1. An Overview of HIV/AIDS Epidemic Situation and Programmatic Response in Uttar Pradesh IAPSM Conference Dehradun 30-31 Oct 2010 Dr Pramod Gautam Dr Sudipta Mondal FHI

2. About FHI 1971 - The establishment of Institute for Family Health (IFH) managing research and field activities (North Carolina) 1986 - The establishment of Institute for HIV/AIDS (IHA) managing the work on HIV prevention Programs 1990 - FHI Foundation Established 1993 - HIV Prevention Research and Women’s Studies 1995 - PQC Established 1999 - Pharma Link FHI Established 2001 - Youthnet, IFA and IHA 2004 - Malaria Clinical Trials 2006 - HPV, Avian Flu, Rotavirus and Unification for Greater Impact

3. Mission, Values and Beliefs

5. SAMARTH Project Overview Background: Strengthen Abilities to Manage And Respond effectively To HIV/AIDS (SAMARTH) is a five-year Technical Assistance (TA) grant under the United States Mission to the India Five-Year Strategic Plan for the PEPFAR during 2006-2011 Goal: Improve the effectiveness of the response of the government and civil society for evidence-based HIV policy and programs in India

6. Objectives To enhance capacities of government and civil society for effective management of HIV /AIDS program To strengthen quality of HIV prevention, care and treatment in the public and private sector To improve planning, collection analysis, and use of strategic information (SI) at the national, state, and district levels To foster bold leadership and visibility of USG-supported programs through strategic communication

7. Vulnerability Factors for HIV Epidemic in UP • Population 180-200 million (growth rate 2.5%) • 48 - 50% in reproductive age group • Low literacy (rural 36.66%, state 57.2%) • High incidence of poverty • Low status of women & Gender disparity • Large presence of high risk groups * Migrants : 10 million * Truckers : 50,000 (8 national highways) * FSWs : 20000-25000 * IDUs : 10000-12000 * MSM : 10000-12000 • Long porous Indo - Nepal border

8. Levels and Trends of HIV in UP

9. Adult HIV Prevalence in Indian and UP

10. HIV Prevalence in UP: NFHS-III Estimate

11. Trend in HIV Prevalence among General Population

12. Trend in HIV Prevalence among High Risk Groups

13. HIV prevalence trends at ICTC in Eastern UP and rest of UP

14. Prevalence of HIV among clients tested at ICTC by region

15. Prevalence of HIV among clients tested at PPTCT by region

16. HIV Positivity among HRGs in UP 2008 – 2009 Data Source: CMIS -UPSACS

17. BSS Indicators

19. Comprehensive knowledge about HIV - FSWs By Region Total

20. Number of different types of clients and partners in the last week

21. Condom use during last sex with occasional and regular clients

22. Consistent condom use with occasional & regular clients in last 30 days Base: Those who used condoms during sex

23. Aware of free Government counseling and testing services Total By Region Base: All

24. Injecting Drug Users (IDUs)

25. HIV/ AIDS Knowledge and Prevention- IDU

27. Mean age at first sex with a female partner was 19 years

28. 8% of IDUs ever had sex with a Female Sex Worker

29. Mean Age at first sex with a FSW was 21 years

31. Men Having Sex With Men (MSM)

32. Knowledge of HIV/AIDS-MSM Knowledge on transmission of HIV/AIDS among respondents COMPREHENSIVE KNOWLEDGE ABOUT HIV/AIDS 18% - 2009 UP BSS 16% - 2006 UP BSS

34. Condoms not available - casual partners

35. Never heard of a condom, condom not available and decrease in pleasure - paid partners

38. FSWs and MSM Estimates distribution of total 22,425 FSWs across 1,496 sites Estimates distribution of total 10,922 MSM across 799 sites

40. Migrants concentrated in 68 towns with 12.7% reporting high risk behaviour

41. High proportion of IDUs – Easy accessibility and less expensive

43. Estimates of Female Sex Workers (FSWs) in Uttar Pradesh 36

44. Estimates of Men Having Sex with Men (MSM) in Uttar Pradesh 150 225 96 97 31 516 191 154 207 293 181 178 155 122 138 298 138 106 7 445 2 180 20 127 3 18 135 43 414 59 12 104 65 88 23 56 868 299 79 95 41 65 119 117 465 123 185 130 591 580 16 102 145 142 8 237 115 64 120 825 24 20 150 8 10 56 46 37 37

45. Estimates of Injecting Drug Users (IDUs) in Uttar Pradesh 142 267 280 118 289 268 484 172 337 74 371 343 123 258 714 202 366 139 560 67 100 3 16 403 2 61 31 43 318 88 66 130 320 69 151 247 5 133 72 49 73 111 195 110 769 190 27 1372 466 29 180 155 91 107 169 149 219 166 163 51 51 758 17 159 57 23 126 82 38

46. 747 615 25,786 39,037 1,333 367 3,557 122,564 10,213 339 1,050 616 294 563 324 625 958 214 337 324 276 671 9,600 208 2,107 660 781 287 36,066 389 1,502 1,116 500 313 1,856 509 238 1,525 44,985 1,600 986 240 800 318 1,256 163 18,521 375 1,812 3,640 400 352 308 442 Estimates of Single Male Circular Migrants in Uttar Pradesh 39

47. 11.97 million people are migrants in Maharashtra

48. Most of the migrants are from UP Source: Behavioral Surveillance Survey, Maharashtra, 2009

49. Allahabad, Gorakhpur, Varanasi, Jaunpur, Sultanpur, Kanpur, Faizabad, Pratapgarh, Mughal Saray, Sant Kabir Nagar, Sardar, Azamgarh, Faijabad, Basti, Siddharth Nagar & Lucknow

50. Challenges and Opportunities Gaps: Being low prevalent state, the number of HSS, ICTC and PPTCT sites are low The quality of services statistics in recording and reporting needs improvement in terms of Consistency Completeness Correctness Changes: Recently attention has been laid on data quality and data use Data Triangulation Exercise Capacity building of all level of staff are being done

51. Programmatic response to combat HIV/AIDS in Uttar Pradesh

52. National AIDS Control Programme Phase III (NACP III) Goal: Halt and reverse the epidemic in India over the next five years Specific Objectives: Reduce new infections by 60% in high prevalence states 40% in vulnerable states

53. NACP III - Four pronged strategy Prevent new infections Increase proportion of PLHA receiving care, support, and treatment Strengthen capacity at district, state and national levels Build strategic information management systems

54. Strategic shift from NACP II to NACP III NACP III NACP II Aims toshift the focus from raising awareness to behavior change Through interventions, particularly for groups at a high risk of contracting and spreading HIV Aims at saturation of coverage of the core target population (80%) Guiding Principles: 3 Ones principle Evidence-based planning A & B districts – more focus Decentralization

56. Integrated Counselling and Testing including PPTCT

57. STI care

58. IEC and social mobilisation

59. Mainstreaming

60. Targeted Interventions (TIs)

61. STI care

62. Condom promotion

63. Enabling environment

64. ART

65. HIV-TB co-ordination

66. Treatment of OIs

67. CCCs

68. Post-Exposure Prophylaxis (PEP)

69. HIV Sentinel Surveillance

70. Behavioural Surveillance

71. Monitoring and Evaluation

72. Operations research

73. DAPCU

74. Technical resource groups

75. Enhanced HR at NACO, SACS and districts

78. Urban to rural areas

79. Adults to vulnerable youth

81. Involving a large number of donors /key stakeholders

82. Avoiding program overlaps and duplication

83. Strengthening capacities in states, districts

85. UPSACS - HIV/AIDS related services and Interventions

87. HIV/AIDS related messages on Meghdoot Postcards (15 lakh)

89. 200 Gram Sabha Meetings in Banda and Deoria

90. 70 folk troupes trained

92. Sensitization of RJs and other staffs of Radio City, Radio Mirchi, Big FM

95. 30 hoardings installed and 30 wall writings done

96. 52 wall writings by Gram Pradhans – free of cost

99. Rally on 1 Dec, 09 with support of CMO, Lko. Approx. 7000 participants

100. Inter Colleges street play competition with support of IIM,LKO

101. Awareness campaign in slums with support of Rotary Club and Lucknow University

103. Activities in Kanpur IIT, Antaragini 09. Approximate 350 youth get tested themselves in Antaragini.

106. Antyodaya Anna Yojana / BPL card for PLHIV in all dist

107. Bar Association in 3 districts providing free legal aid to HIV+

108. NREGA providing employment to HIV+ without stigma

109. 1 orphanage functional in Lucknow for PLHIV and children.

110. Grievance redressal mechanism in UPNP+ active

111. Govt. officials oriented on HIV in 15 districts

112. PRI members trained in 5 districts (1700 Nos)

113. 2059 ASHA & 2176 AWW trained in 5 ‘A’ category districts

114. 56 Pradhans did wall paintings from their development funds

116. District Wise Distribution of *Core Tis –Uttar Pradesh LEGEND - Distribution of Core TIs FSW MSM & IDU FSW & MSM FSW & IDU FSW (F) IDU (I) MSM (M) Nos. in circles indicates no. of Tis in the respective district Saharanpur Bijnor Muzaffarnagar Meerut I-350 Baghpat 1 1 JP Nagar Rampur 3 Ghaziabad Moradabad I-200 1 Pilibhit (F-500 +M-600 +I-500) GB Nagar (F-500+M-1000+I-200) 2 Bareilly I-250 Bulandshahar Lakhimpur Kheri Budaun Shahjahanpur I-500+I-200 Aligarh Sharwasti Sant Kabir Nagar Bahraich Etah Balrampur Hathras 2 Mathura Sitapur Farrukhabad Siddharthnagar Hardoi Maharajganj F-500+M-300 1 3 Firozabad 1 Gonda Mainpuri Kannauj Kusinagar F-250 Agra 1 Bara Banki 4 Basti F-300+I-250 Etawah Gorakhpur I-750 Lucknow Faizabad Unnao (F-500+M-350+I-300) 1 I-200 Ambedkar Nagar F-250 Kanpur Nagar Auraiya Deoria Kanpur Dehat Rae Bareli F-250 1 1 Sultanpur Jalaun Mau M-550 2 Azamgarh Ballia I-250 Pratapgarh Fatehpur 1 1 M-200 Jaunpur 1 1 Hamirpur Jhansi Ghazipur F-500 Banda I-200 Varanasi Kaushambi Mahoba Bhadohi (F-500+M-400+I-500) 3 Allahabad Chitrakoot 4 Chandauli 1 Mirzapur Lalitpur F-250 (F-500+M-900+I-500+F-250) Total Nos. Of Core Tis 37 (FSW 13, MSM 8, IDU 16) Sonbhadra

117. District Wise Distribution of FSWs Reached & Mapped Saharanpur Legend - Based on FSWs reached Nos. in colour indicates FSWs reached No. Tis in the districts Up to 199 200 to 299 300 to 399 400 & more Nos. in colour indicates FSWs mapped Muzaffarnagar Bijnor Moradabad Meerut JP Nagar Rampur Bagpat Pilibhit Ghaziabad Bulandshahar Bareilly Budaun GB Nagar Bahraich Sant Kabir Nagar Aligarh Lakhimpur Kheri Sharwasti Mathura Shahjahanpur Balrampur Hathras Etah Siddharthnagar Farrukhabad Sitapur Maharajganj Firozabad Hardoi Agra Kannauj Bara Banki Gonda Gorakhpur Unnao Basti Kusinagar Faizabad Lucknow Auraiya Etawah Ambedkar Nagar Deoria Rae Bareli Sultanpur Kanpur Dehat Mau Kanpur Nagar Azamgarh Jaunpur Pratapgarh Ballia Jalaun Fatehpur Hamirpur Jhansi Ghazipur Allahabad Bhadohi Varanasi Mahoba Kaushambi Banda Mirzapur Chitrakoot Chandauli Lalitpur Sonbhdra TSU, UPSACS

118. District Wise distribution of MSMs Reached & Mapped Saharanpur Legend - Based on MSMs reached Nos. in colour indicates MSMs reached No. Tis in the districts Up to 199 200 to 299 300 to 399 400 & more Nos. in colour indicates MSMs mapped Legend - No. Tis in the districts <=200 <=300 <=400 >400 Muzaffarnagar Bijnor Moradabad Rampur Meerut JP Nagar Bagpat Ghaizabad Pilibhit Bulandshahar Bareilly Budaun Shahjahanpur GB Nagar Bahraich Aligarh Lakhimpur Kheri Sant Kabir Nagar Sharwasti Sitapur Mathura Balrampur Etah Hathras Farrukhabad Maharajganj Siddharthnagar Mainpuri Firozabad Hardoi Agra Gonda Kannauj Kusinagar Gorakhpur Basti Unnao Bara Banki Etawah Kanpur Dehat Faizabad Lucknow Auraiya Ambedkar Nagar Deoria Jalaun Sultanpur Kanpur Nagar Rae Bareli Pratapgarh Mau Ballia Azamgarh Kaushambi Fatehpur Jaunpur Jhansi Hamirpur Ghazipur Allahabad Bhadohi Banda Varanasi Mahoba Chitrakoot Mirzapur Chandauli Lalitpur Sonbhadra TSU, UPSACS

119. District Wise distribution of IDUs Reached & Mapped Saharanpur Legend - Based on IDUs reached Nos. in colour indicates IDUs reached No. Tis in the districts Up to 199 200 to 299 300 to 399 400 & more Nos. in colour indicates IDUs mapped Muzaffarnagar Bijnor Moradabad Bagpat Meerut Rampur JP Nagar Ghaziabad Pilibhit GB Nagar Bulandshahar Bareilly Budaun Shahjahanpur Bahraich Aligarh Lakhimpur Kheri Sant Kabir Nagar Mathura Sitapur Balrampur Hathras Sharwasti Etah Farrukhabad Siddharthnagar Maharajganj Hardoi Firozabad Bara Banki Mainpuri Agra Gonda Kusinagar Kannauj Gorakhpur Basti Etawah Unnao Kanpur Dehat Faizabad Lucknow Ambedkar Nagar Auraiya Jalaun Sultanpur Deoria Rae Bareli Mau Kanpur Nagar Pratapgarh Ballia Azamgarh Kaushambi Fatehpur Jaunpur Hamirpur Jhansi Ghazipur Allahabad Banda Bhadohi Varanasi Mahoba Mirzapur Chitrakoot Chandauli Sonbhadra Lalitpur TSU, UPSACS

120. District Wise Distribution of HRGs Reached& Mapped Saharanpur Legend – Nos. in colores indicates HRGs reached Up to 500 501 - 750 751 - 1000 More than 1000 Nos. in colores indicates HRGs mapped Bijnor Muzaffarnagar Moradabad Meerut Rampur Baghpat Pilibhit Ghaziabad Bareilly JP Nagar Lakhimpur Kheri Shahjahanpur Bulandshahar GB Nagar Bahraich Aligarh Budaun Etah Sharwasti Sant Kabir Nagar Balrampur Sitapur Mathura Hardoi Hathras Farrukhabad Maharajganj Siddharthnagar Mainpuri Bara Banki Firozabad Gonda Agra Kannauj Gorakhpur Basti Kanpur Nagar Etawah Kusinagar Faizabad Lucknow Unnao Auraiya Ambedkar Nagar Rae Bareli Deoria Kanpur Dehat Sultanpur Mau Pratapgarh Ballia Jalaun Fatehpur Azamgarh Jhansi Banda Hamirpur Ghazipur Jaunpur Kaushambi Varanasi Mahoba Bhadohi Allahabad Chitrakoot Chandauli Mirzapur Lalitpur Sonbhadra

121. ICTC Govt. ICTC: 250 PPP-ICTC: 27 Mostly ICTCs are in District Hospitals and in Medical Colleges In ‘A’ category districts up to sub-district level

122. Saharanpur Legend - Up to 100 101 - 300 301 – 500 501 - 1000 1001 - 3000 More than 3000 Muzaffarnagar Bijnor Baghpat Moradabad Meerut JP Nagar Rampur Ghaziabad Pilibhit Gautam Buddha Nagar Bareilly Bulandshahar Lakhimpur Kheri Budaun Sant Kabir Nagar Shahjahanpur Bahraich Aligarh Sharwasti Etah Mathura Balrampur Sitapur Hathras Farrukhabad Maharajganj Siddharthnagar Hardoi Firozabad Agra Mainpuri Gonda Agra Kannauj 3570 Kusinagar Bara Banki Basti Lucknow Etawah Gorakhpur Faizabad Unnao Auraiya 5016 Kanpur Dehat 4267 Deoria Ambedkar Nagar Sultanpur Rae Bareli Jalaun Kanpur Nagar Azamgarh Mau Ballia Pratapgarh Fatehpur Jaunpur Hamirpur Ghazipur Jhansi Kaushambi Banda Bhadohi Varanasi Mahoba 8788 Allahabad Chandauli Chitrakoot 4084 Mirzapur Lalitpur Total no. of persons tested HIV Positive 44212 (2002-Aug. 2008) Sonbhadra Cumulative number of persons tested HIV positive in ICTC 2002-2009 Total no. of test found HIV Positive = 55,596

123. Persons tested in ICTCs General Clients 1992 - 2009

124. No. of Tests HIV+ in ICTCs and Sero-positivity 2005 – 2010

125. Persons tested in ICTCs Pregnant Women 2005 - 2009

126. STI Total SACS supported STI clinics: 86 In District Hospitals and in Medical Collges Medicine kits received from NACO and distributed through STI Clinics Doctors, paramedic and counselors trained Private Health Care Providers (TI-NGOs) trained - 353

127. Basic Services - STI STI attendance and treatment 2005-2010

129. Initiated Condom distribution through Fair Price shops in 10 districts & distributed 147658 pcs of condom.

131. NACO supported Blood Bank: 68

132. Private Blood Bank: 106

133. Military Blood Bank: 8

134. DLBB: 44

135. MBB with BCSU: 14

136. MBB without BCSU: 6

138. AnnualRegistrations in HIV-care - 2005 to 2010 Total Registered till July 2010 – 32,760 Alive and on ART till July 2010– 13,018

139. Number of Patients registered on ART from different district Up to March 2009 Saharanpur Legend - Up to 100 101 - 300 301 – 500 501 - 1000 More than 1000 Muzaffarnagar Bijnor Baghpat Moradabad Meerut Rampur JP Nagar Ghaziabad Pilibhit Gautam Buddha Nagar Bareilly Bulandshahar Lakhimpur Kheri Budaun Sant Kabir Nagar Shahjahanpur Bahraich Aligarh Sharwasti Mathura Etah Sitapur Hathras Balrampur Farrukhabad Hardoi Siddharthnagar Maharajganj Gonda Mainpuri Firozabad Bara Banki Agra Kusinagar Kannauj Basti Lucknow Gorakhpur Etawah Unnao Faizabad Auraiya Ambedkar Nagar Deoria Rae Bareli Sultanpur Kanpur Nagar Kanpur Dehat Jalaun Mau Azamgarh Ballia Pratapgarh Fatehpur Jaunpur Ghazipur Hamirpur Jhansi Banda Kaushambi Varanasi Allahabad Mahoba Bhadohi Chandrali Chitrakoot Mirzapur Lalitpur Sonbhadra Total number of persons registered in HIV Care 17885 ART Centre ‘A’ Category District * Note: Total no. of patients registered in HIV care up to march 09 is 18447 (from CMIS), out of these, 562 patients registered in HIV care but no specification about districts/origin. TSU, UPSACS

140. No. of Patients registered on ART From Different District Up to March 2010 Saharanpur 110 Bijnor 169 Muzaffarnagar 266 Bagpat 106 Rampur 64 Meerut 893 Moradabad 169 JPNagar 72 Gaziabad 358 Pilibhit 26 Bareilly 108 Gautam Buddha Nagar 39 Buland Shahar 178 Lakhimpur Kheri 53 Sant Kabir Nagar 673 Badaun46 Shahjahanpur 49 Aligarh 350 Bhraich 141 Sarawasti 65 Sidharthnagar 631 Hathras 210 Sitapur 84 Mathura 275 Etah 144 Farrukhabad 42 Balrampur 349 Maharajganj 626 Mainpuri 53 Hardoi 43 Gonda 417 Firozabad 170 Kannuaj 68 Kusinagar 829 Agra 1091 Bara Banki 132 Etawah 86 Lucknow 472 Basti 747 Unnao 258 Auraiya 41 Faizabad 262 Kanpur Nagar 515 Gorkhpur 1808 Kanpur Dehat 0 A.N.Nagar 285 Sultanpur 544 Deoria 1238 Rai Bareli 254 Mau 433 Azamgarh 1219 Jalaun 88 Fatehpur 178 Pratapgarh 1048 Gazipur 644 Hamir Pur 41 Jhansi 66 Ballia 434 Varanasi 858 Jaunpur 1505 Kaushambi 215 Banda 148 Allahabad 1734 Mahoba 13 Chandauli 241 Chitrakoot 89 Mirzapur 299 Lalit Pur 24 Sonbhadra 152 25238

141. Cumulative no. of Persons on ART – District wise 13018

142. Persons on ARTAdded every year 2005 - 2010

143. Support to UPSACS and TSU by FHI/USAID SAMARTH project HRG Mapping and BSS-2009 Training of Govt. Health Care Providers across 71 districts within a short period – 2009 and 2010 Training of UPSACS and TSU staff on Documentation Coordination and facilitation of UPSACS Classroom training and exposure visit Annual report preparation Developing at least one TI in each region which demonstrate good quality program interventionsand process documentation to develop these TIs as learning sites Data Triangulation Developing two Districts Gorakhpur and Agra as learning sites for district-level HIV service decentralization.

144. AAP and % Funds Utilization(Fiscal Year wise 2005 - 2010)

145. Gaps Identified Awareness about disease still low Stigma still persists, though situation is better Awareness about testing and care facilities still low Wide gap between estimates and actual tested Wide gap between tested and enrolled in care Target populations yet to be reached fully

146. Gaps Identified Care and support activities need to be expanded Home based care to be increased Reach for PPTCT can be increased- social and cultural barriers Issues related to Nutrition Outreach activities for patients LFU / Missed Reaching out to young and too young Issue of orphans, infected and affected children

147. Thank You