By M Prasanna Kumar

Each of the three phases of the National Aids Control Programme in India have focused on, or emphasised, different aspects of the HIV epidemic in efforts to contain the spread of the disease

The presence of HIV infection was first detected in India in 1986, when Dr Jacob John and Dr Suniti Solomon identified 10 HIV positive samples out of a group of 102 female sex workers from Chennai. At this time it was believed that India had little to fear from a disease that was then believed to spread primarily through sex between men, through injecting drug use and through multi-partner heterosexual sex. It was felt that this country saw very little of these risk behaviours.

However, soon, a number of surveys done in many urban centres among various groups such as blood donors, female sex workers and injecting drug users revealed that HIV infection was already established among these risk groups in India. It was now necessary to have answers to two essential questions: What was the geographical extent of the infection in India? What are the main routes of transmission of the infection in the country? A chain of 62 AIDS surveillance centres was gradually established nationwide to provide answers to these essential questions. 

Results from these centres indicated that the infection was widespread in the country but as yet limited to those with high risk behaviour or to recipients of infected blood. It had not so far spread into the general community. Second, the main mode of transmission was heterosexual although injecting drug use was predominantly responsible for the epidemic in the northeast. About eight per cent of all infections were related to receiving infected blood or its products. The virus was established in the country; it had already reached a prevalence of 10 per cent among female sex workers in Chennai and was present in regions of the country that were geographically widely apart.

That same year, 1986, the government set up an AIDS Task Force under the Indian Council of Medical Research (ICMR) and established a National AIDS Committee (NAC) chaired by the Secretary, department of Health and Family Welfare.

In 1987, the National AIDS Control Programme (NACP) was initiated, with help from the World Bank, to coordinate the national response to HIV/AIDS.  In the next four years, the programme’s main activity was the screening of the “sexually promiscuous population”, and blood donors, and carrying out some educational programmes.

In 1989, a Medium Term Plan for AIDS Control was developed with the support of the World Health Organisation (WHO). It was funded by WHO, the Swedish International Development Agency (SIDA) and the United States Agency for International Development (USAID), and channelised through WHO. According to NACO’s 1995 Country Scenario Update, this support amounted to US $19 million.

The Medium Term Plan was low key and focused only on Maharashtra, Tamil Nadu, West Bengal, Manipur and Delhi, areas that surveillance data indicated were at high risk of HIV infection. State AIDS Cells were established in these states and awareness activities and some early targeted interventions were field tested. In the rest of the country little took place; the state health departments were expected to carry out surveillance and prevention activities under the coordination of the Director General of Health Services.

Till 1992, the bulk of funds for AIDS-related projects were used for improving blood testing and surveillance facilities. In addition to the 62 surveillance centres, testing facilities were set up for screening transfused blood for HIV to assure the safety of donated blood and prevent HIV infection from this source. ELISA machines and HIV test kits were supplied to blood banks throughout the country.

The National AIDS Control Programme -1

In 1991, several international donors such as the UK Department for International Development (DFID), the Norwegian Agency for Development Cooperation (NORAD), USAID, the Ford Foundation, the International Development Association which is a wing of the World Bank, the United Nations Development Programme (UNDP), and the United Nations Drug Control Programme (UNDCP), expressed their willingness to support the NACP.

Accordingly, the Strategic Plan for Prevention and Control of AIDS in India was developed for the period 1992-97, later described as the first phase of the NACP. (This first phase was extended to 1999 when it was realised in 1997 that barely half of earmarked funds had been utilised.) The final estimated cost of NACP-I was US$27.5 million from the government of India, $2.2 million from WHO, and IDA credit of $84.2 million. (The International Development Agency or IDA provides long term loans of 15-25 years to eligible countries at zero or low levels of interest.)

NACP-I was the first effort in India to develop a national public health programme in HIV/AIDS prevention and control. The aims of the programme were to prevent HIV transmission, decrease the morbidity and mortality associated with HIV infection, and minimise the socio-economic impact of HIV infection.

A National AIDS Committee was established headed by the health minister for overall policy making and overseeing the programme’s performance. The National AIDS Control Organisation (NACO) was established in June 1992 under the Department of Health for implementation of the programme. A National AIDS Control Board was constituted for approval of NACO policies, expediting sanctions and for approval of major financial and administrative decisions. State AIDS Cells (SACs) were constituted in all 32 states and union territories (UT) to implement programme activities locally. The state programme was supported by technical and support staff and used the administrative machinery of the state health departments. However, it was felt that the programme was hindered by administrative and financial bottlenecks. As an experiment, the SACs in Tamil Nadu and Pondicherry were converted into registered societies under the chairmanship of the secretary of health.

NACP-I sought to provide certain services: education campaigns, protection of the blood supply, condom promotion, a system to monitor the prevalence of HIV, treatment for sexually transmitted diseases and limited treatment for AIDS-related conditions. Two components were added later: targetted interventions and “intersectoral collaboration”.

Services of NACP-1
1. Mass “information, education and communication” programmes were launched to create public awareness of HIV/AIDS using various media and aimed at different audiences from the general public to school children. In some ways the NACP took a bold step by starting to talk about sex - the main route of transmission of HIV - in a society which didn't like to talk about such things. Public information campaigns were launched which actually spoke of how HIV infection was acquired - and how it wasn't, through casual contact, for example. Some of the campaigns were based on the ill advised principle of preventing people from behaviour that puts them at risk of HIV infection, by making them afraid of it. It was common to find early awareness messages with fear-provoking images such as skull and crossed bones. Such campaigns were to lead to the long term problems of AIDS phobia and stigma and discrimination of infected people at all levels including at health care facilities.

2. Following a Supreme Court judgment in 1996 on a public interest litigation that called for a revamping of the entire blood collection, processing, storage and distribution system in the country, national and state blood transfusion councils were established, a National Blood Transfusion Policy was formulated and guidelines were issued covering all aspects of blood donation, testing and storage. Blood banks were required to obtain licences to function. The NACP provided funds to states to modernise existing blood banks. Zonal blood testing centres were set up. On the understanding that professional blood donors were more likely to be exposed to sexually transmitted infections such as HIV, and to reduce the risk of unsafe blood from such donors, professional blood donation was banned. To address the gap between supply of and demand for safe blood, component separation units were set up in very large blood banks; these could split a single unit of blood into several components and patients were provided only those components that they needed.

3. Condoms were known to be effective in preventing the transmission of HIV and other STDs. NACP-I sought to popularise the use of condoms, improve their quality and increase their availability. NGOs were engaged to promote and distribute condoms through “social marketing”.
(using studies on consumer needs, preferences, perceptions, barriers to condom use, condom availability etc to design marketing strategies such as branding, advertisements, increasing supply outlets, etc to increase condom use. Often this involves subsidies to vendors at all levels, especially to sellers at small shops/outreach workers supplying condoms; they are given low priced condoms and allowed to sell at higher prices, keeping a share of the profit for themselves.)

4. An annual sentinel surveillance system was instituted to monitor trends in HIV prevalence. (These are described as “sentinel” because they are meant to indicate trends, not provide comprehensive information. Blood samples collected from the sentinel sites are tested for HIV to give a “snapshot” picture of HIV prevalence in those sites.) Initially, 180 sites were set up to monitor HIV prevalence among those attending clinics for antenatal care and for the treatment of sexually transmitted diseases.

5. People with untreated sexually transmitted diseases are much more at risk of HIV infection if they are exposed to the virus through sex. So control of STDs is an important strategy for HIV prevention. The first phase of NACP planned to upgrade 504 existing STD clinics with equipment, and laboratory facilities and drugs for STDs. It also planned to train doctors to provide “syndromic” treatment of STDs where laboratory facilities were unavailable.

In addition to the above five components, NACP-I tried to put some elementary treatment facilities in place and introduce strategies that were then developed during NACP-II. It planned for a cadre of ‘Physicians Responsible for AIDS Management’, one in each district, to provide care for AIDS patients and also act as trainers for other care-givers. The “continuum of care” model of community based care used health care staff and NGOs to help families care for people with AIDS at home, refer them to the health facility when required, and follow them up at home once they returned. NACP-I also introduced the targetted intervention, a strategy that eventually became the mainstay of the AIDS programme. Pilot projects were started on the “targetted interventions” for education and condom promotion directed at groups identified to have high risk behaviour. Finally, it was during NACP-I that discussion began on a “multisectoral” approach: the collaboration of many governmental departments, the private sector, the corporate sector, and national and international organisations on issues concerning HIV/AIDS.

NACP-II - 1999-2007

In November 1999, NACP-II was launched with financial credit support from the World Bank of US$ 191 million. The final outlay from all sources was about Rs 2,000 crore (see table). UN agencies as well as other international donors provided funding as well as technical assistance. While the World Bank and DFID are the major donors, the Bill and Melinda Gates Foundation and the Global Fund for AIDS, TB and Malaria, have become increasingly important donors since 2004.

Source of funding for NACP-II

The focus of NACP-II moved from the more diffuse goal of generating awareness on HIV prevention, to targetted intervention, a concept introduced in the latter part of NACP-I. The targetted intervention was meant to change high risk behaviour in populations who were at risk of contracting the infection and spreading it in the general population. On the understanding that the HIV epidemic in India was driven by groups with high risk behaviour, and their partners, NACP-II set up more than 1,000 targetted interventions, mostly through non-governmental organisations, for commercial sex workers, men having sex with men, injecting drug users, street children, prisoners, truck drivers and migrant labour. The projects were meant to use peer educators to counsel, provide condoms through social marketing and provide information to encourage a change in behaviour (“behaviour change communication”). Some 845 clinics providing STD treatment were upgraded during this programme.

NACP-II also contained a number of programmes directed at the general community.
Mass education campaigns were conducted using print media, electronic media and folk art forms, especially directed at people under the age of 25 years. Sex education programmes were introduced in schools, colleges and youth forums such as the National Service Scheme, Nehru Yuva Kendras and the Village Talk AIDS programmes.

By the end of the second phase of the programme, the number of licenced blood banks increased to 1,230 including 82 blood component separation centres. In addition to testing for HIV, blood banks were required to test all donated blood for Hepatitis C and an external quality assurance system for HIV testing was set up. By the end of NACP-II, HIV transmission through blood was reduced to less than two per cent (from eight per cent when surveillance first started in the late 1980s).

Voluntary counselling and testing centres (VCTCs) were introduced early in NACP-II. Counselling and testing enabled those at risk to know their HIV status and seek treatment which was becoming available more widely. VCTCs also provided referrals to services for treatment and care. Services for the prevention of mother to child transmission of HIV, and for the provision of antiretroviral drugs to people with AIDS, became linked to the VCTCs as and when these were instituted by the government.

The Programme for Prevention of Mother (later Parent) to Child Transmission (PPTCT) of HIV aimed to prevent the transmission of HIV from pregnant, HIV-positive women to their children. They offer pregnant women testing for HIV and provide drugs and advice to those who are HIV-positive. Towards the end of the programme, PPTCT centres were combined with VCTCs to form Integrated Counselling and Testing Centres (ICTCs). By November 2006, there were 3,396 such ICTCs in the country.

Surveillance of the HIV epidemic was upgraded during NACP-II. In the annual rounds of countrywide sentinel surveillance, unlinked blood samples are collected from high risk groups from targetted intervention projects, from STD clinic attendees and from pregnant women from certain designated sentinel sites and tested to provide information on trends in the HIV epidemic in the country and to estimate the HIV burden of the country. Reported AIDS cases were also tracked as an additional source of information.

Treatment and prophylaxis for opportunistic infections was an important strategy in NACP-II as the programme began to recognise the need to move beyond prevention and start providing medical services related to AIDS. For people with more advanced illness, the programme advocated the “continuum of care” model with home-based care and hospital referral when appropriate, implemented through NGOs. By the end of NACP-II, 122 community care centres or hospices for the care of terminally ill AIDS patients were set up throughout the country.

Though effective antiretroviral drugs were on the market by the start of NACP-II, it was only when Indian companies started manufacturing generic copies of these drugs and marketing fixed drug combinations at low prices that the government considered providing them through its services. The antiretroviral therapy (ART) programme started in April 2004 in the high prevalence states. By December 2006, about 56,000 patients were receiving first line antiretroviral drugs from 107 ART centres throughout the country.

The NACP II institutionalised the use of the society model for the programme at the state level. The State AIDS Cells of all 32 states and union territories were converted to societies registered under the Charitable Societies Act for greater flexibility and more effective programme management. These Societies had representatives from several government departments, from NGOs and representatives of communities such as people living with HIV. Phase II of the NACP also had, as stated objectives, the provision of decentralised services and the strengthening of the system's long-term capacity to respond to HIV.

NACP-III: 2007-2012

The third stage of the National AIDS Control Programme is meant to provide an integrated package of prevention, care and support and treatment with the aim of reducing incidence - as estimated in the first year of the programme - by 60% in high prevalence states and by 40% in the vulnerable states. It is not known whether the latest National Family Health Survey (NFHS) estimates of prevalence will modify these goals. The incidence rates are also not known.

Source of funding of NACP-III

NACP-III plans to prevent new infections by “saturation coverage” of high risk groups with targetted interventions (TIs) and by scaling up existing interventions directed at the general population.

It will use “behaviour change communication” with the further involvement of NGOs and community-based organisations. It plans to set up more than 2,000 TIs across the country for high risk groups and vulnerable groups. Further, it will extend the existing infrastructure for care, support and treatment. By developing guidelines and training modules for health care staff and services, it aims to improve the quality of medical care for AIDS. It plans to further decentralise its activities from the state to the district level and also involve various government departments and the private sector in its efforts. The financial resources required for the programme are estimated to be approximately Rs 11,600 crore over the five-year period, with about two-thirds for prevention, and one-sixth for care and support.

Strategies of NACP-III

Targetted interventions
The programme lists three levels of priority populations: first, with the highest risk of exposure to HIV are the “core transmitter” groups or those at maximum risk of acquiring HIV infection and transmitting the infection to others: sex workers, men who have sex with men and transgenders, and injecting drug users - a total estimated 4 million.

Second are what it describes as “bridge populations” - those who are at risk of HIV because they have a sexual partner in the core group and one or more partners in the general population and thus form a bridge for the HIV infection to pass from core groups to the general population. Clients of sex workers are the most common bridge group; long distance truck drivers and migrant labourers (a total estimated 12 million in the country) are in the sexually active age and their separation from regular partners for extended periods of time predisposes them to paid sex or sex with non-regular partners.

In addition to providing information, promoting condom use and making condoms available and referring to treatment centres for STDs when needed, TIs are meant to provide detoxification, de-addiction and rehabilitation, needle exchange, substitution therapy, abscess management to IDUs, and lubricants and appropriate condoms to MSM. Peer led interventions by community based organisations or NGOs are encouraged.         
 
NACO has developed Operational Guidelines on Targetted Interventions for Truckers and Migrants. Interventions to the estimated 3.4 million truckers involve providing information on sexually transmitted infections (STI), HIV/AIDS prevention and safe sex. So far, all interventions were carried out by NGOs at locations where truck drivers halt for sufficient duration like along highway stretches, business activity areas, check posts or port areas. Under NACP-III, the National Highway Authority of India, social marketing organisations, NGOs and truckers’ organisations are to be involved for better outreach.  Prevention interventions for migrants are focussed on 8.64 million temporary, short duration migrants who frequently move between source and destination areas, and uses NGOs, factory owners, construction companies and other employers engaging their services.

Finally, NACP-III addresses those in the general population who are at lower risk of HIV infection but are also very vulnerable. In India, women account for around one million out of 2.5 million estimated number of people living with HIV/AIDS. Apart from awareness programmes, locale specific programmes are held for women who are more vulnerable because they are spouses of truckers, migrants or construction workers.

Women are often reached through programmes done through self-help groups and anganwadis. People in the age group of 15-29 years comprise almost 25 % of the country’s population; however, they account for 31 % of the AIDS burden. The school adolescent education programme is an important means of providing HIV related information to school children. There are similar programmes for college students on a much lower scale. Youth out of school are reached through programmes organised by agencies such as the Nehru Yuva Kendra.

Condom promotion
Condom promotion under NACP-I & II led to an increase in the awareness about its consistent use in HIV/AIDS prevention. The availability of free, subsidised and commercial brands of condoms was also increased but did not have a significant impact on its use. NACP III aims to distribute 3.5 billion condoms every year (up from 2.25 million in 2006) by 2010, distributing them at STI/RTI clinics, through social marketing at targetted interventions, and through commercial sales via condom vending machines at unconventional sales outlets such as post offices and rural banks, and in areas where sex is solicited. Female condoms will be marketed in eight states to evaluate their acceptability and thicker, more lubricated condoms will be marketed to cater to the special needs of the high risk groups.

Safe blood
The specific objective of the blood safety programme is to ensure reduction in the transfusion associated with HIV transmission to 0.5 %, while making safe and quality blood available within one hour of its requirement in a health facility. The programme aims to bridge the gap between the demand for blood (8.5 million units annually) and supply (4.4 million units, of which only 52 % is through voluntary donation), and improve the quality of blood. This will be done through improving the quality and reach of the infrastructure for blood storage, component separation and transport; through encouraging clinicians to make the optimum use of blood and blood products as well as autologous blood donation, and promoting voluntary blood donation; and through a regulatory and monitoring structure.

Counselling and testing 
HIV counselling and testing services are a key entry point to prevention of HIV infection and to treatment and care of people with HIV. In the decade since the start of counselling and testing services in India, there are now more than 4,000 counselling and testing centres, mainly located in government hospitals. In 2006, more than 2.1 million people availed of counselling and testing services. Yet estimates indicate that just 13 % of people with HIV are aware of their status.

NACP-III aims to provide counselling and testing to 22 million people by 2012. Under NACP-III, VCTCs are merged with treatment facilities such as antenatal services and tuberculosis treatment centres, and renamed Integrated Counselling and Testing Centres (ICTC). The ICTC provides voluntary counselling and testing, provides basic information on HIV and how to reduce the risk of acquiring it, and referring to care and treatment services.

Prophylactic treatments
The programme also promises to provide “prophylactic drugs to health workers who are exposed to HIV infection and to HIV positive pregnant women.” ‘Post-exposure prophylaxis’ is a course of antiretroviral drugs given to reduce the chances of an infection in people, especially health care workers, who suffer needlestick injuries or other exposures to blood or body fluids that may be infected with HIV. Healthcare institutions are expected to train their staff and also institute practices to reduce the chances of such exposure.

The Prevention of Parent to Child Transmission of HIV/AIDS (PPTCT) programme was started in 2002 following a feasibility study in 11 major hospitals in the five high-HIV-prevalence states. Women who are HIV-positive are offered a dose of the antiretroviral drug Nevirapine during labour and their child is given a dose immediately after birth, to reduce the chances of HIV transmission from mother to child. Currently, more than 4,000 ICTCs, most in government hospitals, offer PPTCT services to pregnant women. An estimated 189,000 of the 27 million pregnancies in India every year occur in HIV-positive women and without any intervention will result in 56,700 babies born infected. At present, PPTCT services cover about 10 % pregnancies in the country. Under NACP-III, this service will be offered at community health centres and primary health centres as well as through the private sector. The target is to achieve the UNGASS target of reducing the proportion of infants infected with HIV/AIDS by 50 % by 2010.

Care, support and treatment
In terms of treatment, NACP-III promises treatment for opportunistic infections (such as TB and fungal infections), and first-line antiretroviral drugs to those adults and children who qualify according to its medical criteria. In February 2008, the government introduced second-line drugs to those who have become immune to the first-line drugs, and the programme has started in two centres, Mumbai’s JJ hospital and Chennai’s Tambaram hospital, as of March 2008. Universal access to first line ARV drugs to all will be assured. By 2011 it is expected that ART will be provided to 3 lakh infected individuals.

Under NACP-III it is planned for all HIV/AIDS linked services to be integrated and scaled up to sub-district and community level. All 611 districts in the country have been graded into four categories and the package of services in a particular area will be based on the prevalence there. Community health centres and primary health centres will promote condom use, offer counselling and testing for HIV, and provide PPTCT services, treatment of STDs and of opportunistic infections.

In high prevalence districts, the spectrum of preventive, supportive and curative services will be available in medical colleges or district hospitals. Non-governmental organisations and community based organisations are expected to link people needing care to hospitals providing HIV services, provide support services and home-based care for people living with HIV/AIDS, and outreach services at the district level. The services of private medical practitioners are also to be integrated into the treatment programme.

Under NACP–II, the focus was on low-cost care, support and treatment of common opportunistic infections; antiretroviral drugs were offered half way through NACP II and to a limited population. NACP-III plans to increase the availability of ART by doubling the number of ART centres from 127 in June 2007, to 250 by 2012, in medical colleges, district hospitals and non-profit institutions. It also plans to improve counselling for drug adherence, information on nutritional needs and referral for other treatment. NACP–III seeks high levels of drug adherence (95 %) and compliance of the prescribed ART regimen. It also plans to monitor drug resistance in syndromic STDs and develop guidelines for their treatment.

So far, there has been little support for the approximately 50,000 children below 15 years infected by HIV every year. NACP–III plans to promote early diagnosis and treatment of HIV exposed children; develop comprehensive guidelines on paediatric HIV care; train counsellors for counselling HIV-positive children; provide links to programmes for social support for infected children; give subsidies to facilitate ART and follow up, and establish and enforce minimum standards of care and protection of children in institutions and foster care.

Collaborations

NACP-III works with various types of organisations in prevention, care, support, treatment and service delivery: NGOs that provide nutrition and other welfare services; community care centres providing medical and social support, women’s groups, youth groups, trade unions, private sector, civil society organisations, networks of people living with HIV/AIDS and government departments to integrate HIV prevention into their activities.

Mainstreaming

Altogether 31 Union ministries and departments of the Government of India have mainstreamed HIV/AIDS prevention in their day-to-day functioning. Each of these organisations has one dedicated HIV/AIDS unit with at least one focal person on the staff. All these organisations have developed a situation assessment report and five-year HIV/AIDS action plan. Thirteen government ministries have also been identified that have direct or indirect relevance to the HIV and AIDS response and who must integrate the various activities in prevention and treatment into their work. These are: the ministries of rural development; urban development; urban employment and poverty alleviation;  tribal welfare; tourism;  panchayati raj; home affairs; labour and employment; human resource development; youth affairs and sports; social justice and empowerment; women and child development, and road transport, highways and shipping. 

A number of private companies have taken up prevention campaigns and other programmes within their corporate and field locations, including removing stigma and discrimination in the workplace. NACP-III formally recognises and encourages partnerships and alliances with the corporate/ public /private sector. NACO has signed memorandums of understanding with Ballarpur Industries Limited and ACC for ART centres to be operated out of their company locations with the companies providing the human resource and infrastructure. Workers will receive free testing and first line antiretrovirals, and NACO bears the costs of testing and drugs. 

NGOs and civil society organisations have made significant contributions in reaching HIV prevention and care services to the highly vulnerable population groups. The National AIDS Control Programme recognises the importance of their participation, particularly in preventive or targetted interventions for high risk groups, care  and support of people living with HIV/AIDS and  in general awareness campaigns.

CSOs and NGOs have played a critical role in implementing targetted interventions for HIV prevention among marginalised and vulnerable populations such as female sex workers, men who have sex with men and injecting drug users and bridge populations such as migrant workers and truckers. In 2006, community based organisations (CSOs) and NGOs were involved in 1,080 projects. A further scale up is due under NACP-III. NACO also plans to involve CSOs and NGOs more in providing home-based care and setting up community care centres; it also encourages NGOs in the non-health/HIV sector to expand the scope of their work to include HIV issues, especially stigma and discrimination. NACO also supports faith-based organisations in prevention, care and support activities in distant and unreachable areas.

Surveillance

One of the achievements of NACP is a credible HIV sentinel surveillance system. Information gathered through HIV sentinel surveillance, AIDS case surveillance, behavioural sentinel surveillance and STD surveillance helps in tracking the epidemic and provides the direction to the programme. NACP-III will include PPTCT and ANC surveillance.  In addition, a nationwide computerised management information system (CMIS) provides programme monitoring and evaluation. When planning NACP-III it was felt that data from sentinel surveillance and CMIS was not sensitive enough. Therefore NACP II introduced a Strategic Information Management System to provide effective tracking of the epidemic and the response to it.

In NACP-II, in addition to the Rs 2,000 crore budget, there were extra-budgetary funds used for the programme, mainly from the Gates Foundation. For NACP-III, about Rs 7,600 crore is the budgetary allotment. An additional Rs 4,000 crore is expected mainly from the World Bank and the Global Fund. This takes the total for NACP-III to Rs 11,600 crore.

References and further reading

1. See the website of the National AIDS Control Organisation www.nacoonline.org for reports of programmes, policies and the state of the epidemic in India. The Annual Report of NACO 2002-04 is downloadable from the website
2. See http://www.avert.org/aidsindia.htm for a history of the HIV epidemic and the country’s response.
3. Anup K Karan, ‘Financing of HIV/AIDS efforts in India: need for direction’. Oneworld.net Digital Opportunity Channel.  July 4, 2005.  www.digitalopportunity.org/article/view/114239/
4. The HIV portal of the University of California, San Francisco:   http://hivinsite.ucsf.edu/global?page=cr08-in-00
5. Progress Report of India on the Declaration of Commitment on HIV/AIDS United Nations General Assembly Special Session on HIV/AIDS : http://data.unaids.org/pub/Report/2006/2006_country_progress_report_india_en.pdf
6. UNAIDS http://www.unaids.org/en/
7. Achievements of NACP II http://www.nacoonline.org/upload/NACO_04/
   Achievements%20of%20NACP-II.pdf
8. World Bank, ‘HIV/AIDS South Asia. India: the state of the epidemic’, August 2007.  http://siteresources.worldbank.org/INTSAREGTOPHIVAIDS/
   Resources/HIV-AIDS-brief-Aug07-IN.pdf
9. ‘National AIDS Control Programme Phase III: 2006-2011. Strategy and implementation plan’. NACO, Ministry of Health and Family Welfare, Government of India. November 30, 2006. http://www.nacoonline.org/upload/Publication/
   Strategy%20and%20Implementation%20Plan%20-%20NACO%20
   Programme%20Phase%20III%20(2006-2011)%202006.pdf
10. Operational guidelines for Integrated Counselling and Testing Centres. http://www.nacoonline.org/Quick_Links/Publication/
    Basic_Services/Operational__Technical_guidelines_and_policies/
    Operational_Guidelines_for_Integrated_Counseling_and_Testing_Centres/
11. NACO, Country Scenario An Update; New Delhi: National AIDS Control Organisation, Ministry of Health and Family Welfare, Government of India; 1995

(Dr M Prasanna Kumar, former deputy director of the Kerala State AIDS Control Society, is based in Thiruvananthapuram)

InfoChange News & Features, March 2008