BASICS OF HIV

BY DR.A.K.GUPTA, ADDITIONAL PROJECT DIRECTOR

DELHI STATE AIDS CONTROL SOCIETY

• DELHI STATE AIDS CONTROL SOCIETY- 1ST NOVEMBER, 1998 HAVING A STAFF OF 56 PROGRAMME OFFICERS & SUPPORT STAFF & HEADED BY PROJECT DIRECTOR.

• SERVICE OUTLETS – 95 ICTC CENTRES, 17 STI/RTI CLINICS, 9 ART CENTRES, 8 CCCs, 5 DICs, 62 T.I PROJECTS FOR HRGs RUN BY NGOs, 21 BLOOD BANKS & 3 BSC, QA -4 SRLs.

• FUNDED BY NACO, GOI• SOCIETY & EC CHAIRED BY CHIEF SECY, GNCT OF DELHI• DELHI STATE AIDS COUNCIL CHAIRED BY HON’BLE C.M. OF

DELHI• GENERAL BODY – PRESIDENT HON’BLE HM

INTRODUCTION TO THE PRESENT TRAINING PROGRAMME

• TITLE: FULL SITE ICTC SENSITIZATION FOR DOCTORS• OBJECTIVES: 1. AWARENESS ON NACP III 2. IMPROVE UTILIZATION OF RESOURCES 3. REFERRALS• TOPICS: BASICS OF HIV/AIDS, ICTC INCLUDING PREVENTION

OF PARENTS TO CHILD TRANSMISSION, SERVICES UNDER NACP III,HIV TB COORDINATION, PEP, MYTHS & MISCONCEPTIONS

Indian Scenario (till March 2012)• First case: 1986, Estimates 2007: 2.31 million PLHAs, • 86.5% -15-49 years age group (27.9 % in 15-29 and 58.6%

in 30-49 age groups)• Epidemic concentrated in H.R.Gs; Spreading From :

H.R.Gs to the general population & Urban to Rural areas• Feminization (39.3% - women) of epidemic• > 12 lakh HIV +VE Regd. In HIV Care At ART Centers • 4,50,000 alive on ART

High Prevalence

(7)

Moderate Prevalence

(3)

Highly Vulnerable

(14)

Vulnerable States (14)

Tamil NaduAndhra PradeshMaharashtraKarnatakaNagaland Manipur

Gujarat GoaPondicherry

AssamBihar

DelhiHimachal PradeshKeralaMadhya PradeshPunjabRajasthanUttar PradeshWest BengalChhattisgarhJharkhandOrissaUttranchal

Arunachal PradeshHaryanaJammu & KashmirMeghalayaMizoramSikkimTripuraAndaman & Nicobar IslandsChandigarhDadra & Nagar HaveliDaman & DiuLakshadweep

HIV Prevalence : States Classified

• Total population - 16 million, First case- 1988• Estimated PLHAs (2007)- 32,000 • Low prevalence state (Prevalence in Gen. population- 0.22%)• Highly vulnerable state- (Migrant labour- 0.88 million, Truckers stationed/day-35000)• Total high risk population ->1.00 Lakh (FSW-61261, MSM- 28999, IDU- 17173)• PLHAs detected at ICTCs/VCTCs since 2002- 34,759• HIV +VE Regd. In HIV Care At ART Centers : 23,657• •No. Currently Alive & on ART-11,084• LFU (7%), DIED (8%) OR TRANSERRED OUT TO ART CENTRES (21%) OF OTHER STATES.

DELHI SCENARIO (March 2012)

CATEGORIZATION OF DISTRICTS IN DELHI

HIV & Nephrology 23-08-07

> 1% ANC/PPTCT prevalence in district in any time in any of the sites in the last 3 years (NIL Districts)

A

< 1% ANC/PPTCT prevalence in all the sites during last 3 years associated with > 5% prevalence in any HRG group (STD/CSW/MSM/IDU) (4 districts)

B

< 1% in ANC prevalence in all sites during last 3 years with < 5% in all STD clinic attendees or any HRG with known hot spots (Migrants, truckers, large aggregation of factory workers, tourist etc) (5 Districts)

C

< 1% in ANC prevalence in all sites during last 3 years with < 5% in all STD clinic attendees or any HRG OR No or poor HIV data With no known hot spots/unknown (nil-districts)

D

Categories of Districts In Delhi

Dynamics of HIV Transmission

GENERAL POPULATION

GENERAL POPULATION

Bridging Population

Clients, Truckers, migrant population etc.

High Risk Population

0.22%0.22% (2.6 -11%)

HIV Trend Among Ante Natal Cases

0.1

0.2 0.2

0.125

0.31 0.31

0

0.05

0.1

0.15

0.2

0.25

0.3

0.35

2003 2004 2005 2006 2007 2008

HIV Trends among STD clinic attendees, IDUs, MSM and CSWs

4.08

7.6

4.38 3.16

9.8

22.8

10.2

18.4

12

20.4

7.93

11.73

2.72

5.6

2.172.640

5

10

15

20

25

2005 2006 2007 2008

Perc

ent p

ositi

ve

STD IDUs MSM CSW

NO OF SAMPLE TESTED

NO OF

HIV+ VE

Comparing 2007-8 and 2009-10 ( % HIV +VE)

2007 2008 2007 2008 2007 2008

ANC 2000 2000 4 4 0.20 0.20

STD CLINICS 1120 1109 49 35 4.38 3.16

CSW (BROTHEL BASED)

250 246 25 14 10.00 5.69

CSW (NON BROTHEL BASED)

1000 998 8 13 0.80 1.30

MSM 750 744 88 59 11.73 7.93

IDUs 500 500 51 92 10.2 18.40

SENTINEL SURVEILLANCE

OTHERS

PERINATAL

I.D.Us

BLOOD TRANSFUSION

SEXUAL

RISK OF TRANSMISSION

• TRANSFUSION OF INFECTED BLOOD / BLOOD PRODUCTS-> 90%

• PERINATAL TRANSMISSION- 25-30% • SEXUAL ROUTE-(ORAL- 0.01%, VAGINAL -0.1%,

ANAL-0.5%)• PERCUTANEOUS NEEDLE STICK- 3: 1000 (0.3%)

•Targeted intervention-65

•STI Diagnosis & treatment-13

•Condom promotion

•Blood Safety-53

•ICTC-89

• IEC and social mobilisation

•AEP- launched

• PEP- all govt hospitals

•Mainstreaming-7 departments

•ART Centres-9

•CCCs-4

•DICs-5

• Holistic Approach-

Widow pension & jobs for PLHAs

1. PreventionOf New Infection 2. Care,

Support &

Treatment

3. InstitutionalStrengthening

Capacity building

4. Strategic ManagementInformation

system

• COE for ART-LNH

•Model Blood bank -DDUH

• Regional STD Lab-MAMC

• TSU for DSACS & Parivar Sewa for PPP STI clinics

• Training

•EQAS-4 SRLs

•Operational Research

•Programme management (CMIS & CPFMS)

• Surveillance-25 sites

•M & E

•Computerization of ICTCs & STI clinics• Common National reporting format

PREVELANCE OF HIV POSITIVITY• GENERAL POPULATION- INDIA : 0.36%, DELHI-

0.22% ( SENTINEL SURVEILLANCE ANC DATA 2007)

• HIGH RISK GROUPS- 2.64% to 11.73%• STI ATTENDACE: 4.38%• VULNERABLE POPULATION ATTENDING ICTC:

3.5% • TB PATIENTS HIV POSITIVE: 5%• TRUCKERS - 2.5% (TCI) (INTERVENTION TO BE

STARTED THIS YEAR BY DSACS)

Natural History of HIV Infection

Initial Infection (lasting 4–8 weeks), Acute HIV Syndrome (lasting 1 week–3 months),HIV-Specific Immune Response (1–2 weeks), Clinical Latency (10 years, median), AIDS-Defining Illnesses (2 years on average),and Death

W.P.

Natural History of HIV-1 InfectionPrior to treatment

4-8 wks Up to 12 years 2-3 years

Initial Infection

Seroconversion

Asymptomatic Symptomatic AIDS

Death

1000

500

0

CD4+ Cells/L ARS

10%

60%

30%

Characteristic Viral Load ,CD4 & CD8 Changes Over Time In Cases with HIV Infection

CD4 COUNT

VIRAL LOAD

P24 Ag

CD8 COUNT

500

200

50

CD 4 COUNT & OPPORTUNISTIC INFECTIONS

The Changing Natural History Of HIV/AIDS In The 'HAART' Era

Dramatic reductions in the incidence of 1. Opportunistic Infections

2. HIV-related Malignancies 3. Kaposi's Sarcoma

4. Deaths in advanced AIDS cases

IMPACT OF ANTI-RETROVIRAL TREATMENT (DELHI STATISTICS)

AIDS DEATHS/CASES

Cumulative till 1999

2000 2001 2002 2003 2004 2005 2006 20072008 till Sept 2009

Cumulative deaths 118 142 169 201 230 237 283 363 526 602 668

Cumulative Cases 359 498 656 762 881 956 2421 4346 6409 6976 8027

% of Deaths 32.8 28.5 25.7 26.3 26 24.8 11.7 8.4 8.2 8.63 8.32

WHO Clinical Staging HIV Infection

Clinical Stage I:• Asymptomatic • Persistent Generalized lymphadenopathy

(PGL)

WHO CLINICAL STAGE II• Moderate unexplained weight loss (< 10% of body

weight). • Recurrent bacterial upper respiratory tract infections

(current event plus one or more in last six-month period). • Herpes zoster • Angular cheilitis • Recurrent oral ulcerations (two or more episodes in last

six mths. • Papular pruritic eruption • Seborrhoeic dermatitis• Fungal nail infections.

WHO CLINICAL STAGE III• Unexplained severe weight loss (> than 10% of body wt)• Unexplained chronic diarrhoea for longer than one month.• Unexplained persistent fever > one month• Oral candidiasis• Oral hairy leukoplakia.• Pulmonary tuberculosis (current).• Severe bacterial infection for example, pneumonia, meningitis,

empyema, pyomyositis, bone or joint infection, bacteraemia or severe pelvic infl ammatory disease.

• Acute necrotizing ulcerative gingivitis or necrotizingulcerative periodontitis.

• Unexplained anaemia, neutropenia or chronic (more than one month) thrombocytopenia

WHO CLINICAL STAGE IV• HIV wasting syndromei

• Pneumocystis carinii pneumonia • Recurrent bacterial pneumonia.• Chronic herpes simplex virus (HSV) infection (orolabial, genital or anorectal) of more than one

month, or visceral of any duration.• Oesophageal candidiasis. • Extra Pulmonary tuberculosis • Kaposi’s sarcoma. • Cytomegalovirus disease (other than liver, spleen or lymph node).• Central nervous system toxoplasmosis. • HIV encephalopathy. • Extrapulmonary cryptococcosis (including meningitis)• Disseminated nontuberculous mycobacteria infection. • Progressive multi focal leukoencephalopathy (PML). • Cryptosporidiosis (with diarrhoea lasting more than one month). • Disseminated mycosis (coccidiomycosis, histoplasmosis, penicilliosis) • Cerebral or non hodgkins Lymphoma, invasive cervical Carcinoma,• Recurrent non salmonella typhoid• HIV cardiomyopathy, nephropathy

SOCIO-ECONOMIC PROFILING OF PLHAsA STUDY WAS UNDERATKEN IN COLLABORATION WITH ILO AT TWO ART CENTRTERS (RML & LNH)SALIENT FEATURES: SAMPLE SIZE: 1171 PLHAs (816 MALES, 333 FEMALES & 22 TS/TGLNH: 584 PLHAs, RML:587 PLHAs90.9% PLHAs BELONG TO 16-45 YRS AGE GROUPSEX COMPOSITION: MALES 70%, FEMALES-28%, TS/TG-2%MARITAL STATUS: MARRIED-72%, WIDOW-12%, SINGLE-16%STATUS OF RESIDENCE: 62% FROM DELHI, 38% ARE MIGRANTS (UP,HARYANA)EDUCATIONAL STATUS: MAJORITY (61%)- LOW EDUCATION STATUS: 25%-ILLITERATE, 36% PRIMARY SCHOOL. ONLY 29%-SEC SCHOOL & 10% COLLLEGE GRADIATEEMPLOYMENT STATUS: > 51% -UNEMPLOYED (90% WOMEN, 50% TS/TG & 35% MEN); 12% DAILY WAGE, 37% REGULAR EMPLOYMENTOCCUPATIONAL BREAKUP OF EMPLOYED : SELF EMPLOYED/BUISENSS-34%, PVT SECTOR-35%, GOVT -8%, LABOUR-14%, FARMER-5%, HAWKERS-4%MONTHLY HOUSLEHOLD INCOME: 46.9% < RS. 2000/PM; 79.2% < RS. 4000/PM; 18.2% BETWEEN 4000-10,000/PM; 2.6% . > RS. 10,000/PM

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