National AIDS Control Program of India

Saurabh Bisht

Abstract

Although India currently witnesses a low adult HIV prevalence of 0.22%, with 2.3 million people living with HIV, India is the third largest epicenter of the HIV/AIDS epidemic in terms of absolute numbers. The fourth phase of the NACP aimed to (i) reduce the number of new HIV infections to half from the baseline of 2007, and (ii)provision of comprehensive care, treatment and support to everyone living with the virus.

The NACP-IV, started with a target of speeding up the process of reversal of the epidemic and making India’s response against the virus stronger over its five years through a careful and well-defined integration process, has now been extended in its fifth phase, NACP-V, till 31 March 2026. The program provides free antiretroviral therapy¹(ART), a game changing treatment against the virus, to anyone living with it. It aims to achieve its objectives by using prevention strategies, including a targeted intervention for the High-Risk Groups (HRGs), Employer Led Model²(ELM) and harm reduction program³, along with working on some identified priorities and thrust areas. 

This research paper explores, and analyzes, the National AIDS Control Program of India, and the other associated programs and policies, through the health policy triangle framework, and how they have evolved over the years. 

Introduction & Background

In 1986, India detected its first known case of the Human Immunodeficiency Virus (HIV) in the state of Tamil Nadu, where the blood samples of six female sex workers were tested positive for the virus. With the much-dreaded virus now in the country, the Government of India launched its first National AIDS Control Program (NACP-I) with an International Development Association (IDA) credit of $84 million. The NACP-I was instituted with an aim of impeding the HIV cases to curb the mortality and repercussions of the virus. The National AIDS Control Organization (NACO), along with the National AIDS Control Board, was constituted as an autonomous body in the same year and was tasked with implementing the program. 

While the NACP-I focused on generating awareness, putting in place a system for surveillance of the virus, ensuring measures for access to safe blood and preventive services for those at high risk, in November 1999, with World Bank support of $191 million, the NACP-II was launched. The NACP-II aimed at (i) reducing the HIV infections in India, and (ii) increasing the country’s scope of response to the virus. Implementing the objectives of NACP-II led to many policy initiatives being taken to strengthen the country’s fight against HIV/AIDS⁴.  

While the NACP-II comprehensively laid the policies and programs to make the country’s fight against the HIV/AIDS epidemic stronger in the long term, in response to the evolving nature of the HIV epidemic, the NACP-III was launched.

NACP-III had an objective of reversing the HIV/AIDS epidemic over its five years span. To achieve its aims, the efforts pertaining to HIV prevention were scaled up for those deemed as High Risk Groups⁵(HRG) as well as the general population by incorporating them with services for care, support and treatment. It made Prevention and Care, and Support and Treatment (CST) as the foundations for the efforts to control HIV/AIDS in the country. 

After an elaborate process of consulting multiple stakeholders, the fourth phase of the NACP was launched in 2012.The NACP-IV aimed to (i) reduce the new HIV infections by 50%, from the base year of 2007 of NACP-III, and (ii) ensure a thorough care, support and treatment to People Living with HIV/AIDS (PLWH). The program succeeded with achieving its goal, more or less, and paved the way for the unfurling of its fifth phase⁶, starting April 1, 2021, till March 31, 2026.

Analysis of NACP and Related Policies and Programs

1. Design

1.1 Problem 

Although modern medicine has evolved over time and hailed progress by changing the status of HIV, as an illness, from terminal to chronic, the virus still has no cure. With the evolution of medicine, the policies and programs against HIV/AIDS have evolved in multiple phases of the NACP since its inception. 

Though the HIV epidemic in India had its peak in the period of 2000-01, with its then prevalence rate at 0.54%, the virus prevalence has steadily decreased over the years (Datta & Lahiri, 2022). Despite its declining prevalence, it is indeed important to curb the spread of the virus via ART and other preventive, curative, promotive and rehabilitative methods.  Hence, the program will be relevant as long as India wishes to ‘end’ AIDS. NACP offers integrated healthcare services to PLWH and the general population. It is preventive for the general population and HRGs as it promotes safe sex behavior, like condom promotions and integration of IEC with school curriculum in NACP-IV and focus on awareness generation in NACP-I.  

With the advent of ART, and the evolved endemic, the program also focused on strengthening its curative healthcare services in the long run via the introduction of the National ART program to strengthen its curative measures, thereby making ART free and accessible, with integrated CST, to all PLWH. The NACP also realizes the importance of promotive services in the context of HIV and has made efforts to enhance it through measures like NAEP, GIPA and youth interventions to strengthen the promotive measures over the years. It has also strengthened its rehabilitative services over the past decade by introducing CST for all, a dedicated national AIDS helpline and making ART more accessible by involving the network of PLWH and NGOs. 

1.2 Goal 

The NACP is a phase wise program, with each phase identifying its priorities and thrust areas, with specific and broad goals and strategies. It aims to provide comprehensive Care, Support and Treatment (CST) services to PLWH, intensify and consolidate the prevention services, expansion of Information, Education and Communication (IEC) services for the HRGs and the general people, focusing on inducing behavior change. It also aims to strengthen the existing capacity of the institutions and roll out a Strategic Information Management System (SIMS).  

Although NACP-IV has succeeded in its broader goals of providing care, support and treatment to PLWH and reducing the annual HIV infections by 48%, against the global 31% (2010 baseline), it still has unclear metrics, of success and failure, on how it has induced behavior change through IEC services and its penetration in the general population. 

1.3 Scope 

While NACP is considered to be extremely successful in terms of declining HIV prevalence, CST for PLWH and an 82% decline in annual AIDS death (2010 as the base year), its objectives of minimizing the stigma, even though legislations, like the HIV and AIDS (Prevention and Control) Act, 2010, have often been overshadowed by its sheer statistics of a nationally declining HIV prevalence. 

The goals of the previous phases are often extended in its subsequent phases in a more elaborate manner. Its achievements of objectives as a national program are met with challenges in its decentralized implementation at the state and district levels. While the program covers the HRGs and general population, thereby aiming to cover the entire population through various means under its umbrella, its strength of coverage is a blurred figure.  

Despite the declining national HIV prevalence, there is no reliable way to know if the same is a result of increase in safe sex practices from the program intervention or due the suppressed viral load⁷from ART treatment covering PLWH. Owing to plurality of the socio-cultural fabric of the Indian society, there is also the challenge of estimating accurate quantitative figures of HRGs, like IDUs, Men who have Sex with Men (MSMs) and transgenders. 

1.4 Principle 

Some of its key priorities include prevention of new infections by making current  interventions sustainable, preventing parent to child transfer, promoting behavior change  in the HRGs using the IEC strategies, ensuring Greater Involvement of PLWH (GIPA),  decentralization of the services, using the strategic information for all program levels  effectively, strengthening participation of Non-Governmental Organizations (NGOs) and  civil societies in states where the virus is emerging, phased integration of HIV services in the health systems and prioritization of mainstreaming of HIV related services with all  important ministries and departments at the central/state levels.

The program takes a step towards ‘integrated responses’ via mainstreaming and partnerships to develop multi sectoral responses against the virus. It also makes youth interventions through programs like NAEP, to improve the sexual and reproductive awareness to prevent HIV/AIDS.

1.5 Activities 

The important activities of the NACP include IEC, youth engagement and mainstreaming.  Further the NACP focuses on enhancing its strategies for communication for generating demand by expanding the services of counseling, testing, ART, treatment for STIs and promoting condoms. Through the IEC activities, the program focuses on awareness generation, on prevention of HIV/AIDS, as well as motivation for access to treatment, testing and support.  

However, it is unclear how NACP can effectively measure the success of implementation of its activities apart from the statistics of the falling overall HIV burden. The penetration rate of the activities can be affected by the socio-cultural setup and wrong estimations of the target groups. It is also uncertain how well the general population responds to the program activities and other interventions since the virus is still talked about in a shushed voice. 

2. Process  

2.1 Agenda Setting 

India has committed itself in achieving the Target 3.3 of Sustainable Development Goal (SDG) 3⁸of ‘ending the AIDS epidemic as a public health threat’ by the year 2030. To do so, the NACP has taken on the goal of 90-90-90⁹.  

The program further identifies key¹⁰ and bridge¹¹ populations for targeted interventions.  The Opioid Substitution Therapy¹² (OST) has been started as a part of the program targeting the IDUs. Nationally, the IDUs are most vulnerable to HIV transmission among the HRGs. It has further focused on other intervention models like the prison intervention, employer led model (ELM)¹³ and link worker scheme (LWS)¹⁴.

The agenda setting of the program involves multiple stakeholders offering help, through monetary, planning, implementation, knowledge sharing and proliferation of resources. Given the large number of stakeholders and resources needed, the program is vulnerable to errors and coordination failure. 

2.2 Consultations 

NACP is led, and guided, by NACO. It is implemented by the SACSs at state levels¹⁵.  Every SACS has a governing body¹⁶ of its own which is its utmost policy making composition.  

Since 2017, NACO along with the respective State AIDS Control Societies (SACS), collaborating with the Department of Women and Child Development (WCD) and State Prison Department (SPD), has started the prison intervention program in phases, against HIV and Tuberculosis (TB). 

Despite the provisions for an elaborate consultative process, it is difficult to say if the SACSs actually adhere to them. Rather, apart from the provision of ART to PLWH, there is little/scattered data on other activities that shape the program. 

2.3 Legislation 

The HIV and AIDS (Prevention and Control) Act, 2017¹⁷ is the key legislation that protects and promotes the rights of PLWH. The Act aims to intercept and control HIV and AIDS from spreading and guarding the human rights of those living with it. It not just protects the rights of PLWH but also of those involved in provision of healthcare services. It also provides a mechanism for grievance redressal through provision of an Ombudsman and Complaint Officer at levels of state and establishment respectively.  

However, the grievance redressal mechanism has not been the most efficient as many states have either not appointed the Ombudsman or are still in the process of doing so. Despite the framing of many policies and sub-programs around NACP, there is no comprehensive assessment on them. Currently available assessments, like the Sankalak report¹⁸, are largely limited to the statistical data from the ART centers on PLWH. 

2.4 Implementation 

The program implementation is largely based on NACO’s twin objective of HIV prevention and access to treatment to PLWH. With the help of SACS and NGOs, NACO leads the program at the levels of states, districts and villages for prevention against the virus¹⁹. The program especially extends to women, along with the healthcare workers, HRGs, bridge and general populations and co-works with multiple education boards at school level for education on the virus. 

Despite the implementation mechanisms, the insufficient and unavailable data makes its execution ineffective. Many states have insufficient data on multiple parameters related to program execution and such spots are left blank even in the Sankalak reports. In such cases, the targeted intervention gains larger probability to be ineffective as the data on targets can be under-calculated, or even wrongly weighed in. Further, the under-addressed stigma makes the implementation slacked off since it limits the participation of PLWH in the process.  

3. Actors

3.1 Individual & Collective 

Since the program runs at a national level, it targets the entire population of the country, directly or indirectly, through its IEC and other initiatives for awareness and intervention.  The program, through its targeted intervention, prioritizes the HRGs like Female Sex Workers (FSWs), MSMs, transgenders and IDUs. It further focuses on the bridge population, like truckers and migrant workers, and develops its intervention aiming at them since they bridge the transmission of the virus from the HRGs to those at low risk.  

The union government, along with the state governments, act as major actors/stakeholders in the program. It is a nationally planned program that flows through its autonomous decentralized SACSs and District AIDS Prevention and Control Units²⁰ (DAPCUs). The other notable stakeholders to the program include the NGOs, civil societies, network of PLWH and donor organizations that help the program’s execution and finances.  

Despite the bold and comprehensive goals of the programs, its criteria, of classifying targets/groups, finds some doubt. Its classification of truckers and migrants as bridge population and the estimates on the numbers of vulnerable groups does not have many valid answers. Not identifying the right targets can render its execution ineffective. 

3.2 Program Targets & Interest Groups 

Though the policy, at large, is working towards SDG 3, Target 3.3 to end HIV/AIDS by 2030, it has evolved its own targets over the years in its phased implementation. Further, the program envisages the 90-90-90 target and end of mother to child transmission of HIV by adapting the National Strategic Plan 2017-24 with the goal of testing up to 127 million individuals annually and other targets²¹. 

While the program runs at the national level, through the decentralized SACS and DAPCUs, the network of PLWH, civil society organizations, NGOs along with multilateral organizations like UNAIDS are some of the key influencers in shaping its policies and implementation. The NACP-IV garnered inputs for its mechanisms from government departments, civil societies, development partners and the private sector. The program in itself aims for an inclusive and consultative participation, including experts, on the cause.  

Though the program welcomes participation from various interest groups, its execution is mostly carried out by the government. It is also difficult to say, how much and how well, the participation of NGOs and PLWH shapes its implementation, The guidelines are often limited to papered instructions and is inordinately implemented in spheres dealing beyond ART. 

4. Context 

4.1 Social & Political 

The NACP not just works for the elimination of the disease but also towards eliminating the stigma, around, and about, the virus through the HIV and AIDS (Prevention and Control) Act, 2017. Despite the measures, the social picture of HIV still remains at a shushed spot. As a part of the program, NACO generated materials on IEC in a bid to fight the stigma and discrimination faced by PLWH during the pandemic of COVID-19²².  Further, youth interventions, like the Red Ribbon Club (RRC), are aimed towards reducing stigma and discrimination.

Though the NACP is a program which is globally steered by the World Health Organization, HIV is the only disease with a dedicated UN agency, UNAIDS²³. NACP being a nationally run program, is also a part of the political priorities.  

While the program, its efforts and success are, at large, lauded, the utilization of its full potential and associated policies, finds some questions. Since the HIV prevalence has nationally gone down significantly over the past decade, the zeal to implement the program with its full potential has found many doubts by critics. The data from a few of the states over the past year shows many possible incomplete implementations of the provisions of the HIV and AIDS (Prevention and Control) Act, 2017 (Bathini, 2020). 

4.2 Economic  

In 2014, the government took a major economical undertaking of the program by announcing that it would bear most of the expenses of NACP. This was a major decision as since the inception of the program, the government relied largely on its donors for the NACP²⁴. However, in the fourth phase of the program, the government decided to fund almost 80% of the program through its pockets (Pandey, 2014). In 2017, the government announced that ART would be free for anyone living with HIV, irrespective of their CD4²⁵ count. 

It is a distributive program since the treatment, and other program activities, to PLWH is fully sponsored by the Indian government’s budget.  

Conclusion

The NACP of India is scientifically driven. Since the detection of the first HIV case in India in 1986, the program has evolved with the evolving needs of the epidemic. It aims to tap into the spaces that shape life for PLWH. From management of HIV-TB co-infection to development of multiple supporting schemes and policies, the program, in its phases, harnesses mean to strengthen its fight against the virus.

It aims to not just work on the national level targets, but also at the global level targets. Over the years, irrespective of the political power at the Center, the program has seen positive results and commitment towards its fight. The contributions from the government, especially financially, have seen an increase as well.  

Though NACP aims for the decentralized approach in addressing the epidemic, its implementation through so many stakeholders becomes complicated at times. With the functional independence given at the district and state levels, how they lay out their plans and execute them remains an abstract answer. Although the program also aims to socially address the epidemic through community mobilization interventions, the participation cannot be fully harnessed when PLWH continue to face stigma and marginalization.

In an environment where most of the implementation weightage is given to a declining national prevalence, PLWH continue to live in fear of discrimination, as reduction of stigma does not find the same impetus. Their participation in policy making is limited, if not ignored, in the very programs and processes meant for their empowerment. 

In India, HIV is still not as openly talked about in society, and hence in politics. Though the program’s implementation has never been hindered by the political party in power, it has never been openly discussed as a public issue at a political platform either. Talking about the program at political stages can potentially help in significantly reducing the stigma and discrimination faced by the PLWH and make India’s fight against it even more strong. 

The program runs in a decentralized fashion, allowing the states and districts to steer it as per their needs. It is an ongoing and evolving program, with an ambition to end the AIDS epidemic in India by 2030. Given the seriousness of HIV/AIDS as a public health challenge, to achieve the goal of ending AIDS by 2030, India must strictly adhere, evolve and implement the intended programs and policies with an incremental pace, without any slowdowns or slacked off attitude. There is also a need to simultaneously look at, and beyond, the figures of overall declining national HIV prevalence, as the wellbeing of the PLWH is not just a function of access to medicines but it also depends on an enabling, equitable socio-cultural setup with an empowering ecosystem for all.

Footnotes

• ¹ The Anti-Retroviral Therapy, known as ART, is a drug combination prescribed to anyone living with HIV. ART  does not cure HIV but treats it, allowing the PLWH to lead longer and healthier lives. 
• ² The ELM model was started to reach the vulnerable informal workers, in both, organized and unorganized, sectors. ³ The policy for the harm reduction program was adopted in the NACP-II for preventions of HIV/AIDS in Injecting  Drug Users (IDUs). Currently, in NACP-IV, the provision of Female Outreach Workers (ORWs) for reaching out to  the spouses of men who are IDUs. It has also added another typology of Female Injecting Drug Users (FIDUs)
• ⁴ The National AIDS Prevention and Control Policy was introduced in 2002, the targeted interventions were scaled  up for those at higher risk for the virus in the states which had high HIV prevalence and the GIPA (Greater Involvement  for People with AIDS) strategy was launched. Further, the National Adolescent Education Program (NAEP) was  introduced, along with HIV counseling and testing and Prevention of Parent to Child Transmission (PPTCT) program.  Furthermore, the National Antiretroviral Treatment (ART) program was launched and an inter-ministerial group was  formed to set up the National Council on AIDS, chaired by the Prime Minister and State AIDS Control Societies were  set up as well. 
• ⁵ The HRGs are the communities who are most vulnerable to HIV infection. The NACP treats the commercial sex  workers, men having sex with men (MSM), transgenders and injecting drug users (IDUs) as HRGs. ⁶ The NACP-V has broadly laid out its aims to (i) cover 80 million people annually through tailored prevention  detection, (ii) keep more than 99.5% of the adults free from the virus, (iii) carry 270 million tests, including 140 million for pregnant women, over its 5-year period, (iv) put 2.1 million PLWH on ART by the end of its tenure, and,  (v) conduct 8 million tests on viral load to follow the effectiveness of treatment. A more comprehensive detail of the  program is yet to be revealed by the government.
• ⁷ The suppressed viral load refers to the reduced HIV viral load in the body, after starting ART treatment, which helps  in keeping the immune system healthy. It is defined as less than 200 copies of HIV per milliliter of blood.
• ⁸ The objective of SDG 3 is ‘good health and wellbeing’. Target 3.3 of SDG 3 aims to ‘end AIDS, tuberculosis, malaria  and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases’ by 2030. ⁹ The three 90s translate to (i) 90% of PLHIV knowing their HIV status, (ii) 90% of PLHIV aware of their status to  be on ART, and, (iii) 90% of the PLHIV on ART have their viral load suppressed. 
• ¹⁰ The key population is considered as those who are most vulnerable to contracting the virus. ¹¹ Bridge population refers to those who have sexual partners from the HRGs as well as the general population. ¹² The OST, started since 2007 under the NACP, is defined as a ‘directly observed treatment’ under a medical officer  at designated clinics known as OST centers.
• ¹³ The ELM has been developed to create awareness and provide services for prevention and care against HIV to  informal workers linked, directly or indirectly to industries. 
• ¹⁴ To cover the HRGs and other vulnerable populations in rural areas, the LWS was launched. ¹⁵ By allowing the SACS functional independence, they act as autonomous decentralized bodies.  ¹⁶ The governing body is led either by the health minister in charge or the chief secretary. They further have  representatives from important departments of the government, civil societies, industries and trade, the private health  sector and networks of PLWH. The program director and executive committee manage the administration and  finances. They have meetings twice in a year to approve new policies, plans and yearly budgets, appointment of  statutory auditors and accepting yearly audit reports.  
• ¹⁷ The HIV and AIDS (Prevention and Control) Act, 2017 came into effect from 10 September, 2018. It aims for an  unhindered equally accessible service pertaining to HIV to all without any stigma. It forbids any discrimination, at  areas of work, healthcare services and education, and even within families and communities. It further has provision  for penalizing anyone who propagates hate or physical violence against those protected under the legislation. The Act  empowers the states and union territories for drafting state rules and appointing the Ombudsman.
• ¹⁸ The Sankalak report is NACP’s evidence-based flagship report which provides details on the national AIDS  response for the 2020 fast-track goals and the 2030 goal of ending the AIDS epidemic. 
• ¹⁹ NACO hosts periodic meetings, seminars and training sessions with the healthcare organizations and providers and  augmentation of prevention and treatment services against the virus.  ²⁰ It was decentralized to district level, to the DAPCUs, during NACP-III. With the data on HIV Sentinel Surveillance,  the districts, based on their disease burden, were classified into four categories, A, B, C and D.
• ²¹ The other important targets of the program include a targeted intervention for the HRGs and bridge population,  LWS, integrated testing and counseling, accessibility of treatment for adults with STIs, expansion of blood transfusion  services, condom promotion and comprehensive CST for PLWH and an 80% reduction in new infections. 
• ²² NACO has also collaborated with National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru  to address the mental health issues faced by PLWH. The counselors over NACO’s helpline were trained in issues  pertaining to the same. 
• ²³ The UNAIDS leads the efforts to globally end AIDS by 2030 as a part of the SDGs. 
• ²⁴ The government contributed 45% in NACP-I, 9% in NACP-II and 25% in NACP-III. 
• ²⁵ CD4 are a type of white blood cells in human bodies that finds and destroys invading bacteria/virus/germs. The  normal levels of CD4 in those without HIV/AIDS is 500 to 1400 cells per cubic millimeter of blood. The CD4 count  declines for PLWH without treatment.

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Saurabh Bisht is a final year student of M.A. in Public Policy at Jindal School of Government and Public Policy, O. P. Jindal Global University. 

Read more by the author: Beti Bachao, Beti Padhao: Through the Trans-Himalayan Terrain.