the infected person fails to
attend to his or her work and the family members of the family members fall ill and
spend their time taking care instead of indulging in productive work. This is most
pronounced and pronounced when the patient is too ill to continue his or her own
work and has to rely on others for his or her daily activities and at the time of death.
The family seems to be partially recovering later. Available evidence suggests that an
increase in income volatility could lead to an increase in poverty levels (Kenneth A. et
al., 2009).

A study conducted by the National Council of Applied Economic Research

(NCAER) in collaboration with the National AIDS Control Organization (NACO) and
UNAIDS revealed that an increasing number of families infected with HIV need to
dispose of their land. Or have to borrow significantly from lenders for medical
treatment and other financial expenses of the house and infected people. The report
warns that the epidemic could significantly increase not only households but also
government health- related spending. This can lead to loss of savings, aversion to
investment and a strong negative impact on economic growth. The results of the study
clearly show that the country's economic growth is likely to decline by about 0.86
percentage points per annum and that per capita GDP will also decline by 0.55 per
cent. The report predicts that per capita GDP will decline significantly over the next

26
 HIV/AIDS- An Introduction

10 years due to the epidemic and that labor supply growth will also slow (Karthikeyan
S et al, 2007).

National Response to the Epidemic

The government of India, in response to the challenges and challenges posed
by HIV/AIDS, first established the National AIDS Control Agency (NACO), which
aims to ensure that every person living with HIV in the country receives quality
treatment, care and inclusion in society. NACO believes it is possible to provide
effective preventive care and support for people living with HIV/AIDS in an
environment where human rights are respected by all and those living with HIV/AIDS
are not stigmatized or discriminated against. NACO has therefore taken steps to
ensure that PLHA has equal access to quality health services. In addition, NACO
hopes to enhance service accessibility and accountability by enhancing close
collaboration with NGOs/CBOs, women's Self-Help Groups, numerous trust- based
organizations, networks of positive individuals and communities. The services at the
state, district and grassroots levels- it is committed to building an environment in
which those infected or affected by HIV play a major role in all responses to
infection. NACO Services is committed to curbing the spread of HIV in India by
building an all- encompassing response that reaches out to a diverse population.

Accordingly, NACO is launching and implementing the National AIDS

Control Programme (NACP) at various stages. The main activity of the NACP was
initially limited to monitoring the rate of HIV infections in at-risk populations in
selected urban areas. The range of the NACP was expanded in 1991 in an effort to
focus on prevention, blood safety, and greater awareness of the general population on
high- risk populations as well as raising awareness of HIV infection. The programme
is primarily focused on the prevention and control of HIV infection in the country by
increasing prevention efforts for High Risk Groups (HRGs) and integrating services
with support, care and treatment of the general population.

Implementation of National AIDS Control Programme

At the first phase of the National AIDS Control Programme (NACP-I) lasted
for seven years, from 1992-1999. The programme received US $84 million in loan
assistance with active support from the World Bank. At this stage, the main goal of
the programme is to prevent the spread of infection, primarily through blood

27
 HIV/AIDS- An Introduction

transfusions, and to raise awareness of the dangers of injecting drugs through

treatment and inducing dangerous sexual safe behavior (Mead over et al., 2004). The
programme has been very successful in achieving the stated goals or objectives, the
most important of which is raising awareness among the people. And professional
blood donations were reduced and then legally prohibited. For this final step, it is
mandatory to carefully test the donated blood. It has become a universal phenomenon
in the country. However, its performance is not consistent across many states, and
many of the efforts made by states to control the disease vary from one state to
another. By 1999, Kaka had established a decentralized mechanism to facilitate
effective positive response to programmes at the state level. However, there have been
significant differences between states in terms of commitment and capacity. Of the
many states, states like Andhra Pradesh, Tamil Nadu and Manipur have shown a high
level of political commitment and have shown a strong response to the disease, while
states like Uttar Pradesh and Bihar have not reached that level.

The progress of this first phase is encouraged by recognition. In addition, the

second phase of NACP (NACP-II) was formulated by the Government of India in
1999. Its NACP-II started in 1999 and lasted till March 2006. The financial allocation
for this NACP-II is Rs.2064.65 Crore. As part of this second phase programme, the
two main objectives are to strengthen India's ability to overcome the challenges posed
by HIV/AIDS in the long run and on an appropriate basis to curb the spread of HIV
infection in the country. Much has been done to achieve its goals through Programme
Law through prevention efforts and interventions to be undertaken by high risk groups
and the general population by enhancing the many services available for their care by
supporting every People living with HIV/AIDS. The programme at this stage sets out
five priorities, including targeted interventions for people at high risk of infection;
these include a number of preventive measures and a number of intervention
programmes to raise awareness among the general public; providing low- cost health
care to people living with HIV and AIDS; for their organizational strengthening and
inter-sectoral cooperation (Ramesh Singh, 2008).

The third phase of NACP (NACP-III) was implemented in 2007-2012. In

order to achieve greater coverage of individuals in these High Risk Groups (HRGs),
the programme is dramatically scaled through these targeted interventions (TIs).

28
 HIV/AIDS- An Introduction

Management has also been able to gain a big boost with intelligence and good
strategic information as part of NACP-III.

The first focus of NACP-I is mendacity on the safe blood of general

prevention. The NACP-II began working with NGOs in the face of an increase in HIV
infection and working with AIDS Control Societies in the states. In addition, the
government has effectively built on these achievements in NACP-III, has formed
partnerships with civil society organizations and has been actively involved in a
number of initiatives with its goal of engaging the community diligently.
Opportunistic innovations (OIs) due to HIV/AIDS treatment under the National Rural
Health Mission (NRHM) and STIs and ART Services are increasingly integrated with
the health system response to improved services to the level required for infections.

The builds a strong foundation of NACP-III programme' duty policies,

guidelines, schemes, rules and operating rules. The Targeted Interventions for High-
Risk Groups (HRGs) with strategies to control the spread of HIV infection and the
new infections those come with HIV as well as its transmission. Strategies include
implementing a link worker scheme for high-risk and vulnerable people living in rural
areas, raising awareness among the public on the control and prevention of sexually
transmitted diseases, changing behavior towards communication and mainstreaming,
and promoting condom use the safe blood for HIV patients, counseling, testing
services and ensuring that the virus is not transmitted from mother to child. Care,
support and treatment strategies for this infection include providing first line and
second line antiretroviral drug treatment free of charge to HIV- infected individuals,
providing psychological support and proper nutrition to HIV- infected individuals and
families, referral detection and treatment of cross-HIV-TB co-infections, and
treatment Providing better treatment for the resulting opportunistic infections, positive
prevention and mitigation.

This is one of the four key strategies of NACP-III to make stronger the
Strategic Information Management System nationwide is to create an effective
response to the HIV epidemic in the country. The programme is assisted by strategic
information management related to tracking the infection and measuring the scope,
level and effectiveness of the response to the programme. It manages the production
of vital information related to the spread of HIV and the level of risk behaviors, the

29
 HIV/AIDS- An Introduction

implementation of interventions, the impact of the service delivery system and the
level of access to the beneficiaries. Another important function under strategic
information is to promote the use of data for programme design, advocacy, planning,
implementation and review of the programme at the district, state and national levels.

NACP-IV was implemented in 2012-17 and continues to provide care, support

and treatment to all eligible, along with preventive measures or services with a special
focus on high-risk groups and vulnerable populations. The planning for NACP-IV is
similar to NACP-III in that it adopts a participatory and broad-based consultative
approach and aims to further strengthen NACP-III's globally acclaimed and
successful planning efforts. The process involves a wide range of consultations with a
large number of stakeholders, including government departments, developed partners,
NGOs, civil society, PLHA representatives, positive networks and experts in various
fields. NACP-IV development worn precise mechanisms and followed a structured
process.

NACP-IV consists of five main components: 1) Intensifying and consolidating

prevention services with a focus on HRG and vulnerable populations- a) Increasing
coverage of TIs between HRG and scaling interventions between other vulnerable
populations; 2) Expanding IEC services for (a) General population and (b) High Risk
Groups with a focus on behavior change and demand generation; 3) Comprehensive
Care, Support and Treatment; 4) Strengthening Organizational Capabilities; And 5)
Strategic Information Management Systems (SIMS). Important services provided
under NACP and schemes implemented are discussed below.

Prevention Services
The complete service programmes provided by NACP-III and NACP-IV
include (I) Female Sex Workers (FSWs), Men Who Have Sex With Men (MSM) and
High-Risk Groups that include injection drug users as well as targeted interventions
(IDUs and transgender (TGs) but bridge population with truckers and migrants) (II)
Needle- syringe exchange programme for injection drug users (NSEP), (III)
Preventive interventions not only at source for migrant population but also in
transport and destinations (IV) In Rural Areas Link Worker Scheme (LWS) (V) Blood
Safety (VI) Sexually Transmitted Infections/ Reproductive Tract Infections (STI/RTI)
Prevention as well as Control (VII) Maternal to Child Prevention (VIII) HIV
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 HIV/AIDS- An Introduction

Counseling and Testing Services (IX) Promoting Condom Use (X) Communication
for a Change in Information, Communication and Education (ICE) Behavior (BCC)-
Mass Media Campaigns through Television and Radio (XI) Flagship programmes
such as the New Intervention, Social Mobilization and Adolescent Education
Programme (XII) Red Ribbon Express; (XIII) Workplace intervention (XIV)
Mainstreaming HIV/AIDS response (XV) Care and support and treatment services
(XVI) Cluster of differentiation 4 (CD4) Laboratory services for testing and other
research (XVII). ART Centers, Link ART and Free first line and second line Antiviral
Treatment (ART). (xviii) Through the ART Centers, (LACs) Centers of Excellence
(COE) and ART Plus Centers. Pediatric ART for children, early infant diagnosis for
HIV-infected infants and children under 18 months, nutrition and psychological
support through Community Care Centers (CCC) (XIX) HIV-TB Co-ordination (XX)
opportunistic infections treatment (XXI) Drop-in Centers for PLWHA Networks.

Targeted Interventions
Targeted Interventions (TIs) are gobbledygook other than peer-led preventive
measures or interventions that focus on HRGs and bridge populations. These are run
by Community-Based Organizations (CBOs) and Non-Governmental Organizations
(NGOs) located in specific geographical areas. As part of their duties they will be
involved in specific prevention service activities such as condom distribution,
behavior change communication, needle & syringe exchange, STI/RTI services,
recommendations and connectivity to health facilities that provide awareness services
to HIV/AIDS, community mobilization and creating an enabling environment. Given
the concentrated nature of the HIV epidemic in India, NACO has focused its
preventive measures on sub-groups of the population identified as high-risk groups in
order to obtain the infection.

Currently, there are over 1500 such interventions for prevention, care and
support services through HIV treatment for various high risk groups and bridge
populations. Targeted Interventions (TIs) projects include a package of prevention,
support and liaison services for high risk groups through Drop-In-Centers (DICs) and
outreach-based service delivery models. With the help of these, many sexually
transmitted infections (STIs) can be screened and treated after detection of these
infections in high-risk populations. Similarly, free condom lubricant facility between

31
 HIV/AIDS- An Introduction

core groups, social marketing of condoms, care and support services for HIV positive
high risk groups, linkages to integrated counseling and testing centers (ICTC) for HIV
testing, communication for communication, especially behavior (IDUs) Free
distribution of needles and syringes, Option Substitution Therapy (OST) and
integration with detoxification, pus prevention and management, creating a conducive
environment for community involvement and partnership also take place under
Targeted Intervention Programmes. To provide guidance and support for targeted
interventions, the NACP has adopted a peer-lead approach in partnership with
CBOs/NGOs, the State AIDS Control Societies (SACS) and the Technical Support
Unit (TSU). It initiates targeted interventions to provide quality services and improve
the overall performance of the programme.

The performance of targeted interventions in relation to coverage of high risk

groups has been consistent over the years. NACO is making consistent efforts to scale
the programme and expand coverage in high-priority states, especially High-Risk
Groups (HRGs), Hijras/ Transgender Populations (HTG). It asked states to reconstruct
targeted interventions based on the NACP-IV's mid-term evaluation, taking into
account parameters such as HRGs affiliation, positivity, and changing dynamics of
injection methods with the Targeted Intervention Programme of Sex work etc. These
strategies help in registering new and young high risk group members throughout the
typology. Technical Support Units (TSUs) have been asked to provide assistance and
to provide handholding support to help cover difficult and hidden populations and
thereby help plan outreach.

The below table 1.2 shows the number of targeted interventions by state in
India for HRGs and bridge populations in 2018-19. It can be observed that the total
number of targeted interventions operating in 2018-19 was at 1469. The highest
numbers of them (179) are targeted interventions operating in Maharashtra. Andhra
Pradesh is the next state with the highest targeted interventions (92). Haryana is the
state with the lowest number of targeted interventions at 5. In the case of the Union
Territories, the Diu and Damans had the highest number of interventions (5). The
lowest number of targeted interventions took place in Dadra & Nagar Haveli (2).

32
 HIV/AIDS- An Introduction

Table 1.2
State-Wise and Typology-Wise Distribution of Targeted Interventions (TIs)
Supported By NACO during 2018-19
Core Total TIs
HT Migrant
State/UT FSW MSM IDU Composit Truckers functiona
G s
e l
Andhra Pradesh 8 - 3 - 71 8 2 92
Arunachal
4 1 2 - 7 6 - 20
Pradesh
Assam 29 1 6 - 11 2 2 51
Bihar 4 3 8 - 12 - 1 28
Chandigarh 4 2 2 - 1 2 1 12
Chhattisgarh 9 - 3 - 16 5 3 36
Dadra & Nagar
- - - - - 1 1 2
Haveli
Daman & Diu - - - - 2 2 1 5
Delhi 32 11 13 6 - 13 4 79
Goa 6 3 1 - 1 2 2 15
Gujarat 13 13 3 2 22 1 6 90
Haryana 2 2 1 - - - - 5
Himachal
9 - 1 - - 3 - 19
Pradesh
Jammu &
2 1 3 - 3 3 2 14
Kashmir
Jharkhand 18 - 2 - 8 1 3 32
Karnataka 31 19 2 2 11 8 4 77
Kerala 20 13 6 6 - 3 2 60
Madhya
18 5 9 - 26 5 3 66
Pradesh
Maharashtra 59 16 1 9 30 2 12 179
Manipur 2 1 37 - 13 2 - 55
Meghalaya 3 - 4 - 2 - - 9
Mizoram 1 1 18 - 7 4 - 31
Nagaland 2 3 23 - 15 1 1 45
Odisha 12 - 6 1 22 9 2 52
Pondicherry 1 1 - - 2 1 - 5
Punjab 11 - 20 - 19 4 2 56
Rajasthan 12 2 4 2 9 7 3 39
Sikkim 3 - 3 - - - - 6
Tamil Nadu 11 11 1 2 37 6 4 72
Telangana 16 - 2 - 27 6 2 53
Tripura 8 - 2 - - 1 3 14
Uttar Pradesh 12 3 10 2 47 4 6 84

33
 HIV/AIDS- An Introduction

Uttarakhand 6 - 5 - 8 7 3 29
West Bengal 21 3 4 1 2 2 4 37
Total 389 115 205 33 437 211 79 1469
Source: NACO Annual Report, 2018-19.
It can be seen from Table 1.2 that the total number of Targeted Interventions
for HRGs per FSW is 389, the highest in Maharashtra (59) and the lowest in Mizoram
and Pondicherry (each). The total number of targeted interventions for MSM is 115,
the highest in Karnataka (19) and the lowest in Arunachal Pradesh, Assam, Jammu
and Kashmir, Manipur, Mizoram and Pondicherry (each). The total number of
targeted interventions for IDUs is 205. Manipur State has the highest (37) and Goa,
Haryana, Himachal Pradesh, Tamil Nadu and Maharashtra (each) Delhi (13) at the
lowest in the states of Orissa and West Bengal. The total number of targeted
interventions in the ‘Core Composite Group’ class is 437 the highest in the state of
Andhra Pradesh (71) and the lowest in the state of Goa (1).

It can be seen from above table 1.2 that the total number of Targeted
Interventions for migrants related to bridge population is 211, the highest in the state
of Maharashtra (52) and the lowest in the states of Tripura, Pondicherry and
Nagaland. Jharkhand, Dadra & Nagar Haveli (each) The total number of targeted
interventions for truckers is 79, the highest in the state of Maharashtra (12), and the
lowest in the states of Goa, Chhattisgarh, Chandigarh, Dadra & Nagar Haveli. Daman
& Diu, Nagaland (each).

Below table 1.3 provides details on State-wise and Typology-wise coverage of

High Risk Groups under the Targeted Intervention Programme for the financial year
2018-19 (April-September 2018). Notice that only one number of FSWs is covered
below. 65.42 per cent (10.07 lakhs) of the total HRGs were 6,59,104. After MSM,
IDU and HTG, FSWs are the largest group of HRGs covered under absolute and
relative target interventions. Andhra Pradesh topped the list at 84,018 in terms of
FSW coverage, which is 12.75 per cent of the total FSWs covered under targeted
interventions in the country. The interventions targeting the bridge population covered
42.74 lakhs Migrants and 3.35 lakhs truckers.

34
 HIV/AIDS- An Introduction

Table 1.3
State-Wise and Typology-Wise Coverage of High Risk Groups under the
Targeted Interventions Programme during the year 2018-19
Name of State/ Core Group Bridge Population
UT FSW MSM IDU HTG Migrants Truckers
Andhra Pradesh 84018 17068 789 1480 95521 6345
Arunachal
2194 620 1062 - 66022
Pradesh
Assam 15699 2558 2800 291 1192 5417
Bihar 10075 2271 4076 - - -
Chandigarh 2846 1716 1307 103 33630 3327
Chhattisgarh 19203 1584 2462 472 243768 17927
Dadra & Nagar
- - - - 7526 6580
Haveli
Daman & Diu 626 726 - - 5445 1202
Delhi 40148 12891 9278 5368 65492 -
Goa 3845 2907 275 - 30003 2776
Gujarat 18969 22147 904 1479 676990 37118
Haryana 1831 2158 434 - - -
Himachal Pradesh 5159 530 313 - 4252 -
Jammu &
1349 338 1385 - 8154 3221
Kashmir
Jharkhand 71755 703 490 59 - 4885
Karnataka 80708 26678 1846 2062 11863 5715
Kerala 15185 11191 2360 1825 395599 108233
Madhya Pradesh 22773 7364 6331 - 106578 29329
Maharashtra 72871 23920 704 7118 1770708 -
Manipur 5727 1137 16703 - 4640 -
Meghalaya 1268 270 1946 - - -
Mizoram 690 532 8579 - 87992
Nagaland 2884 1273 15614 - 470 422
Odisha 10667 2595 2447 2242 67782 13940
Pondicherry 1861 1863 - 99 30797 -
Punjab 12793 2110 11745 51031 6685
Rajasthan 12492 3691 1361 618 253305 7730
Sikkim 809 - 1138 - - -
Tamil Nadu 40575 28679 516 3978 - -
Telangana 51557 12366 1051 483 - -
Tripura 5016 196 581 - 32411 -

35
 HIV/AIDS- An Introduction

Uttar Pradesh 20619 8063 13168 2634 59995 14863

Uttarakhand 5131 1789 1753 101 152431 46103
West Bengal 17761 1321 1036 234 9914 13537
2,03,25 1,14,45
All India 6,59,104 30,646 42,73,511 3,35,355
5 4
Source: NACO Annual Report, 2018-19.

Link Workers Scheme (LWS)

The Link Workers scheme is a Community-Based Intervention that promotes
the use of condoms, distributes condoms, and provides information on HIV, such as
referrals. Addresses both of HIV prevention and care needs of vulnerable and
vulnerable populations in rural areas. It’s also counseling testing and STI/RTI
services. The fourth phase of the NACP (NACP-IV) Link Worker Scheme (LWS) is
designed to integrate and intensify immediate prevention services for HIV infection
by focusing on high-risk populations in rural areas of the country. At 17 states in 131
districts of the country in 2018-19 This Link Worker scheme is designed to address
the complex needs of the rural HIV population. At other than stakeholders on
HIV/AIDS sexuality or sexually of transmitted infection to raising a gender issues
that. The plan is primarily to create a demand for various services related to
HIV/AIDS, to connect the target population to existing services, to continue to access
targeted population information, to create a seamless, favorable environment, and to
create connectivity with them. Other departments assist with the services of
Anganwadi Workers, ASHA Volunteers, Panchayat Raj Heads, etc.

The scheme consists of well-trained and highly motivated members. There are
20 cluster link workers working in each district for this scheme. There are five
villages in each cluster. These workers are responsible for establishing and
maintaining relationships between the community and the services provided by
HIV/AIDS infected individuals through objects and information. Two zonal
supervisors oversee the work of cluster link workers in each district.

The Link Workers Scheme (LWS) is organism put into services in 109
districts of the country by August 2019. With the help of this intercession,
approximately 68,119 people belonging to various high risk groups such as FSWs,
MSMs, TGs and IDUs are being reached. Rural areas at the national level In addition
36
 HIV/AIDS- An Introduction

to these sections of the population, the scheme will also reach a bridge population of
8.29 lakhs. Moreover the bridge population includes migrants, truckers and other
vulnerable population groups. The programme also reached out to 26,980 people
living with HIV with its services. In 2018-19, approximately 43,054 people belonging
to high risk groups (HRGs) were diagnosed as HIV positive. Under this intervention,
1562 individuals with HRGs are being treated for symptoms related to sexually
transmitted infections (STIs). Has been integrated with existing services Through this
intervention approximately 29,99,577 free condoms were distributed to HRGs as well
as 2,48,328 socially sold condoms distributed in 2018-19.

Management of STIs/RTIs
The Sexually Transmitted Infections (STIs) and Reproductive Tract Infections
(RTI) increases the risk of HIV infection becoming more or less dangerous. Improved
services provided for STI and RTI Law focus on preventing the transmission of HIV
and promoting sexual as well as reproductive health under NRHM's NACP-III
Reproduction through Child Health (RCH-II).

Information, Education and Communication

Awareness rising about prevention and motivation to access treatment, care
and support regarding HIV infection comes through information, education and
communication programmes. Important activities undertaken under the IEC in
relation to HIV/AIDS are as follows:

(i) Mass Media Campaigns

The annual calendar is designed to streamline, strategize, and co-ordinate
mass media campaigns with other outreach worker, mid-media activities. The main
focus of this multi media campaign is to promote condom use under the name
"Condom- Ek Aachi Aadat" which has been promoted across the country in two
phases through various media. NACO received the award for its promotion at the
Outdoor Advertising Awards (OAA-2017) in Mumbai. Similarly, during the
financial year 2017-18, three campaigns were conducted in the country on PPTCT
and the Test& Treatment Strategy to bring awareness among the people towards
HIV/AIDS.

(ii) Outdoor Activities

37
 HIV/AIDS- An Introduction

In order to disseminate HIV-related services and information in the

community, the State AIDS Control Associations conducted public or awareness
campaigns, services, such as bus panels, hoardings, information panels, pole kiosks,
panels on metro trains and railways.

(iii) Folk Media and IEC Vans

As part of the National AIDS Control Programme, folklore is being widely
used as a medium to reach out to people in remote rural areas. State AIDS Control
Associations have prepared standard scripts. Special training was given to folk groups
to perform them in rural areas. These folk groups are performing in remote villages to
raise awareness about HIV/AIDS. But this work has also been assigned to 21 state
AIDS control societies for folk workshops in the state capital.

(iv) Adolescence Education Programme

Treating the life skills of the youth in this programme Aims to help
adolescents develop positive behaviors in order to adjust their stress and manage their
stress with peers to bring awareness about sexual health in order to prevent HIV
infection. Under this programme, subsequent sessions are scheduled for students in
grades VIII, IX and X. SACS has adopted the NCERT module to manage AEP in
classrooms. The programme is currently running in more than 55,000 schools.

(v) Red Ribbon Clubs

Red Ribbon programme is running in educational institutions. It is a
comprehensive prevention and promotion programme to harness the potential of
students attending schools. These clubs educate students about HIV/AIDS prevention,
care & support and treatment. Improve stain reduction through these voluntary blood
donations. They train young faculty members in the peer group on and off campus.
More than 12,000 clubs across the country are active working to raise awareness of
this.

Educational institutions, especially red ribbon clubs set up in colleges, serve

as a platform for students to not only come together, but also to promote HIV/AIDS
information and safe sexual behavior. In the same way, discussions on issues related
to HIV/AIDS are also held in these clubs. They have a passion for service by

38
 HIV/AIDS- An Introduction

participating in service programmes that motivate students to participate in voluntary

blood donation.

(vi) Drop in Centres

A Coordinating Psycho-Social Support for People Living with HIV/AIDS
with counseling through Drop-In Centers (DIC) provides a platform for drug
adherence, legal issues and livelihoods. They are set up in A and B category districts
and are mainly managed through PLHA networks. PLHA Networks are networks of
experienced men and women who are HIV positive at the district, state and national
levels. Through such networks the PLHA can serve as a platform for them to share
their fears and concerns or seek support and legal assistance. They discuss issues
related to discrimination and stigma among their members. Social support is also
provided to individuals who are isolated by their families and community. These
networks engage HIV positive people and encourage them to make the most of HIV
related services.

Condom Promotion
The NACO's strategy to encourage the use of condoms focuses on two main
areas. These ensure the availability of condoms and create their demand. Condoms
supplied by the government are sold in two ways- free and through the social
marketing method free condoms are distributed to HRGs through service delivery
outlets in TI projects, ICTCs and STI clinics under the free marketing programme.
Condoms are distributed free of charge through these programmes. Conventional and
non-traditional condom outlets- TIs, outlets at rural outlets and truck halt points
provide condoms at subsidized prices to HRGs and the general public, through the
Targeted Condom Social Marketing Programme. Condom use is very high in the
country. It follows from the above discussions that there is also a high level of
awareness and use of condoms among the public, especially HRGs and bridge
population, regarding the use of condoms.

The Government of India has a long history of condom promotion

programmes run by the Ministry of Health & Family Welfare. Initially the use of
condoms will also be sponsored and promoted under the National Family Planning
Programme. However, as HIV/AIDS emerged as a single fatal problem, the
promotion of condoms to prevent this HIV/AIDS was brought under NACP. NACO

39
 HIV/AIDS- An Introduction

has been working tirelessly to raise awareness about the use of condoms, even among
the general public, to prevent the spread of HIV/AIDS, following numerous reports
that up to 86 percent of HIV infections are transmitted through unprotected sex.
NACO believes that HIV/AIDS can only be prevented through safe and sexual
practices and as a result it strongly promotes the use of condoms.
With the help of mass media campaigns, NACO promotes their regular
condom use and safer sex. These campaigns promoting the use of condoms are aired
on popular cable& satellite channels, television, national networks, digital cinema, All
India Radio, private FM channels, print media, social media, etc. These campaigns
take place across the length and breadth of the country. Recently, a new mass media
campaign was developed. It is being promoted in Hindi and national and regional
languages. The main purpose of this campaign is to get into the habit of using
condoms.

Free Supply of Condoms

It is focuses on optimizing the free supply of condoms to ensure the aging and
availability of condoms to vulnerable groups as provided by the NACO. In order for
the State AIDS Control Associations (SACS) to track the use of free condoms, an
institutional mechanism has been established to ensure the supply of free condoms to
the State AIDS Control Associations (SACS) to analyze the distribution of free
condoms from the SACS. This includes targeted interventions by NGOs and
subsequently levels of SACS and TI- NGOs to assess the most vulnerable population
(MARPs), free condoms. In close collaboration with the State AIDS Control Societies
(SACS), NACO ensures the availability of free condoms under the NRHM. It
transfers stocks of condoms from NRHM to SACS where needed.

Blood Safety
As part of the blood safety programme, blood banks have been set up across
the country to encourage voluntary blood donation in the community. Voluntary
donation of this blood ensures that every unit of blood collected is tested and freed
from HIV and other infections transmitted through the blood.

Laboratory Services
The widespread arrangement of National Reference Laboratories (NRLs)
facilitates their control over compliance with HIV testing at blood banks and ICTCs

40
 HIV/AIDS- An Introduction

under the programme by conducting evaluation of test kits along with State Reference
Laboratories (SRLs). Laboratory support is also provided for DNA PCR testing of
infants and children less than 18 months of age by CD4 testing of HIV positive
individuals.

Counselling and Testing Services

Through the Integrated Counseling and Testing Center (ICTC), an individual
will be tested for HIV on his/her own contract (client initiated) as advised by the
health care provider after appropriate counseling. All this activity takes place in a
confidential and supportive environment. These centers were started as focal points to
link HIV positive individuals to HIV care, support and treatment services to
strengthen or reaffirm the prevention messages of HIV. It has many opportunities to
provide public HIV testing services, including parent-to-child transmission, voluntary
counseling and testing for HIV/AIDS, diagnostic testing in patients and screening of
TB patients.

Care, Support & Treatment

HIV attacks the immune system in the early stages and weakens it. After it
weakens the immune system, it can cause the body to host a series of infections for a
few years. As a result the person suffers from various ailments, otherwise the body
resists. Medical treatment for HIV infection involves partial efforts to treat
'opportunistic infections' that visit the body. It is includes efforts to combat HIV
directly so that the body’s natural defenses or body can resume its role of fighting
against invasive diseases.

The HIV infection is treated with antiretroviral therapy. This antiretroviral

therapy includes advanced pharmaceutical products used to combat HIV. This
antiretroviral therapy does not provide a complete cure for HIV infection but it does
reduce the risk of infection to some extent. It can add extra years to the lives of
infected people. This can add two to five years of life depending on the patient's
infection management quality.

There is no medical treatment available for opportunistic infections caused by

this HIV infection and for HIV infection 15 years ago. ART slows progression from
HIV infection to AIDS or AIDS to death. ART was made available in affluent

41
 HIV/AIDS- An Introduction

countries 10 years ago. However, it can be very costly; costing as much as $ 20,000
per patient per year and its impact is very limited. The effect of this ART has now
significantly improved and the cost of treatment has also been significantly reduced,
costing the patient $10,000 per year. This means that developing countries can
effectively negotiate with multinational pharmaceutical companies to reduce the price
of ART. Indian pharmaceutical companies are now making generic versions of
advanced therapies. And they are selling them at significantly lower prices. In India,
people living with HIV/AIDS used to take such drugs with their own money by
paying for these and other medical care expenses. Subsequently, national and
international interest groups negotiated and succeeded with the Government of India
in providing broad access to ART free of charge to the affected population of the
country (Mead over et al., 2004).

The NACP plays a vital role in meeting the needs of people living with
HIV/AIDS, i.e. Care, Support and Treatment (CST). The main objective of this
component is to include people living with HIV (PLHIV) with a policy package to
improve their quality of life and quality of life by providing comprehensive HIV care
of:
I. Given that free universal access to HIV-infected individuals for their
lifetime standard of Antiviral Therapy (ART).
II. Lab diagnostic and monitoring services are available free of charge to HIV
patients for CD4 testing, baseline testing, and targeted viral load.
III. Facilitating long-term retention care for them.
IV. Detect, prevent and manage opportunistic infections immediately.
V. Linking to Linkages, Care and Support Services for Social Security
Scheme.
The NACP's Care, Support and Treatment programme aims to provide
comprehensive management of preventive measures and treatment for other
Opportunistic Infections in people living with HIV/AIDS (PLHA), especially with TB
and psychosocial support, to intensify the positive prevention and impact of ART on
Home-Based Care. The reducing First-line and Second-line Anti Retroviral Treatment
is provided free of charge to medically qualified individuals living with HIV/AIDS
(PLHA) in specific centers across the country. As soon as a person is diagnosed with
HIV positive in the ICTC, they are sent to the ART center for immediate registration

42
 HIV/AIDS- An Introduction

on the ART, where all basic research, including the CD4 count, is done on him at the
time of registration. If this person is medically qualified for treatment he/she will be
given first line of ART. Then he/she will then be followed up every six months for a
CD4 count.
Through a view to bringing ART services closer to the home of eligible
beneficiaries, Sub-District/District Level Hospitals have set up Link ART Centers
primarily at ICTC and are connected to the available Nodal ART Center.
Establishment of Community Care Centers (CCCs) in the Non-governmental sector
with the aim of providing psycho-social support, treatment for opportunistic
infections, drug adherence and counseling for nutrition, referral and outreach services
and even home-based care for people living with HIV/AIDS (PLWHA) Has been
done.

The present condition of the CST programme in India is shown in Table 2.4.
As of August 2019 the number of ART centers is 537 as can be seen from Table 1.5.
Similarly the number of Link ART Centers is 1108 and the number of Care and
Support Centers is 361. The number of patients enrolled in ART is 11.33 lakhs and
the number of patients in pre-ART care is 1.25 lakhs.

Table 1.4
Status of the Care, Support & Treatment Programme in India (As on August, 2019)
Number of
Number of Number of Care & Patients on Patients in pre-
Link ART
ART Centres Support Centres ART ART care
Centres
537 1108 361 11, 33, 950 1, 24, 811
Source: NACO Annual Report, 2018-19.

Finance
Mainly aims to review the flow of funds, accounting and internal control
systems in financial management, annual budgets and plans. The main objective of
this financial management is on financial analysis for management and programmatic
use, which provides a reasonable guarantee in laying a solid foundation for
minimizing delays and removing barriers to better decision making that:
 These programmes are being carried out efficiently, effectively and also in
accordance with the regulations of the NACP;
 The reliability of this financial activity reporting;

43
 HIV/AIDS- An Introduction

 And Compliance with the laws and regulations of these organizations was
relating to HIV/AIDS programmes.

The main functions of financial management under NACP are budgeting,

accounting and auditing. Especially in the budget a) preparation of demands to
provide grants. B) Prepare for budget estimates/revised estimates in consultation with
the sections of this programme. The functions of accounting are a) approving the
processing of the Annual Action Plan (AAP), b) releasing the funds to the state
governments, which are subsequently transferred to the relevant SACS, c) at the
expense of the NACO and SACS, and d) its supervised utilization certificates.
Auditing functions include coordination for legal and internal audit of SACS,
submission of audit reports to the Ministry of Health and donor agencies, and
facilitation of auditing at the NACO level. NACP-IV is affiliated with the 12th Five
Year Plan and subsequently extended from 2017 to 2020 in the Annual Action Plan.
The annual expenditure under NACP-IV from 2014-15 to 2018-19 is shown in Table
1.5. Everyone can see that the annual expenditure under NACP-IV during 2014-19
was between Rs.1169 Crore and Rs.1749 Crore.

Table 1.5
Year-Wise Expenditure under the NACP-IV from 2014-15 to 2017-18
(Rs. Crore)
2014-15 2015-16 2016-17 2017-18
Expendit Expendit Expendit Expendit
RE RE RE RE
ure ure ure ure
1397.00 1287.39 1615.00 1605.72 1753.00 1749.12 2000.00 1169.26
Source: NACO Annual Report, 2018-19

Non-Governmental and Community Based Organizations

Many Non-Governmental Organizations (NGOs) and Community- Based
Organizations (CBOs) work on issues related to HIV/AIDS at the local, state and
national levels in the country. These HIV/AIDS related projects also include targeted
interventions with key populations. These general awareness campaigns include the
direct care of people living with HIV/AIDS, and the care of orphaned children with
AIDS. These NGOs/CBOs are funded through a variety of sources. These funds are
usually sourced from government sources, not from national and state governments,
but from international donors and local collaborators. Many CBOs have also come up
with innovative approaches to combat stigma and discrimination that serve as barriers

44
 HIV/AIDS- An Introduction

to accessing effective HIV prevention, treatment and other allied Care Services for
High- Risk Individuals.

HIV Lookout Surveillance

The National AIDS Control Organization (NACO) established the HIV
Sentinel Surveillance (HSS) system in 1992 and expanded to include ANC (antenatal
care) and STD (STI) clinics nationwide in 1998. It selected HRGs to systematically
monitor infections maintains HIV Sentinel Surveillance (HSS) during alternate years
of NACO. It was created by HSS to assess the trends and levels of the HIV epidemic
in the country. This is done on high risk groups (HRGs) with bridge populations,
including FSWs, IDU, MSM, Hijras/Transgender Population (HTG), Long Distance
Truckers (LDT) and Single Male Migrant (SMM). In addition to these groups, those
who attend STD clinics are also screened within the ANC. Areas in this shadow cover
a total of 651 districts, including 35 States and Union Territories. The structure and
functions of the key agencies participating in the HIV Sentry Surveillance Survey are
described here.

National level: The NACO is the nodal agency for formulating the policy along with
the commission for each of the circles in the HSS. The Technical Resource Group
(TRG) consists of experts in use from a variety of domains, including demography,
epidemiology, biostatistics, surveillance and laboratory services, to work on this
surveillance and assessment. This group of resources advises NACO on the broader
strategies to be followed for HIV surveillance and assessment. There are two national
agencies that support national level planning, coordination and operation. They are
the National Institute of Medical Statistics (NIMS) and the National Institute of
Health and Family Welfare (NIHFW). Along with these are independent professionals
to assist in supervision and training. In addition, technical assistance is provided by
organizations such as the US Center for Disease Control and Prevention (CDC), the
United Nations Programme on HIV/AIDS (UNAIDS), and the World Health
Organization (WHO).

Regional level: At the Six government agencies in the country have specially
appointed Regional Agencies (RIs) for HIV Sentinel Surveillance to provide technical

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assistance to State AIDS Control Societies (SACS) for all types of activities related to
HIV. These government agencies are responsible for locating, training, assisting, and
supervising new sites. They assist in improving the quality of the data they collect and
in the analysis of the collected data and also assist regional organizations in data
entry.

State level: The State AIDS Control Society (SACS) is the primary body responsible
for the implementation of HSS at the state level. Each state has a surveillance team of
microbiologists and public health professionals who assist SACs in the training and
monitoring of individuals involved in sentinel surveillance. In addition, regional
agencies set up State Surveillance Teams (SSTs) in consultation with the SACS.

District level: The Staff at District AIDS Prevention Control Units (DAPCUs)
participates in the coordination of HSS activities in test labs and sentinel sites in the
district.

Laboratory network: The Testing and Reference Labs Networks HSS supports
operations lab. A total of 137 testing laboratories are involved in conducting
preliminary testing of blood samples at ANC sites using HSS serum samples.
Similarly, 13 national reference laboratories also provide external quality assurance to
these Serum Testing Labs (STLs). They do this by repeatedly testing the blood
samples of these HIV positive 5 percent HIV negative samples. In addition, testing for
bridge population and high risk groups followed the Dry Blood Spot (DBS) approach
at HSS 2017. These 17 DBS testing labs are conducted to test for the presence of HIV
antibodies. The apex laboratory is where the National AIDS Research Institute
(NARI) DBS tests are conducted in Pune.

The role of HIV Sentinel Surveillance is very important and crucial in

monitoring both HIV epidemic trends and levels in different population groups in
different parts of the country. This HSS is located in about 650 districts. The HIV
epidemic is tracked every two years as one of the nation's largest network sites. Two
national and six regional organizations will provide technical assistance in this
endeavor for the monitoring and training of the HSS.

The based on data collected by HIV Sentinel Surveillance sheds light on

developing a national response to the HIV epidemic. It helps generate data to improve

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tracking of HIV trends. It also helps to better understand the symptoms of the disease
and its extent of spread across different geographical areas. Surveillance data are of
paramount importance in this plan for the management of appropriate programmes for
HIV infection prevention, care and support, treatment and resource allocation in the
country. In addition, it also informs legal efforts to mobilize political commitment.
The surveillance system is therefore efficiently designed to fit the model of the HIV
epidemic in India and focus on collecting data from populations that are considered
vulnerable and vulnerable to HIV infection. The resources for this HIV surveillance
are focused on areas that provide this data that are very useful in preventing the
spread of infections and providing care to those infected.

This HIV Sentinel dictionary is maintained by NACO/SACS. It assists them in

the efforts of the National Institute of Medical Statistics (NIMS) and the National
Institute of Health and Family Welfare (NIHFW). In return, seven regional agencies
(RIs), central team members (CTMs) and state intelligence agencies (SSTs) also
cooperate with NACO/SACS.

The HIV Sentinel Surveillance is implemented with the technical support of a

dedicated to surveillance for working group, including WHO and UNAIDS, the
aforementioned government agencies and government agencies and advanced
technology partners. To understand the current picture on HIV prevalence at the
national level, the important results of the two latest reports, HSS 2014-15 and HRG
2017-18, as well as HRGs and bridge populations among ANC clinic attendees, are
significant results. Levels and variations vary across different states and survey sites.
This analysis indicates the impact of interventions undertaken over time at different
stages of NACP.

Community Based Problems: The infection is most common in men and women
aged 15-54 years. The Hetero-sexuality has been identified as a major factor in the
transmission of men and women in India. Bilbutler referred to segregated housing as
the “housing with mean mentality” and said segregated housing is the killer,” because
separation reinforces people's tendency to deviate from normal life, thereby depriving
them of opportunities to develop skills and work confidence without them. HIV/AIDS
positive victims in the environment face problems in the local community when it

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comes to lime light, even neighbors who have lost their friends behave with them and
feel lonely and abusive and abusive.

Personal Problems: The insults faced by the respondents in this society are thus
caused by the loss of his prestige in the society, suspicion, insult, and refusal to work
jobs for their child abuse luck and immorality. They may have stressful life, events
negative affection health stressful events, stressful events the body undergoes many
small or large physical changes. This creates psychological stress between the
partners, which is sometimes followed by physical stress.

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