Introduction

 AIDS
• Acquired immuno-deficiency syndrome
• Is a fatal illness caused by retrovirus known as the
human immuno-deficiency virus (HIV)
• Breaks down the body’s immune system leaving the
victim vulnerable to a host of life threatening
opportunistic infections, and neurological disorders
or malignancies
 History
• AIDS was first described in USA in 1981 among
homosexuals, Haitians, heroine addicts and
haemophiliacs
• Virus was isolated by Luc Montagnier in 1983 and
called it “lymphadenopathy-associated Virus (LAV)”
• Robert Gallo named it “human T-Cell lymphotropic
Virus-III (HTLV-III)” in 1984
• The International Committee on Taxonomy of
Viruses gave virus a new name: human
immunodeficiency virus (HIV)
 Problem Statement

Year Annual new No. of people Annual AIDS

infections living with HIV related deaths
2005 2.5 million 31.8 million 2.0 million

2010 2.2 million 33.3 million 1.5 million

2015 2.1 million 36.7 million 1.1 million

 Types of HIV epidemic
1. Low level HIV epidemics
 HIV may be existed for many years but has not spread to
substantial levels in any sub-population
 HIV prevalence has not consistently exceeded 5% in any
defined sub- population
2. Concentrated HIV epidemics
 HIV spread rapidly in a defined sub-population but is not
well established in the general population
 HIV prevalence is consistently over 5% in at least one
defined sub-population but is below 1% in pregnant
women of urban areas
3. Generalized HIV epidemics
 HIV firmly established in the general population
 HIV prevalence consistently over 1% in pregnant women
 HIV/AIDS in Nepal
• Starting from a ‘low level epidemic’ over the period of
time; HIV, in Nepal evolved itself to become a
‘concentrated epidemic’
• This epidemic state suggests active networks of risks
within the sub population
• The epidemic that peaked in 2000 A.D. with almost 8,000
new cases has declined to about 1,331 new HIV
infections in 2015 A.D.
HIV Estimation in Nepal (2015)
Number of people living with HIV 39,397
Children (0-14 years) 1,589
Adults (15-49 years) 30,074
Adults (50+ years) 7,733
Adult HIV prevalence (15-49 years) 0.20 %
Estimated new infection 1,331
Deaths due to AIDS 2,263
0.35%

0.13%
899
Male 24,449 62.05 %
Female 14,948 37.94%
Reproductive age group (15-49 years) 76.33 %
 Epidemiological features
1. Agent factors
a) Agent: Human immunodeficiency virus (HIV)
• Two types : HIV 1 (most common) and HIV 2
• It is a protein capsule containing:
–two short strands of
genetic material(RNA)
–enzyme
• Replicates in actively
dividing T4 lymphocytes
b) Reservoir of infection : symptomatic cases and
asymptomatic carriers

c) Source of infection
– Greater concentration : blood, semen, CSF
– Lower concentration : tears, saliva, breast milk,
urine, cervical and vaginal secretion
2. Host factor
a) Age : sexually active population aged 20-49 years
b) Sex : homosexual in developed countries and equally
among homo and heterosexual in developing
countries
c) High risk groups :
• Male homosexuals and bisexuals
• Heterosexual partners
• Intravenous drug abusers
• Transfusion recipients
• Haemophiliacs
• Clients of STD
3. socio-environmental factors
a) Globalization
b) Ignorance
c) Tourism
d) Lack of awareness
e) Socioeconomic status
 Modes of transmission
I) Sexual transmission
• Male to female twice likely than female to male: due to
larger exposed area and high concentration of HIV in
semen than in vaginal/cervical fluid
• Anal intercourse has more risk than vaginal intercourse
due to more chances of injuries
• Teenage girls and women > 45 years of age more at risk
due to thin cervical mucosa at those periods
• Presence of STDs increases the risk 8-10 times
• More chance of transmission in window period and
symptomatic stage due to high viral load
II) Blood contacts
• Contaminated blood – transfusion of whole blood cells,
platelets, factor VIII and IX from plasma (95% risk)
• Depends on dose of virus injected, so, risk from needle,
syringe is low than transfusion
• High risk in IVDU due to repeated exposure frequently
• Skin piercing ( Injections, ear piercings, tattooing,
acupuncture) can transmit virus
III) Maternal to fetal transmission
• 20-25% chance of mother to child transmission
• Peri-partum transmission:- 1/3rd to 2/3rd of overall
infected
• Increased risk if mothers is newly infected or in
symptomatic stage
Not transmitted through:
• mosquito or any other insects
• causal social contact with infected person
• food or water
• Coughing and sneezing

Incubation Period
Uncertain ranges from few months to 10 years or more
from HIV infection to development of AIDS.
 Clinical manifestations of HIV
It is categories into :-
• Initial infection with the virus and development of
antibodies
• Asymptomatic carrier state
• AIDS – related complex (ARC)
• AIDS
Initial infection
• People generally experience mild illness (fever, sore throat
and rash), a few weeks after initial infection but most HIV
infected people have no symptoms for first five year or so
• Look healthy and feel well
• Can transmit virus to others
• HIV antibodies take between 2 to 12 weeks to appear in
the blood stream
• Window period :
– Period between the onset of HIV infection and appearance
of detectable antibodies to the virus
– Person is infectious
– Test negative on standard antibody blood test
Asymptomatic carrier state

– Antibodies against HIV virus

– No signs except persistent generalized
lymphadenopathy
AIDS-related complex
– Illness caused by damage to the immune system
– Clinical signs
• Unexplained diarrhoea lasting longer than a month
• Fatigue
• Malaise
• Loss of more than 10% of body weight
• Fever
• Night sweats
• Other milder opportunistic infections : oral thrush,
• Generalized lymphadenopathy
• Enlarged spleen
• Patients from high risk groups who have two or more
of these manifestations including generalized
lymphadenopathy and who have a decreased
number of T-helper lymphocytes are considered to
have ARC
AIDS
 End stage
 Death due to uncontrolled and untreatable infection
 Affected by wasting syndrome : involves chronic
diarrhea and severe weight loss
 Several opportunistic infections and/or cancer occur
in people
• Tuberculosis
• Persistent generalized lymphadenopathy
• Kaposi sarcoma
• Oropharyngeal candidiasis
• CMV retinitis
• Pneumocytosis carinii pneumonia
• Toxoplasma encephalitis
• Hairy leukoplakia
• Cryptococcal meningitis
• Herpes zooster or shingles
• Severe prurigo or pruritic dermatitis
• Severe or recurrent skin infections
 CLINICAL DIAGNOSIS OF AIDS
I) WHO case definition for AIDS surveillance
-In adult or adolescent (>12 years)
-In children

• The clinical case definition was developed to enable

reporting of the number of people with AIDS for the
purpose of public health surveillance, rather than
public health care.
 In adult or adolescent (> 12 years of age)

 If at least 2 of the following major signs are present in

combination with at least 1 of the minor signs.

Major signs
 weight loss ≥ 10% of body weight
 chronic diarrhoea for more than 1 month
 prolonged fever for more than 1 month
(intermittent or constant)
Minor signs
 persistent cough for more than 1 month
(for patient with tuberculosis it should not be
considered as a minor sign)
 generalized pruritic dermatitis
 history of herpes zooster
 oropharyngeal candidiasis
 chronic progressive or disseminated herpes simplex
infection
 generalized lymphadenopathy

* The presence of either generalized Kaposi sarcoma or

cryptococcal meningitis is sufficient for the diagnosis of
AIDS for surveillance purposes.
 In children
 If at least 2 major signs and 2 minor signs are present (if
there is no other known cause of immunosuppression)

Major signs
 weight loss or abnormally slow growth
 chronic diarrhoea for more than 1 month
 prolonged fever for more than 1 month
Minor signs
 generalized lymph node enlargement
 oropharyngeal candidiasis
 recurrent common infections e.g. ear infection,
pharyngitis
 persistent cough
 generalized rash

* Confirmed HIV infection in the mother counts as a

minor criterion.
II) Expanded WHO case definition for AIDS surveillance

 In adult or adolescent (>12 years of age)

If a test for HIV gives a positive result and one or more of
the following conditions are present.
 ≥ 10% body weight loss or cachexia, with diarrhoea or
fever or both for more than 1 month
 cryptococcal meningitis
 pulmonary or extra pulmonary tuberculosis
 neurological impairment
 candidiasis of the oesophagus
 Clinically diagnosed life threatening or recurrent
episodes of pneumonia
 Invasive cervical cancer
 CLINICAL STAGING

• WHO has developed a clinical staging of HIV/AIDS in 1990

and revised in 2007
• Staging is based on clinical findings that guide the
diagnosis, evaluation, and management of HIV/AIDS.
• Clinical stages are categorized as 1, 2, 3, and 4;
progressing from primary HIV infection to advanced
HIV/AIDS
• These stages are defined by specific clinical conditions or
symptoms
WHO clinical staging of HIV/AIDS in adolescents and
adults

I) Clinical stage 1
• Asymptomatic
• Persistent generalized lymphadenopathy

II) Clinical stage 2

• Moderate unexplained weight loss (<10% of presumed or
measured body weight)
• Recurrent respiratory infections (sinusitis, tonsillitis, otitis
media, and pharyngitis)
• Herpes zoster
• Angular cheilitis
• Recurrent oral ulceration
• Papular pruritic eruptions
• Seborrheic dermatitis
• Fungal nail infections
III) Clinical stage 3

• Unexplained severe weight loss (>10% of presumed or measured

body weight)
• Unexplained chronic diarrhea for >1 month
• Unexplained persistent fever for >1 month (>37.6°C, intermittent
or constant)
• Persistent oral candidiasis
• Oral hairy leukoplakia
• Pulmonary tuberculosis
• Severe presumed bacterial infections (e.g., pneumonia,
empyema, pyomyositis, bone or joint infection, meningitis,
bacteremia)
• Acute necrotizing ulcerative stomatitis, gingivitis, or periodontitis
• Unexplained anemia (hemoglobin <8 g/dL)
• Neutropenia (neutrophils <500 cells/µL)
• Chronic thrombocytopenia (platelets <50,000 cells/µL)
IV) Clinical stage 4
• HIV wasting syndrome, as defined by the CDC
• Pneumocystis pneumonia
• Recurrent severe bacterial pneumonia
• Chronic herpes simplex infection (orolabial, genital, or anorectal
site for >1 month or visceral herpes at any site)
• Esophageal candidiasis (or candidiasis of trachea, bronchi, or
lungs)
• Extrapulmonary tuberculosis
• Kaposi sarcoma
• Cytomegalovirus infection (retinitis or infection of other organs)
• Central nervous system toxoplasmosis
• HIV encephalopathy
• Cryptococcosis, extrapulmonary (including meningitis)
• Disseminated non-tuberculosis mycobacteria infection
• Progressive multifocal leukoencephalopathy
• Candida of the trachea, bronchi, or lungs
• Disseminated mycosis (e.g., histoplasmosis,
coccidioidomycosis, penicilliosis)
• Recurrent nontyphoidal Salmonella bacteremia
• Lymphoma (cerebral or B-cell non-Hodgkin)
• Invasive cervical carcinoma
• Atypical disseminated leishmaniasis
• Symptomatic HIV-associated nephropathy
• Symptomatic HIV-associated cardiomyopathy
 WHO clinical staging system for HIV infection
and related disease in children
 Stage 1
• Asymptomatic
• Persistent generalized lymphadenopathy

 Stage 2
• Unexplained chronic diarrhea
• Severe persistent or recurrent candidiasis
• weight loss and failure to thrive
• Persistent fever
• Recurrent severe bacteria infections
 Stage 3
• AIDS defining opportunistic infections
• Severe failure to thrive
• Progressive encephalopathy
• Malignancy
• Recurrent septicemia or meningitis
 Laboratory diagnosis

1. Screening test: ELISA

 sensitive test used to detect the HIV-antibodies

2. Confirmatory test: Western Blot

 highly specific test
 based on detecting specific antibody to viral core
protein (p24) and envelop glycoprotein (gp 41)

3. Virus isolation
 HIV can be recovered from cultured lymphocytes
4. Non –specific laboratory findings
 Anaemia, leukopenia (particularly lymphocytopenia) and
thrombocytopenia in any combination , polyclonal
hypergammaglobulinaemia

5. CD4 lymphocyte count

• People with healthy immune system usually have more
than 950 CD4 cells/μl of blood
• The number falls over the course of HIV infection
• People with AIDS usually have CD4 cell count below
200cells/μl of blood
• Patients whose count is substantially above the threshold
for antiretroviral therapy (500cells/μl) should have count
performed every 3 months
 Laboratory findings with HIV infection
Test Significance
HIV enzyme -linked • Screening test for HIV infection.
immunosorbent • Sensitivity >99.9%;
assay (ELISA) • To avoid false-positive results,
repeatedly reactive results must be
confirmed with Western blot.
Western blot • Confirmatory test for HIV.
• Specificity when combined with
ELISA>99.99%.
• Indeterminate results with early HIV
infection,HIV-2 infection, autoimmune
disease, pregnancy and recent tetanus
toxoid administration.
 Test Significance

CBC • Anaemia, neutropenia and

thrombocytopenia common with
advanced HIV infection
Absolute CD4 • Most widely used predictor of HIV
lymphocyte count progression.
• Risk of progression to an AIDS
opportunistic infection or malignancy is
high with CD4 <200 cells/μl
CD4 lymphocyte • Percentage may be more reliable than
percentage the CD4 count.
• Risk of progression to an AIDS
opportunistic infection or malignancy is
high with percentage <14%
 Test Significance

HIV viral load tests • These tests measure the amount of

actively replicating HIV virus.
• Correlates with disease progression and
response to antiretroviral drugs.
B2-Microglobulin • Cell surface protein indicative of
macrophage -monocyte stimulation.
• Levels >3.5mg/dl associated with rapid
progression of disease.
• Not useful with intravenous drug users.
p24 antigen • Indicates active HIV replication.
• Tends to be positive prior to
seroconversion and with advanced
disease.
Prevention and control of
HIV/AIDS
 Prevention and Control of HIV

Modes of Susceptible Host

Source or
Transmission
Reservoir

Intervention

There are four basic approaches to the control of AIDS

1.Prevention
2.Antiretroviral treatment
3.Specific prophylaxis
4.Primary health care
 1. Prevention

• Education
– Avoid unprotected sex; use condom
– Avoid use of shared razors and toothbrushes
– Avoid sharing needles and syringes
– Women suffering AIDS or at high risk of infection
should avoid getting pregnant.
• Combination HIV prevention
Combination prevention programmes use a mix of
biomedical, behavioral and structural interventions to
meet the current HIV prevention needs of particular
individuals and communities so as to have the greatest
possible impact on reducing new infections.
Inventions:
 ARV drugs
 Male and female condoms and condom compatible
lubricants
 Needle and syringe programmes
 Opioid substitution therapy
 Voluntary medical male circumcision (VMMC)
• Prevention of Blood borne HIV transmission
– High risk groups should not be allowed to donate
blood, organs, sperm or other tissues
– Pre-sterilized syringed and needles should be used as
far as possible
– Before transfusion, blood should be properly screened
for HIV1 and HIV2
 2. Antiretroviral treatment

• At present no vaccine or cure for treatment of AIDS

• Antiviral chemotherapy, while not a cure, have
proved to be useful in prolonging the life of severely
ill patients.
 WHO recommended ARV treatment schedule
(2016)

1. WHEN TO START ART

When to start ART in ART should be initiated in all adults living with
adults (>19 years old) HIV, regardless of WHO clinical stage and at any
CD4 cell count
As a priority, ART should be initiated in all adults
with severe or advanced HIV clinical disease
(WHO clinical stage 3 or 4) and adults with a CD4
count ≤350 cells/mm3
When to start ART in ART should be initiated in all pregnant and
pregnant and breastfeeding women living with HIV, regardless
breastfeeding women of WHO clinical stage and at any CD4 cell count
and continued lifelong
When to start ART in ART should be initiated in all adolescents living
adolescents (10–19 years with HIV, regardless of WHO clinical stage and at
of age) any CD4 cell count
As a priority, ART should be initiated in all
adolescents with severe or advanced HIV clinical
disease (WHO clinical stage 3 or 4) and
adolescents with a CD4 count ≤350 cells/mm3
When to start ART in ART should be initiated in all children living with
children younger than 10 HIV, regardless of WHO clinical stage or at any
years of age CD4 cell count:
• Infants diagnosed in the first year of life
• Children living with HIV 1 year old to less than
10 years old
As a priority, ART should be initiated in all
children <2 years of age or children younger than
5 years of age with WHO clinical stage 3 or 4 or
CD4 count ≤750 cells/mm³ or CD4 percentage
<25% and children 5 years of age and older with
WHO clinical stage 3 or 4 or CD4 count ≤350
cells/mm³
Timing of ART for adults ART should be started in all TB patients living with
and children with TB HIV regardless of CD4 count.
1. TB treatment should be initiated first, followed
by ART as soon as possible within the first 8
weeks of treatment.
2. HIV-positive TB patients with profound
immunosuppression (e.g. CD4 counts less than 50
cells/ mm3) should receive ART within the first
two weeks of initiating TB treatment.
ART should be started in any child with active TB
disease as soon as possible and within 8 weeks
following the initiation of anti-tuberculosis
treatment regardless of the CD4 cell count and
clinical stage
2. What to start: first-line ART
What to start: First-line ART for adults should consist of two nucleoside
first-line ART reverse-transcriptase inhibitors (NRTIs) plus a non-
nucleoside reverse-transcriptase inhibitor (NNRTI) or an
integrase inhibitor (INSTI):
 TDF + 3TC (or FTC) + EFV as a fixed-dose combination
is recommended as the preferred option to initiate
ART.
 If TDF + 3TC (or FTC) + EFV is contraindicated or not
available, one of the following alternative options is
recommended:
° AZT + 3TC + EFV
° AZT + 3TC + NVP
° TDF + 3TC (or FTC) + NVP
TDF + 3TC (or FTC) + DTG or TDF + 3TC (or FTC) + EFV 400
mg/day may be used as alternative options to initiate
ART.
Countries should discontinue d4T use in first-line
regimens because of its well-recognized metabolic
toxicities
First-line ART for First-line ART for adolescents should consist of two NRTIs
adolescents plus an NNRTI or an INSTI:
TDF + 3TC (or FTC) + EFV as a fixed-dose combination is
recommended as the preferred option to initiate ART.
TDF + 3TC (or FTC) + DTG or TDF + 3TC (or FTC) + EFV400
may be used as alternative options to initiate ART.

If preferred regimens are contraindicated or not

available, one of the following alternative options is
recommended:
ABC + 3TC + EFV
ABC + 3TC + NVP
AZT + 3TC + EFV
AZT + 3TC + NVP
TDF + 3TC (or FTC) + NVP
First-line ART for For children 3 to less than 10 years of age, the NRTI
children aged 3 to backbone should be one of the following, in preferential
10 years of age order:
• ABC + 3TC
• AZT or TDF + 3TC (or FTC)
For children 3 years and older, EFV is the preferred NNRTI
for first-line treatment and NVP is the preferred
alternative
First-line ART for For infants and children younger than 3 years, the NRTI
children younger backbone for an ART regimen should be ABC or AZT+ 3TC
than 3 years of A LPV/r-based regimen should be used as first-line ART
age for all children infected with HIV younger than 3 years
(36 months) of age, regardless of NNRTI exposure. If
LPV/r is not feasible, treatment should be initiated with
an NVP-based regimen
Where viral load monitoring is available, consideration
can be given to substituting LPV/r with EFV at 3 years of
age after viral suppression is sustained
 For infants and children infected with HIV younger than 3
years, ABC + 3TC + AZT is recommended as an option for
children who develop TB while on an ART regimen
containing NVP or LPV/r. Once TB therapy has been
completed, this regimen should be stopped and the
initial regimen should be restarted.
Infant prophylaxis Infants born to mothers with HIV who are at high risk of
acquiring HIV2 should receive dual prophylaxis with AZT
(twice daily) and NVP (once daily) for the first 6 weeks of
life, whether they are breastfed or formula fed
Breastfed infants who are at high risk of acquiring HIV,
including those first identified as exposed to HIV during
the postpartum period, should continue infant
prophylaxis for an additional 6 weeks (total of 12 weeks
of infant prophylaxis) using either AZT (twice daily) and
NVP (once daily) or NVP alone
Infants of mothers who are receiving ART and are
breastfeeding should receive 6 weeks of infant
prophylaxis with daily NVP. If infants are receiving
replacement feeding, they should be given 4–6 weeks of
infant prophylaxis with daily NVP (or twice-daily AZT)
What ART regimen to switch to (second and third line)
Second-line ART Second-line ART in adults should consist of two
for adults and nucleoside reverse-transcriptase inhibitors (NRTIs) plus a
adolescents ritonavir-boosted protease inhibitor (PI).
The following sequence of second-line NRTI options is
recommended:
• After failure on a TDF + 3TC (or FTC)-based first-line
regimen, use AZT + 3TC as the NRTI backbone in
second-line regimens.
• After failure on an AZT or d4T + 3TC-based first-line
regimen, use TDF + 3TC (or FTC) as the NRTI backbone
in second-line regimens.
Use of NRTI backbones as a fixed-dose combination is
recommended as the preferred approach.
Heat-stable fixed-dose combinations of ATV/r and LPV/r
are the preferred boosted PI options for second-line ART.
A heat-stable fixed-dose combination of DRV/r can be
used as an alternative boosted PI option for second-line
ART.
A combination of RAL plus LPV/r can be used as an
alternative second-line ART regimen
Second-line ART After failure of a first-line LPV/r-based regimen, children
for children younger than 3 years should be switched to a RAL-based
second-line regimen.
After failure of a first-line LPV/r-based regimen, children
older than 3 years should be switched to a second-line
regimen containing two NRTIs plus EFV or RAL
After failure of a first-line NNRTI-based regimen, children
should be switched to a boosted PI-based regimen. LPV/r
or ATV/r are preferred.

After failure of a first-line regimen of ABC or TDF + 3TC

(or FTC), the preferred NRTI backbone option for second-
line ART is AZT + 3TC.

After failure of a first-line regimen containing AZT or d4T

+ 3TC (or FTC), the preferred NRTI backbone option for
second-line ART is ABC or TDF + 3TC (or FTC)
Third-line ART National programmes should develop policies for third-
line ART.
Third-line regimens should include new drugs with
minimal risk of cross-resistance to previously used
regimens, such as INSTIs and second-generation NNRTIs
and PIs.
Patients on a failing second-line regimen with no new
ARV options should continue with a tolerated regimen.
 Post-Exposure Prophylaxis (PEP)

• Consists of:
i. First aid care
ii. Counseling and risk assessment
iii. HIV testing and counseling
iv. Short-term (28 days) provision of anti-retroviral
drugs, with support and follow up depending on
risk assessment.
 Monitoring the efficacy of ART

Efficacy is monitored by:

I) Clinical improvement :
gain in body weight,
decrease in occurrence and severity of HIV-related
diseases
II) Increase in total lymphocyte count
III) Improvement in biological markers of HIV
CD4+T-lymphocyte counts
Plasma HIV RNA levels
 3. Specific prophylaxis
 If CD4 count < 200 cells/µl: Primary prophylaxis against P. jiroveci
pneumonia should given with trimethoprim-sulfamethoxazole, aerosolized
pentamidine and dapsone.
 If CD4 count < 200 cells/µl: Primary prophylaxis against M. avium
complex(which occurs in at least one-third of AIDS patients) should be
offered by giving Rifabutin.
 Prophylaxis against M. tuberculosis is 300 mg isoniazid daily for 9 months to
one year
 it should be given to all HIV –infected patients with positive PPD
reactions( for HIV-infected patients it is more than 5mm in induration)
 Kaposi’s sarcoma might be treated in some stage with interferon,
chemotherapy or radiation.
 Cytomegalovirus retinitis can be controlled by ganciclovir, cryptococcal
meningitis with fluconazole.
 Oesophageal candidiasis or recurrent vaginal candidiasis can be treated by
fluconazole or ketoconazole.
 Herpes infection can be treated with acyclovir or foscamet.
 4.Primary Health Care
AIDS touches all aspects of primary health care
including:
 Mother and child health
 Family planning &
 Education
So its integration to country’s primary health care
system is essential.
 National HIV/AIDS strategy (2011-2016)
• Goal
To achieve universal access to HIV prevention, treatment,
care and support
• Objectives
- Reduce new HIV infection by 50 % by 2016, compared to
2010
- Reduce HIV-related deaths by 25 % by 2016 through
universal access on treatment and care services
- Reduce new HIV infections in children by 90 % by 2016
By the end of 2015 the achievements were:
 New infections reduced by 43%;
 AIDS-related deaths reduced by 12% .
 New infections among children reduced by 57%.
 National HIV strategic plan (2016-2021)

With the National HIV Strategic Plan, Nepal has accepted

the challenges of Fast-Tracking towards ending the AIDS
epidemic as a public health threat by 2030. The global Fast-
Track targets include:
 75% reduction of new infections between 2010 and 2020
(leading to 90% reduction by 2030);
 achieving the 90-90-90 treatment targets by 2020 and
the 95-95-95 targets by 2030;
 achieving zero discrimination by 2020;
 eliminating new infections among children by 2020
Strategies
• Focus on reaching key populations through outreach and,
by communities of key populations, through in-reach.
• Offer HIV “test and treat” services, regardless of CD4 count.
• Retain people living with HIV in treatment, resulting in
undetectable viral load.
• Fast-Track prioritized investments with a scope, scale,
intensity, quality, innovation and speed to have the biggest
impact.
• Establish functional public-private partnerships to bridge
the prevention-treatment continuum through task-sharing.
• Focus on innovative, well-coordinated and integrated
services towards primary HIV prevention for and with key
populations
 HIV Counseling and Testing (HTC)
 HCT service is the process of providing people with
professional counseling before and after an HIV test.
 HIV Testing and Counseling service was first started in
Nepal in 1995 at NCSAC
 It is provided free of cost to the key populations at
higher risk and general population all over the country.
 There are over 263 service sites providing HIV testing and
counseling, including 150 government sites as of July
2016.
 HCT mainly aims for:
1) Prevention of HIV transmission
• From +ve tested people to –ve or untested partner/s
• From +ve tested mother to child
• To –ve tested people from +ve or untested partner/s
2) Promote early uptake of services
• Medical care
• Family planning
• Emotional care
• Counseling for positive living
• Social support
• Legal advice and future planning
• Normalization of HIV
• Challenging stigma
• Promoting awareness
• Supporting human rights
 Anti-retroviral Therapy (ART) services

• ART was started in Nepal in February 2004 from Sukraraj

Tropical and infectious Disease Hospital, Teku.
• ART is available for free of cost for all eligible people
living with HIV (PLHIV).
• Currently ART is available from 65 sites in 59 districts. HIV
care is available from many sites including ART sites.

Total PLHIV currently on ART (July,2016) 12,446

Patient on the 1st line regimen 9,216
Patient substituted on the 1st line 2,974
Patients switched on the 2nd line 256
THANK YOU