Comment on NACO by the Parliamentary standing committee on Health and Family We

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PARLIAMENT OF INDIA

RAJYA SABHA

DEPARTMENT-RELATED PARLIAMENTARY STANDING COMMITTEE ON HEALTH AND FAMILY WELFARE

TWENTY-SECOND REPORT

ON

DEMANDS FOR GRANTS 2007-2008 (DEMAND NO. 46) OF THE DEPARTMENT OF HEALTH AND FAMILY WELFARE

(MINISTRY OF HEALTH AND FAMILY WELFARE)

(PRESENTED TO THE RAJYA SABHA ON 3rd May, 2007)

(LAID ON THE TABLE OF LOK SABHA ON 3rd May, 2007)

RAJYA SABHA SECRETARIAT

NEW DELHI

May, 2007/Vaisakha, 1929 (SAKA)

XVII NATIONAL AIDS CONTROL PROGRAMME

17.1 The AIDS epidemic has become a major health and development concern. Although India remains a low prevalence country with overall HIV prevalence of 0.9 percent, the last few years have seen it moving from high risk groups to the general population with women, youth and the rural population being highly vulnerable.

17.2 According to the Sentinel Survey figures released in 2005, total number of HIV infected people amongst the adult population (15-49 years) numbered 5.206 million. Consequently a mere 0.1 percent increase in prevalence, translates into 0.5 million new infections. India accounts for nearly 13 percent of the global HIV prevalence. The categorization of the country as a low prevalence country hides the large numbers of HIV infected people.

17.3 Sexual transmission is driving India's AIDS epidemic, accounting for approximately 86 percent of HIV infections. The remainder 14% are through, Parent-to-child transmission, use of infected syringes and needles by Injecting Drug Users (IDU), and contaminated blood transfusion etc.

17.4 Presently Phase-III of National AIDS Control Programme (2006-2011) is being implemented NACP-III seeks to implement the principle of a continuum of care. Accordingly, prevention will go hand in hand with access to prophylaxis, management of opportunistic infections and ART. Given the spread of HIV infection into rural areas, NACP–III will further decentralize its organizational structure to implement programmes at the district level. The basic unit of implementation will now be the district. Accordingly, based on the epidemiological and vulnerability criteria, all the 610 districts in the country have been classified into four categories: Category A–141 districts – high prevalence; Category B–46 districts – concentrated epidemic; Category C–309 districts – increased presence of vulnerable population and Category D–114 districts – low/unknown vulnerability.

17.5 The categorization of districts based on vulnerability is useful for enabling the Government to prepare plans that are need based. Accordingly, differential packages of services have been developed for each category of districts. Institutional arrangements and capacities of the SACS as well as the proposed District AIDS Prevention and Control Units (DAPCUs) will be strengthened. To address special vulnerabilities of the North-Eastern States, a Regional AIDS Control Unit (RACU) will be established as a sub-office of NACO but embedded in the governance structure of NRHM. NACP–III has also developed an HRD plan to continuously update and improve the competency and skills of the programme personnel.

17.6 NACO has launched National Paediatric AIDS initiative on 30th November, 2006 to provide comprehensive care & support (including ART) to children infected and affected by HIV/AIDS. NACO, along with the Indian Academy of Paediatrics (IAP), UNICEF, WHO and Clinton Foundation, has developed guidelines for pediatric ART including diagnosis in children. Paediatric drugs formulations as per weight bands for treating 10,000 children in the current year have been provided to the ART centres. Other activities under this initiative include establishment of seven regional Paediatric Centres, free CD4 monitoring, free DNA PCR test for children up to 18 months, liquid formulations for babies weighing less than 5 kg, diagnosis and treatment of opportunistic infection and micro nutrient supplementation.. The initiative also includes training of paediatricians and counselors. The Committee would like to be apprised of the achievements made vis-à-vis the targets fixed under National Paediatric AIDS Initiative .

17.7 The Department in its Annual Report has informed that care and support for CLHA (Children Living with HIV/AIDS) orphans and vulnerable children forms an integrat part of NACP-III. A comprehensive service package for these children will be funded under GFA-RD-VI and will be offered through home and foster based care and support services in 2007. The Committee recommends the Department to inform about the specific steps taken and the progress made in this regard.

17.8 One of the most important components of the National AIDS Control Programme (NACP-II) is the Targeted Intervention (TI) projects that aim to interrupt HIV transmission among highly valnerable populations. These population groups are at a greater risk of acquiring and transmitting HIV infection due to more frequent exposure to HIV, higher levels of risky behaviour and insufficient capacity or power to make decisions and take appropriate action to protect themselves. Such population groups include- commercial sex workers, injecting drug users, men who have sex with men (MSMs), truckers, and migrant workers. The following table reveals the estimated size and estimated coverage of these High Risk Groups.

Sl. N.

High Risk Group

Estimated Size

Estimated coverage

Percent coverage

1.

Sex Worker

8,31,677-12,50,115

5,88,777

55%

2,

IDUs

96,463-1,89,729

1,02,344

53%

3.

MSM

23,52,113

1,46,397

6.0%

4.

Male sex Workers

2,35,213

17.9 The Committee is deeply disturbed to note that all the High Risk Groups have not yet been covered under the Target Intervention Project. The situation is worse in the case of MSM where the percentage coverage is only 6% and Male Sex Workers in respect of whom either the Department do not have the figures of estimated coverage or they are simply not covered at all. The Committee, therefore feels that much ground needs to covered by the Department so far as targeted intervention is concerned. The Committee, therefore, recommends to the Department to double its efforts to bridge the gap between estimated size and estimated coverage.

17.10 Condom promotion has important role to HIV prevention. Behavioral Surveillance Survey (BSS) end line 2006 shows a significant increase in consistent condom use from 32.4 per cent in 2001 to 49.7% in 2006 among those who had sex with any non-regular sex partners in the previous 12 months. Condom use reported during the last sexual intercourse with any non-regular from 40% in 2001 to 58% in 2006. Awareness about condoms increased from 77% to 82% during the last five years. About 65% of respondents during the end line BSS were aware that consistent condom use could prevent transmission of HIV/AIDS, which is an increase of 15% since 2001. Accessibility of condoms within 30 minutes from the nearest source, which is one of the key determinants for condom use, increased from 46% to 81%. In 2001-02 fiscal year, the distribution of condoms under free supply and social marketing was 733 million pieces and 438.79 million pieces respectively. In 2006-07, the distribution has increased to 1250 million pieces and 593 million pieces under free supply and social marketing, respectively. Under NACP-III, the objective is to increase condom use to 3.5 billion pieces per annum by the year 2009 from the present level of about 1.8 billion per annum, through intensive demand generation and supply efforts with support from a Technical Support Group (TSG) to be constituted by NACO with support from the Bill & Melinda Gates Foundation.

17.11 The Committee is appreciative of the fact that use of condoms and its awareness as a preventive weapon to fight AIDS has increased over the years. The Committee, however, notes that use of condoms amongst those who had sex with any non-regular sex partner is still 49.7% which is considered to be low. Since having many sex partners or changing sex partners frequently increases the vulnerability towards AIDS, the Committee recommends to the Department to take effective steps to increase the use of condom amongst this group.

17.12 The Department has informed that in order to reiterate the Government's commitment to prevent the spread of HIV and to facilitate a strong multi-sectoral response to combat it effectively, a National Council on AIDS (NCA) headed by the Prime Minister of India provides the leadership at the national level. 31 Ministries, chief Ministers of select states, representatives of the private sector, civil society and NGOs are members of NCA. Under the directions of the NCA, efforts have commenced to build a multi sectoral response by involvement and participation of the private sector, civil society and key Government Departments. The Committee recommends to the Department to finalize the modalities of the proposed multi-sectoral response and inform the Committee accordingly.

17.13 The Department in the Outcome Budget has informed about the following priorities for programme activities under the NACP during the financial year 2007-08.

(i) Saturation of coverage of high risk groups through Targeted Interventions by upscalling of interventions and increase to the total number of intervention up to 1300.

(ii) Providing greater care & support and treatment services to larger number of People Living with HIV/AIDS through:

· Expansion of Anti-retroviral Treatment, Care and Support to cover the entire country under GFATM Round VI (Project Approved)

· Expansion of ART services through hospitals in other sectors (Railways, ESI, Army etc. ), PSUs, Corporate Hospitals and NGOs.

· It is also planned to upscale from existing 96 ART centres to 120 centers by March 2007 and to provide free ART to 100,000 patients by end 2007 and 300,000 patients by 2012.

(iii) In order to improve access to safe blood, 3070 Blood Storage Centres will be established. The equipment grant for these centres will be provided through NRHM, while NACO will provide training and annual recurring grant as well as the transport facilities for transportation of blood to these Storage Centres. It is also envisaged to initiate the process of establishment of Centre of Excellence in four Metropolitan Cities, one Plasma Fractionation Centre and one Model Blood Bank (in each of the States). The voluntary blood donation will be augmented to more than 65% of the total blood collection in the next financial year.

(iv) The ICTCs and basic services facilities will be extended to Community Health Care level in the country to ensure access to rural population.

(v) Establishing nation-wide Management Information System for effective monitoring of the programme.

(vi) Instituting a mechanism of quality assurance programme in Blood Banks, ICTCs and CD4 laboratories in the country.

(vii) Establish additional Community Care Centres to ensure provision of psycho-social support, outreach services, referrals and palliative care to People Living with HIV/AIDS.

(viii) The major IEC activities to be taken up during the next FY will include:

a. Saturating the mass media channels for disseminating messages on HIV/AIDS.

b. Special programmes on TV and Radio focusing on women and youth

c. Expanding inter-personal communication through units of Directorate of Field Publicity, Song & Drama Division, holding of Advocacy and sensitization workshops.

d. Utilization of existing service centres as communication nodes.

(ix) Strengthening the efforts for mainstreaming and partnership to ensure effective multi-sectoral response from various departments, ministries, other stakeholders, private sector, civil society organizations and PLHA network for effective prevention programmes and service delivery.

(x) Initiate various activities under `Social Marketing of Condoms' for more intensified action.

17.14 The Committee appreciates that the Department has prioritised a number of activities for financial year 2007-08. The Committee is convinced that if tangible progress is achieved towards implementation of the targets set, National AIDS Control Programme will achieve significant sucess. The Committee, therefore, recommends to the Department to inform it about the progress made towards achieving the targets set.

17.15 As per media reports, out of 47000 patients receiving anti-retroviral treatment (ART) under the National AIDS Control Programme, about 3000-5000 patients have become resistant to the treatment. Such patients need second-line treatment which is too costly. In reply to a query whether, the Department/NACO has formulated any scheme to take care of patients, who have developed resistance to first line of ART the following reply was submitted by the Department:-

"The initiation of second line of ART drugs is fraught with a number of operational difficulties and technical issues. We had been able to roll out and stabilise the first line of ART treatment to 60,000 patients after a considerable effort and the launch of the 2nd line drugs would require a far more intensive effort. It has been decided that the rollout of 2nd line ART drugs would be considered only after the coverage of 1 lakh persons is reached".

17.16 The Committee feels that it is highly insensitive and in-human to delay the availability of second line of drugs to the patients till the figure of the first line of ART treatment has 1 lakh patients. The present policy is sure to aggravate the sufferings of already traumatized patients. The Committee, therefore, recommends to the Department to take some initiative towards starting the second line of treatment so that the sufferings of drug resistant patients can be lessened to some extent.

17.17 The Department has informed that in the meeting of the 26th National AIDS Control Board held on the 4th October 2006, it was recommended to create one post of Counsellor for all the major blood banks in the Government sector supported by NACO. These Counsellors will provide the pre and post test counselling to the HIV sero-reactive blood donors along with confirmatory testing for HIV. The Committee would like to be informed about the actual progress made in the matter of appointing Counselors.

17.18 The Department in reply to a question has submitted that at present 107 ART Centres are operational which will be increased to 250 centres by the end of Eleventh Plan. The Committee would like to be apprised of the year-wise target set for establishing ART Centres during the Plan period and also the progress made in this regard during 2007-08.

17.19 The Committee observes that during the Tenth Plan, there has been optimum utilization of allocated funds for NACP. However, 2006-07, the last year was an exception. The Committee is constrained to note that against a provision of Rs. 705.67 crores, actual expenditure reported upto 15th February, 2007 was only Rs. 578.65 crores. The Committee finds that optimum utilization of funds have not happened in respect of even a single of the five components of the NACO. Such low utilization of funds in the opinion of the Committee will not help in arresting the spread of this dreaded disease in this country. The Committee, therefore, recommends that the Department immediately initiate prompt action towards removing the bottlenecks coming in the way of optimal utilization of allocated funds and apprise the specific action taken, to it.

17.20 The Committee is more disturbed by the level of achievement under some of the very crucial physical targets during 2006-07 as indicated below:-

Component (2006-07)

Target

Achievement

Modernization of District Level Blood Banks

39

-

STD Clinics

200

68

Targeted Interventions

350

126

New School to be covered SAEP School AIDS Education Programme

68,000

17,000

What is move worrisome is that under achievement was reported under these targets during 2005-06 also. The Committee notes that similar targets have been set under different components for 2007-08 also. The Committee is constrained to observe that the target of setting up STD clinics, targeted interventions, and new schools to be covered under school AIDS Control Programme have fallen woefully short of the targets. The Committee feels that setting up of only 68 STD clinics against the target of 200, and making only 126 targeted interventions against the target of 350 will have grave future implications. Similarly meeting only a quarter of target of covering 68,000 schools under the school AIDS programme amounts to denying the much required sex education to a large number of adolescent pupils which would have helped them in receiving knowledge about safe sex practices. The Committee, therefore, recommends to the Department to make all efforts to achieve the previous years targets.

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