National AIDS Control Programme (NACP)

Genesis and Growth

India’s response to the HIV/AIDS epidemic was initiated in the form of sero-surveillance in 1985. While initial responses (1985-1991) focused on search of HIV in different population groups and locations, screening of blood before transfusion, and targeted awareness generation; the launch of National AIDS and STD Control Programme (NACP) in 1992 institutionalized beginning of a comprehensive response to the HIV/AIDS epidemic in India. Thirty-five years since then, NACP has evolved as one of the world’s largest programmes through five-distinct phases.

India’s AIDS Control Programme is globally acclaimed as a success story. The National AIDS Control Programme (NACP), launched in 1992, is being implemented as a comprehensive programme for prevention and control of HIV/AIDS in India. Over time, the focus has shifted from raising awareness to behavior change, from a national response to a more decentralized response and to increasing involvement of NGOs and networks of PLHIV.

In 1992, the Government launched the first National AIDS Control Programme (NACP-I) with an IDA Credit of USD84 million and demonstrated its commitment to combat the disease. NACP-I was implemented with an objective of slowing down the spread of HIV infections so as to reduce morbidity, mortality and impact of AIDS in the country. National AIDS Control Board (NACB) was constituted and an autonomous National AIDS Control Organization (NACO) was set up to implement the project. The first phase focused on awareness generation, setting up surveillance system for monitoring HIV epidemic, measures to ensure access to safe blood and preventive services for high risk group populations.

The first phase of NACP (1992-1999) focussed on awareness generation and blood safety. The second phase witnessed launch of direct interventions across the prevention-detection-treatment continuum with capacity building of States on programme management. The third phase (2007-2012) was story of scale-up with programme management decentralised up to the district level. The fourth phase (2012-2017) was a period of consolidation and enhanced Government funding.

In November 1999, the second National AIDS Control Project (NACP-II) was launched with World Bank credit support of USD 191 million. The policy and strategic shift was reflected in the two key objectives of NACP-II: (i) to reduce the spread of HIV infection in India, and (ii) to increase India’s capacity to respond to HIV/AIDS on a long-term basis. Key policy initiatives taken during NACP-II included: adoption of National AIDS Prevention and Control Policy (2002); Scale up of Targeted Interventions for High risk groups in high prevalence states; Adoption of National Blood Policy; a strategy for Greater Involvement of People with HIV/AIDS (GIPA); launch of National Adolescent Education Programme (NAEP); introduction of counseling, testing and PPTCT programmes; Launch of National Anti-Retroviral Treatment (ART) programme; formation of anointer-ministerial group for mainstreaming; and setting up of the National Council on AIDS, chaired by the Prime Minister; and setting up of State AIDS Control Societies in all states.

In response to the evolving epidemic, the third phase of the National AIDS Control Programme (NACP-III) was launched in July 2007 with the goal of Halting and Reversing the Epidemic by the end of project period. NACP was a scientifically well-evolved programme, grounded on a strong structure of policies, programmes, schemes, operational guidelines, rules and norms. NACP-III aimed at halting and reversing the HIV epidemic in India over its five-year period by scaling up prevention efforts among High Risk Groups (HRG) and General Population and integrating them with Care, Support & Treatment services. Thus, Prevention and Care, Support & Treatment (CST) form the two key pillars of all the AIDS control efforts in India. Strategic Information Management and Institutional Strengthening activities provide the required technical, managerial and administrative support for implementing the core activities under NACP-III at national, state and district levels.

National AIDS Control Programme (NACP IV) 

Component 1: Intensifying and Consolidating Prevention services with a focus on HRG and vulnerable populations

This component will support the scaling up of TIs with the aim of reaching out to the hard to reach population groups who do not yet access and use the prevention services of the program, and saturate coverage among the HRGs. In addition, this component will support the bridge population, i.e. migrants and truckers. Component 1 includes the following two subcomponents:

1.1 Scaling up coverage of TIs among HRG

The interventions under this sub-component will include: (i) the provision of behavior change interventions to increase safe practices, testing and counseling, and adherence to treatment, and demand for other services;(ii) the promotion and provision of condoms to HRG to promote their use in each sexual encounter; (iii) provision or referral for STI services including counseling at service provision centers to increase compliance of patients with treatment, risk reduction counseling with focus on partner referral and management; (iv) needle and syringe exchange for IDUs as well as scaling up of Opioid Substitution Therapy (OST) provision. This sub-component also includes the financing of operating costs for about 25 State Training Resource Centers as well as participant training costs over a period of 5 years.

1.2 Scaling up of interventions among other vulnerable populations

The activities under this subcomponent will include: (i) risk assessment and size estimation of migrant population groups and truckers at transit points and at workplaces; (ii) behavior change communications (BCC) for creating awareness about risk and vulnerability, prevention methods, availability and location of services, increase safe behavior and demand for services as well as reduce stigma;(iii) promotion and provisioning of condoms through different channels including social marketing; (iv) development of linkages with local institutions, both public and NGO owned, for testing, counseling and STI treatment services;(v) creation of “peer support groups” and “safe spaces” for migrants at destination; (vi) establishment of need-based and gender-sensitive services for partners of IDUs; and(vii) strengthening networks of vulnerable populations with enhanced linkages to service centers and risk reduction interventions, specifically condom use.

Component 2: Expanding IEC services for (a) general population and (b) high risk groups with a focus on behavior change and demand generation

IEC has been an important component of the NACP. With the expansion of services for counseling and testing, ART, STI treatment and condom promotion, the demand generation campaigns will continue to be the focus of the NACP-IV communication strategy. IEC will remain an important component of all prevention efforts and will include:

• Behavior change communication strategies for HRGs, vulnerable groups and hard to reach populations
• Increasing awareness among general population, particularly women and youth.

Component 3: Comprehensive Care, Support and Treatment

NACP IV will implement comprehensive HIV care for all those who are in need of such services and facilitate additional support systems for women and children affected and infected with HIV / AIDS. It is envisaged that greater adherence and compliance would be possible with wide network of treatment facilities and collaborative support from PLHIV and civil society groups. Additional Centers of Excellence (CoEs) and upgraded ART Plus centers will be established to provide high-quality treatment and follow-up services, positive prevention and better linkages with health care providers in the periphery.

With increasing maturity of the epidemic, it is very likely that there will be greater demand for 2nd line ART, OI management. NACP IV will address these needs adequately. It is proposed that the comprehensive care, support and treatment of HIV/AIDS will inter alia include: (i) anti-retroviral treatment (ART) including second line (ii) management of opportunistic infections and (iii) facilitating social protection through linkages with concerned Departments/Ministries. The program will explore avenues of public-private partnerships. The program will enhance activities to reduce stigma and discrimination at all levels particularly at health care settings.

Component 4: Strengthening institutional capacities

The objective of NACP IV will be to consolidate the trend of reversal of the epidemic seen at the national level to all the key districts in India. Programme planning and management responsibilities will be strengthened at state and district levels to ensure high quality, timely and effective implementation of field level activities and desired programmatic outcomes.

The planning processes and systems will be further strengthened to ensure that the annual action plans are based on evidence, local priorities and in alignment with NACP IV objectives. Sustaining the epidemic response through increased collaboration and convergence, where feasible, with other departments will be given a high priority during NACP IV. This will involve phased integration of the HIV services with the routine public sector health delivery systems, streamlining the supply chain mechanisms and quality control mechanisms and building capacities of governmental and non-governmental institutions and networks.

Component 5: Strategic Information Management Systems (SIMS)

The roll-out of SIMS is ongoing and will be firmly established at all levels to support evidence based planning, program monitoring and measuring of programmatic impacts. The surveillance system will be further strengthened with focus on tracking the epidemic, incidence analysis, identifying pockets of infection and estimating the burden of infection. Research priorities will also be customized to the emerging needs of the program. NACP IV will also document, manage and disseminate evidence and effective utilization of programmatic and research data. The relevant, measurable and verifiable indicators will be identified and used appropriately.

The capacities of State AIDS Control Socities (SACS) and District AIDS Preventionb and Control Units (DAPCUs) have been strengthened. Technical Support Units (TSUs) were established at National and State level to assist in the Programme monitoring and technical areas under National AIDS Control Programme (NACP-IV). A dedicated North-East regional Office has been established for focused attention to the North Eastern states. Strategic Information Management System (SIMS) has been established and nation-wide rolled out across the country. 

The NACP Phase-IV (Extension)

The NACP Phase-IV (Extension) was first approved for the period of 2017-2020 and then further extended for one more year i.e., 2020-21. Several gamechanger initiative were taken during NACP Phase-IV (Extension). The Phase started with the passing of the HIV and AIDS (Prevention and Control) Bill, 2017 and the launch of the ‘Test and Treat’ policy for HIV patients in April 2017. The Bill ensured equal rights for the people infected with HIV and AIDS in getting treatment and prevent discrimination of any kind. The Act came into force in September 2018.  As the ‘Test and Treat’ policy was being scaled-up, the Programme implemented “Mission Sampark” in 2017 to bring back People Living with HIV (PLHIV) who have left treatment after starting ART. ‘Test and Treat’ was complemented by the launch of universal viral load testing for on-ART PLHIV in February 2018.

The year 2020-21 witnessed the onset of the COVID-19 pandemic. The national AIDS response was challenged in the initial months like any other aspect of life. However, the Programme soon took many initiatives turning challenges into opportunities. IT systems were leveraged to enhance programme review and capacity building. This resulted in improved inter and Intra-State coordination. Initiatives like multi-month dispensation and community-based ART refill ensured continuity in service provisions.

National AIDS Control Programme (NACP V) 

Context and formulation of NACP Phase-V

The impact of the national AIDS response has been significant. The annual new HIV infections in India have declined by 48% against the global average of 31% (the baseline year of 2010). The annual AIDS-related mortalities have declined by 82% against the global average of 47% (the baseline year of 2010). The HIV prevalence in India continues to be low with an adult HIV prevalence of 0.22%. Despite the significant achievements and impact, there is no place for complacency given the country's commitment to ending the AIDS epidemic as a public health threat by 2030. HIV remains a national public health priority with new HIV infections happening at a rate highethan the desired level. The annual number of new infections among adults has declined by 48% since 2010, but still has a long way to go to achieve a 90% decline by 2030. The progress on targets of 90-90-90 to be achieved by 2020 has gauzed the country's progress on ending the epidemic. The full realization of 90-90-90 by 2020 would have meant that at least 73% of PLHIV have suppressed viral loads in 2020 cutting down the transmission significantly. At the end of 2020, 78% of PLHIV knew their HIV status, 83% of PLHIV who knew their HIV status were on ART, and 85% of PLHIV on ART were virally suppressed.

The formulation of NACP Phase-V was necessitated by the need for continuous action and the vigil in context of the country commitment on ending of the AIDS epidemic as a public health threat by 2030.  It was initiated in alignment with Fifteenth Finance Commission for 2021-26 of the Government of India. The formulation of NACP Phase-V coincided with formulation of UNAIDS Global AIDS Strategy 2021-2026, WHO Global Health Sector Strategies (GHSS) on HIV, viral hepatitis, and sexually transmitted infections for the period 2022-2030 and The Global Fund cycle of 2021-24. NACP Phase-V takes into account the global contexts, targets and strategies.

Overview of NACP Phase-V (2021-26)

NACP Phase-V is a Central Sector Scheme, fully funded by the Government of India, with an outlay of Rs 15471.94 crore. The NACP Phase-V aims to reduce annual new HIV infections and AIDS-related mortalities by 80% by 2025-26 from the baseline value of 2010. The NACP Phase-V also aims to attain dual elimination of vertical transmission, elimination of HIV/AIDS related stigma while promoting universal access to quality STI/RTI services to at-risk and vulnerable populations.

The specific objectives of the NACP Phase-V are as below:

a. HIV/AIDS prevention and control

i. 95% of people who are most at risk of acquiring HIV infection use comprehensive prevention

ii. 95% of HIV positive know their status, 95% of those who know their status are on treatment and 95% of those who are on treatment have suppressed viral load 

iii. 95% of pregnant and breastfeeding women living with HIV have suppressed viral load towards attainment of elimination of vertical transmission of HIV

iv. Less than 10% of people living with HIV and key populations experience stigma and discrimination

b. STI/RTI prevention and control

i. Universal access to quality STI/RTI services to at-risk and vulnerable populations

ii. Attainment of elimination of vertical transmission of syphilis

Under NACP Phase-V, while the existing interventions will be sustained, optimized, and augmented; newer strategies will be adopted, piloted, and scaled-up under the programme to respond to the geographic and community specific needs and priorities. The HIV and AIDS (Prevention and Control) Act, 2017 will continue to be the cornerstone of the national response to HIV and STI epidemic in NACP Phase-V. The Act will be the enabling framework to break down barriers driving delivery of a comprehensive package of services in an ecosystem free of stigma and discrimination.   

Guiding Principles of NACP Phase-V (2021-26)

Eight guiding principles will be central to strategies and activities to attain the specific targets.

1. Keep beneficiary and community in center
2. Break the silos, build synergies
3. Augment strategic information-driven planning, implementation, monitoring, and mid-course corrections
4. Prioritize and optimize through high-impact programme management and review
5. Leverage technology and innovation as critical enablers
6. Enhance and harness partnership
7. Integrate gender-sensitive response
8. Continue fostering technical arrangements and institutions

Collaboration with public and private sectors

NACP Phase-V will build upon the systematized convergence with the existing schemes of Central Government including synergy with National health programme, related line Ministries as well as State Governments through mainstreaming and partnership extending the reach of various HIV related services in a cost-neutral way. The collaboration framework of NACP Phase-V includes continued strategic engagement with private sector.

Goal 1: Reduce annual new HIV infections by 80%

NACP Phase-V will accelerate reduction in new annual HIV infections through a basket of strategies tailored to the high-risk, at-risk, and low-risk population groups.

1. Continue and evolve the existing peer-led targeted interventions (TI) and Link Worker Schemes (LWS) strategies for integrated services
2. Promote evidence-backed comprehensive prevention packages tailored to location and population
3. Strengthen the population size estimation and field epidemiological intelligence for coverage expansion and saturation
4. Expand and intensify the coverage of NACP interventions including OST among Injecting Drug Users (IDU)
5. Universalize the NACP interventions in prisons and other closed settings through a mix of service delivery models
6. Pilot and scale models for community-based integrated service delivery models
7. Redefine and expand coverage among the bridge population
8. Develop and roll-out new generation communication strategy suitable to current context
9. Cover ‘at-risk’ HIV negative through comprehensive prevention packages to keep them negatives
10. Develop and scale-up sustainable models for ‘at-risk’ Virtual Population
11. Maintain and augment the behavior change communications for general population
12. Sustain focus on adolescent and youth population

Goal 2: Reduce AIDS-related mortalities by 80%

NACP Phase-V will build upon the strong momentum from previous phases and further accelerate the reductions on AIDS-related mortalities through strategies directed across care continuum.

1. Maintain the existing models of HIV counselling and testing services (HCTS) and expand through strategic scale-up
2. Develop and roll-out tailored communication campaigns focusing on risk perception and HCTS uptake
3. Augment the existing HCTS models with efficient approaches for active case findings promoting early detections
4. Appropriately adapt evidence-backed newer technologies to supplement existing models
5. Maintain existing care, support, and treatment (CST) services models and expand further through sustainable manner
6. Continue provisions of high-quality ARVs through differentiated service delivery models improving through sustainable manner
7. Focus on rapid ART initiation and advanced HIV disease management augmenting quality of care
8. Suitably update the treatment guidelines periodically
9. Address linkage loss at all levels 
10. Optimize the uses of public sector laboratories for viral load measurements
11. Offer integrated service delivery packages to ‘at-risk’ people and PLHIV
12. Prioritize sexual and reproductive health services for women at increased risk of HIV infection and women living with HIV
13. Bring efficiencies and improve linkages through single window service delivery models
14. Maintain and expand laboratory quality assurance system

Goal 3: Eliminate vertical transmission of HIV and Syphilis

The NACP Phase-V takes into the account the global guidance towards elimination of vertical transmission of HIV and Syphilis.

1. Augment comprehensive synergy with NHM for testing of pregnant women for HIV and syphilis
2. Strengthen the primary prevention through coordinated actions
3. Introduce and scale-up dual test kits (HIV & Syphilis) to fast-track progress on the dual elimination
4. Strengthen linkage from screening facilities to confirmatory centers and subsequently to the treatment centers
5. Strengthen retention and on-ART adherence among eligible WLHIV
6. Prioritize family planning services for eligible PLHIV
7. Strengthen the early diagnosis of infants and all children living with HIV (CLHIV)
8. Engage with private sector augmenting their role in attainment of dual elimination
9. Strengthen the strategic information in the context of HIV positive pregnant women/mother
10. Prepare strategic roadmap to guide actions towards attainment of validation of elimination of vertical transmission

Goal 4: Promote universal access to quality STI/RTI services to at-risk and vulnerable populations

NACP Phase-V will reinforce the STI/RTI component not only in terms of elimination of vertical transmission of HIV and syphilis but also to augment access to quality STI/RTI services through maximizing its system and opportunities for shared delivery models.

1. Strengthen the strategic information on STIs
2. Maintain the existing model of Designated STI/RTI Clinics (DSRCs) augmenting the role
3. Develop and implement integrated communication strategies
4. Dovetail dual testing at HCTS centers
5. Promote active case findings facilitating early detections
6. Improve collaboration with NHM on STI/RTI services provisions and reporting
7. Strengthen and streamline private sector engagement on STI/RTI management
8. Suitably update the STI/RTI management guidelines periodically
9. Augment the laboratory capacities
10. Strengthen the supply chain management

Goal 5: Eliminate HIV/AIDS related stigma and discrimination

NACP Phase-V will build upon the gamechanger initiatives of NACP-Phase IV (Extension) to accelerate the progress on elimination of HIV/AIDS related stigma and discrimination.

1. Undertake bottom-up institutionalized community system strengthening
2. Accelerate the notification of State rules and appointment of Ombudsman in the context of the HIV and AIDS (Prevention and Control) Act, 2017
3. Undertake sensitization of related stakeholders on HIV/AIDS related stigma and discrimination
4. Design and implement communication strategy on elimination of HIV/AIDS related stigma and discrimination
5. Enhance strategic information on HIV/AIDS related stigma and discrimination
6. Engage with State governments promoting launch and scale-up of social protection schemes