Action Plan for ISO-9001 Certification

Department of AIDS Control Ministry of Health & Family Welfare Government of India National AIDS Control Organisation

Action Action 1: Constitute Management Committee Action 2: Define scope Action 3: Depict organizational structure. Action 4: Review and finalize Vision and Mission Action 5: Identify processes, along with designations Action 6: Define sequence and interaction of processes

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Action 7: Describe duties of each designation Action 8: Prepare list of documents

Action-1: Constitute Management Committee Management Committee for Implementation of ISO 9001:2008 Ministry/ Department: Department of AIDS Control, National AIDS Control Orgaisation S. No 1 Name Shri Sayan Chatterjee Designation Secretary & DG, Department of AIDS Control, NACO Additional Secretary Deputy Director General, STI & LWS Deputy Director General, M&E Deputy director General,TI Deputy Director General Assistant Director General Assistant Director General Joint Director, IEC Director (Admn., P&C, Proc.) Director(Fin.ance) Committee Status Chairperson

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Ms. Aradhana Johri Dr. S. Khaparde

Vice Chairperson Management Representative Member

Dr. S.Venkatesh

Dr. Neeraj Dhingra

Member

Dr Radhay Shyam Gupta Dr. Mohammed Shaukat Dr. Sandhya Kabra

Member

Member

Member

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Mr. Shyama Prasad Mr. R. Rajagopal

Member Member

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Mr.Kanwaljeet Singh

Member

Action-2: Scope Name of the Department/ Ministry Scope for ISO 9001 Department of AIDS Control, Ministry of Health & Family Welfare Prevention and reduction of the HIV burden in India.

Minister (HFW)

Secretary, Dept of AIDS Control & Director General, NACO

DDG(M&E)

DDG(BSD)

ADG(CST)

Director(F)

Additional Secretary

NPO(SIMU)

NPO(ART)

ADG(BS)/ADG(LS)

JD(IEC)

DDG(TI)

DDG(STI/LWS)

Director(A & P)

DD(IEC)

ADG(STI)

US(A & P)

PO(4)

PO(2)

PO(2)

US(F)

PO(2)

US(IEC)

PO(4)

PO(2)

SO(P&C)

Proc.Specialist

SO(Admin.)

TO(5)

TO(3)

TO(3)

Account Officers/ Audit Officers

TO(2) TO TO(4)

Admin Officer(2)

DDG- Deputy Director General; ADG- Assistant Director General; JD- Joint director; US - Under Secretary; NPO- National Programme Officer; PO- Programme Officer; TO- Technical Officer;MEO- Monitoring & Evaluation Officer;SO-Section Officer, BSD- Basic Services Division; BS- Blood Safety; LS- Lab Services; LWS- Link Worker Schme; STI- Sexually Transmitted Infections ; M&E- Monitoring & Evaluation;

Action-4: Review and Finalize Vision and Mission Statements Vision: Prevention and reduction of the HIV burden in India. Mission: To reduce HIV prevalence in population groups at risk of HIV/AIDS by an integrated prevention, care and support programme. Action-5: Identify Processes Sl. No. 1 Process/procedures Process Owner Remarks

Annual Action Plan (National & State level)

Head of all Programme divisions

The process includes the development and finalization of the action plan for the financial year including budgetary allocations for the planned activities of the National AIDS Control Programme. Preparation of indent for the kits based on the annual targets and scale up plan of the programme Ensure receipt and facilitate timely dispatch of the kits to concerned consignees (State AIDS Control Societies)

Procurement and supply kits and drugs

Divisional Heads/ Director of Admin & Procurement

Monitoring, Supervision and technical support

DDG (M&E) in collaboration with concerned programme division heads

Quarterly review meeting of the key programme officers from the state at the national level Supervisory visit of the programme officers to the states Desk review of the programme by using Computerized Management and Information System(CMIS)

Conducting Research and Evaluation to support/ strengthen programme activities NACO Research Fellowship

DDG (M&E) in collaboration with concerned division heads DDG (M&E)

Areas for evaluation and operational research are identified. Protocols developed and studies commissioned. The results are fed back to the divisions. Any young scientist, below 35 years of age at the time of applying and enrolled in fulltime MD/MPhil/PhD degree program in relevant disciplines from any recognized Indian University/Institute, can apply for the fellowship to carry out research relevant to

HIV/AIDS in bio-medical/clinical, epidemiological and social disciplines annually. A total of 20 fellowships shall be awarded every year for financial assistance 6 7 Setting up of Antiretroviral Therapy Centres Hiring of Media Planning, Buying and Monitoring Agency Organising Media Campaigns ADG CST JD(IEC) assisted by PO (IEC) and Procurement Specialist JD(IEC) & IEC Team Setting up Antiretroviral Therapy Centres To implement the mass media campaign.

Communication strategy for national and state level is prepared to undertake mass media, mid media, outdoor and IPC activities. The campaigns are implemented either through media agency or DAVP/NFDC depending upon the funding source. The campaigns implemented are evaluation through third party Creatives are developed through commissioned agency and development partners. Development of training modules , coordination with other ministries/ departments for integration in their training programmes Discussions/ consultations are held for developing and disseminating the policies and guidelines. Draft material for report/ response is prepared, consolidated and submitted for approval. Following approval, it is distributed/disseminated to the intended recipients. Films have been produced for TI trainings and ICTC training A national level planning is carried out in coordination with agencies and states. Then micro plans are developed for coverage in selected districts/halt points. Day to day activities are coordinated with

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Development of creatives for campaigns Mainstreaming with various Ministries for integration of HIV/AIDS prevention, care, support and treatment services.. Develop policies / programs and guidelines in relevant areas for mainstreaming and partnership Preparation of annual report/ Mid term review materials/ Intensive review Report/ Responding to RTI/ Parliament questions/ assurance Developing films, short films for advocacy, creating awareness and training purposes Red Ribbon Express III

JD(IEC) assisted by PO (IEC) and IEC Advisor JD(IEC) assisted by Team Leader and PO Mainstreaming JD(IEC) assisted by Team Leader and PO Mainstreaming Heads of all programme divisions

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JD IEC Respective IEC officers in NACO and States JD(IEC) with support from all officers of the IEC division of NACO and then the PD, JD/DD
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Youth programmeAdolescent Education Programme & Red Ribbon Clubs Size estimation of populations Contracting and monitoring of NGOs by NACO/0SACS and Technical Support Unit Evaluation of TI projects

IEC, and various officials of SACS TO(Y) & Consultant(IEC) TI Division NACO/SACS SACS

the train Manager RRE and consultant RRE. Adolescent Education Programme & Red Ribbon Clubs are implemented by states supported and coordinated by NACO

TI Division NACO/SACS

Action-6: Define the Sequences and Interaction of Processes Ministry/ Department: Process-1 Review, discussion, and sanction of Annual Action Plan of SACS Description Annual Action Plan is prepared in consultation with programme divisions, development partners and representatives from TRG group. The process involves the development of the action plan for a year (including budgetary allocations) for the planned activities of the programme. Detailed plans on human resource in the capacity building, procurement of consumables and equipments, supervision and monitoring, quality assurance, physical targets etc are developed during the planning process in consultation with respective programme division and the concerned states.

Sequence of activities S.No 1 Activity/steps in the process Receipt and review of the proposals from the state Consultation meeting with concerned SACS Sanctioning of final agreed annual action plan for the year
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Responsibility head Head of the programme division, respective Programme Officers and Technical officers Head of the programme division, Programme officers/ Technical Officers Head of the respective programme division

Process-2

Procurement and Supply of kits & drugs

Description

Procurement of Kits and drugs required for the programme

Sequence of Activities S.No 1 Activity/steps in the process Preparation of indent for kits and drugs based on the annual targets and scale up plan of the programme Forwarding indents to Procurement Agent for carrying out procurement process along with Procurement Plan giving timelines for Procurement sub-activities Drafting Bidding document sending it to NACO for approval Approving Biding document Publishing IFB notice and issuing bidding document to prospective bidder Holding pre-bid meeting, issuing clarifications to prospective bidder, receipt of bids, bid opening and evaluation of bids and sending the Bid evaluation Report to NACO for approval Approving Bid Evaluation Report (BER) and issuing financial sanction for advance payment to RITES for subsequent payment to suppliers as per conditions of respective contracts Responsibility head Programme Officer

Director (Admin & Proc)

Procurement Specialist

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Director (Admn & Proc) / Programme Officer Procurement Specialist

Procurement Specialist

Director (Admn & Proc)

Issuing Notification of Award to Procurement Specialist recommended bidders and signing of contract after receipt of performance security, arranging pre-dispatch inspection and testing by third party inspection and testing agencies, issuing dispatch clearances upon receipt of QA report.

Monitoring supplies as per delivery schedule given in contract releasing payment to suppliers as per payment terms given in respective contracts. Monitoring adequacies of stock of kits and drugs and SACS and peripheral units and issuing directions for interstate relocation of drugs and kits to meet crises. Monitoring, Supervision and technical support

Procurement Specialist

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Programme / Technical Officer

Process-3

Description

The process includes monitoring and supervision of the progress made by the programme/states necessary technical support

Sequence of Activities S.No Activity/steps in the process Responsibility head

Quarterly review meeting of the key programme officers/M&E officers from the state at the national level Supervisory visit of the programme officers to the states Desk review of the programme by using Computerized Management and Information System(CMIS) Data sharing to institutions/individuals

Programme/Technical Officer

All Officers

M& E Officers

M&E officers

Preparation of various reports submitted to the parliament/planning commission/Cabinet Secretariat/Universal Access Report/Ministry of Statistics and Programme Implementation/ PM office

DDG (M&E)

Preparation of Result Framework Document/ submission of annual and half

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DDG (M&E)

yearly report

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Preparation of Citizen/Clients charter Conducting Research and Evaluation to support/ strengthen programme activities

DDG (M&E) Description Areas for evaluation and operational research are identified. Protocols developed and studies commissioned. The results are fed back to the divisions.

Sequence of Activities S.No 1 Activity/steps in the process Setting Priority Areas for Evaluation & Operational Research in HIV/AIDS & Development of Research Protocols Proposals invited by NACO on priority research areas from NIIHAR institutes Proposals received from institutions/individuals first reviewed by concerned programme division at NACO and 2-3 external experts from the panel Proposals are then reviewed in the meeting of the Technical Resource Group on Research & Development where the PI is invited to make a presentation Proposal recommended by TRG are discussed in the NACO Ethics Committee for grant of ethical clearance Responsibility head DDG (M&E) along with head of the concerned divisions

DDG (M&E)

DDG (M&E)/Research division

DDG (M&E)/ Research Division/Technical Resource Group,R&D

DDG (M&E)/Research Division/NACO ethics commmitee

Monitoring of the research study progress

DDG (M&E) and Head of the concern programme division DDG (M&E)/Research division

Dissemination on completion of study

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Process-5

NACO Research Fellowship

Description

Sequence of Activities S.No 1 Activity/steps in the process Receipt of new proposals Responsibility head DDG (M&E)/Research divisions

Preliminary examination of proposals by R&D and concerned division &NACO If fit for further review, review by the expert committee If Recommended, submitted for approval of Secretary & DG If recommended, submission of proposed release of funds to IFD for concurrence Funds released by electrical transfer to the colleges/Universities where researchers are working

DDG (M&E)/Research divisions/ programme divisions DDG (M&E)/Research divisions

DDG (M&E)/Research divisions

DDG (M&E)/Research divisions

DDG (M&E)/Research divisions

Process-6

Setting up of Antiretroviral Therapy Description Setting up of Antiretroviral Centres and provision of ART to eligible Therapy Centres and provision PLHIV of free antiretroviral treatment (ART) to eligible PLHIV. Sequence of Activities S.No Activity/steps in the process Responsibility head

Identification of the Proposed Site for the new ART Centre (During AAP planning) Provisional sanction (during April every year as per AAP)

State AIDS Control Societies (SACS)

Head of CST division, NACO

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Meeting between SACS, Dean/Med. Superintendent of Hospital, HOD Med. of proposed ART centre and Regional Coordinator to identify the space for centre and to constitute ART team Feasibility visit of the site by an expert team constituted by SACS in consultation with the RC and approved by NACO Submission of feasibility report in prescribed format to NACO Issue of final sanction after examination of feasibility report at NACO Opening a bank account and release of funds to the centre by SACS ( for initiating refurbishment etc) Training of ART team (multidisciplinary faculty team)

SACS/Regional Coordinators Institution

CST Division, NACO

Expert Team

NACO

Institution/ SACS

NACO/SACS

Recruitment of Contractual Staff at ART Institution / SACS centre (By Steering Committee at the institution as per Operational guidelines for ART centres) Refurbishment of ART centre Supply of CD4 Machine/Linkage plan. Supply of ARV drugs for new centres Operationalisation of ART Centre Centre to be declared functional (after receipt of first report in CMIS at NACO) Hiring of Media Planning, Buying and Monitoring Agency Institution NACO(Lab Services) SACS/NACO/Procurement Division/Supply Chain SACS, Institution NACO

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Process 7

Description

The agency is hired for planning of the campaigns. In addition, agency negotiates with channels for buying space. The monitoring of the campaigns is done through

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TAM to access the reach of the campaigns.

Sequence of Activities S.No 1 Activity/steps in the process Preparation and Publication of EOI Responsibility head PO(IEC) and Procurement Specialist (Over all head JD(IEC) PO(IEC) and Procurement Specialist (Over all head JD(IEC) PO(IEC) and Procurement Specialist (Over all head JD(IEC)

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Short listing of EOI and Approval from World Bank Issue of RFP to the shortlisted agencies for Technical and Financial proposals

Evaluation of proposals , approval of World Bank and concurrence from IFD Signing of Contract Submission of media plan by agency, analysis of the media plan, putting up the plan for approval from Secretary &DG and IFD. Implementation of campaign- the campaign is implemented either through agency or DAVP/NFDC as the approved media plan. Monitoring of campaign and submission of report to competent authority Organising Media Campaigns

JD(IEC)

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JD(IEC) JD(IEC) &PO(IEC)

JD(IEC) &PO(IEC)

JD(IEC) &PO(IEC)

Process 8

Description

Development of protocols, guidelines and systems Execution as planned through media agencies/at the state level. Reporting on implementation

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Monitoring and evaluation of the campaigns Sequence of Activities S.No Activity/steps in the process 1 2 3 Process 9 Planning Implementation Review & Monitoring Development of creatives for campaigns

Responsibility head JD (IEC), Consultant; NACO JD/DD (IEC), SACS Consultant, JD (IEC), NACO Creative are prepared for different mass media campaigns The prototypes of the creatives are shared with SACS for adaptation in regional languages SACS use the creatives for outdoor in sync with the national mass media campaigns Responsibility head JD(IEC), PO(IEC) & IEC Advisor Description

S.No 1

Activity/steps in the process Preparation of media brief and sending to agencies after approval of competent authority Approval of concept and scripts for final production Approval of final edited creatives

JD(IEC), PO(IEC) & IEC Advisor

Additional Secretary Description Mainstreaming with various Ministries for integration of HIV/AIDS prevention, care, support and treatment services

Process 10 Mainstreaming with various division

Sequence of activities S.No 1 Activity/steps in the process Identifying potential ministries for integration
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Responsibility head JD IEC

Consultation for advocacy and assessing the scope of integrating services Training and sensitization of officials of 3 other Ministries Advocacy for integration of schemes and 4 programs at policy level. Explore for a mutually agreeable MOU 5 for formal partnership Implementation and sharing of experience 6 with each ministries regarding the activity Collecting relevant data regarding uptake 7 of services to NACO Process 11 Develop policies / programs and guidelines in relevant areas for mainstreaming and partnership 2

JD IEC JD IEC JD IEC JD IEC JD IEC JD -IEC Description Develop policies / programs and guidelines in relevant areas for mainstreaming and partnership

Sequence of Activities S.No 1 Activity/steps in the process Consultations with stakeholders and beneficiaries for developing content Sharing the consolidated version with stake holders for comments. Finalization of the draft Dissemination of the policy and guideline for implementation Responsibility head JD IEC

JD IEC

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JD IEC JD -IEC

Process 12 Preparation of annual report/ Mid term Description review materials/Intensive review Report/Responding to RTI/ Parliament question assurance

Preparation of annual report/ Mid term report/ Joint Intensive review Report/Responding to RTI/Parliament questions/ assurance/ court case/ RFD/Cabinet note etc

Sequence of Activities S.No Activity/steps in the process Responsibility head

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Capturing updated information of activities/programs/schemes etc from all states /UTs and major stakeholders. Compiling and drafting response/reports/ information

Head of the programme divsions

Head of the programme divsions

Sharing information/ reports with relevant institutions/ boards/ stakeholders Process 16 Size estimation of populations Sequence of Activities S.No Activity/steps in the process 1 Process XI Site validation , mapping, Target setting Selection of NGOs (as outlined below)

Head of the programme divsions

Responsibility head Head of TI Division, Programme Officers/ Technical Officers Description

Sequence of Activties S.No 1 Activity/steps in the process Open advertisement is given on specific scope of work to obtain applications Preliminary screening of applications is done by Technical Advisory Committee (TAC) comprised of JD/DD/AD TI, Procurement Officer, one member from TSU, One NGO representative of the Executive Committee. The JD/DD/AD TI is the convenor. NGOs/CBOs/Network who are legally registered under Societies Registration Act of 1860, Charitable and Religion Act, 1920, The Indian Trust Act, 1920, Cooperatives professional bodies such as IIPA, IMA. The TAC accepted applications and recommend for a JAT, seek clarification in writing or may reject application after recording specific reasons Responsibility head Head of TI division, NACO

Head of TI division, NACO/ SACS/TAC/TSU

Head of TI division, NACO/SACS

Head of TI division, NACO/SACS

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The selected applicants would undergo a Joint Appraisal Team(JAT) visit comprising of Technical Officer of SACS ( may be district/zonal designate person), financial consultant and one external technical consultant. The external experts should be well experienced and have strong programme management expertise The JAT Team would review records and registers, discuss with board members of the applicants, visit field/sites to assess the project work and rapport. The team will score in a specified score sheet The TAC will review the JAT team reports TAC recommend to the SACS Project Director the short listed organisations for conducting needs assessment The needs assessment is part of the project activities and is done by the NGO after signing of the contract

Head of TI division, NACO/SACS

Head of TI division, NACO/SACS

Head of TI division, NACO/TAC

Head of TI division, NACO/TAC

Head of TI division, NACO/TAC/SACS

Process 17 Contracting and monitoring of NGOs by SACS/NACO and technical support units Process 18 Evaluation of TI projects

Description

Description

TIs are contracted through the system of advertisement, shortlisting, field assessments and committee decisions. Third party evaluations at the end of contract periods to access programme delivery and organizations/financial capacity

Sequence of Activities S.No 1 Activity/steps in the process Review of NGO documents and assessment of field level of activity Standardized evaluation tool prepared by TI division, NACO Responsibility head Head of TI Division, Programme Officers/ Technical Officers Head of TI Division, Programme Officers/ Technical Officers

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Action-7: Describe Duties of Each Designated Position Sl. 1 Designation Deputy Director General/Assistant Director General/Joint Director Responsibility Oversight of the division, Planning and coordination of implementation of the programme, Monitoring and review of the actions to make the process and move forward Allocation of work to subordinates and oversight of their performance Coordination with Development partners and other stake holders Programme planning and implementation and monitoring Providing technical support to the states Assist in development of technical and operational guidelines Monitor the progress in expenditure against the budget allocated for the activities including the SACS components Preparation of various reports 3 Technical Officers Assist in programme planning and implementations Develop training plan and coordinate the activity with SACS Identify and plan for procurement of required equipments, supplies and consumables for the programme Assist in monitoring and evaluation of the programme activities Providing technical support to the states Preparation of various reports 4 Office Assistant
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Programme Officers

Admin tasks associated with the programme divsion

Action-8: Prepare a List of Documents Docum ent No. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 Document Title Annual Action Plan and State Annual Action Plan Operational Guidelines for Integrated Counselling and Testing Centres(2007) Cabinet Note Annual report/ News Letter Responses for parliament/ RTI/ Court cases Training Module Guidelines for Network of Indian Institutions for HIV/AIDS Research (NIIHAR) Guidelines for Prevention and Management of Common Opportunistic Infections NACO Ethical guidelines for Operational Research NACO IEC operational guidelines Voluntary Blood Donation- Operational Guidelines Targeted Intervention for Operational guidelines for Migrants, HRGs, Truckers Surveillance operational guidelines
Guidelines for ART in adults & adolescents- March 2007 (Updated: April 2009) Guidelines for ART in children- November 2006 (Updated; September 2009) Guidelines for prevention and management of common Opportunistic infections and malignancies among adults and adolescents- March 2007 Operational guidelines for ART centres- March 2007 (Updated: May 2008 & August 2009) Operational guidelines for Link ART centre/LAC Plus - January 2012

Responsibilit y All officers All Officers All Officers All Officers All Officers Respective Programme Head DDG (M&E)
Head of the Division (CST), NACO DDG (M&E) DDG (M&E) ADG (BS) DDG (TI) DDG (M&E) Head of the Division (CST), NACO Head of the Division (CST), NACO Head of the Division (CST), NACO Head of the Division (CST), NACO Head of the Division (CST), NACO Head of the Division (CST), NACO Head of the Division (CST), NACO Head of the Division (CST), NACO Head of the Division

Post exposure Prophylaxis guidelines- January 2009

Technical guidelines on second line ART in adults and adolescentsNovember 2008 (Updated in February 2012) Technical guidelines for alternate first line ART- October 2009 (Updated: February 2012) Technical Guidelines for Early infant diagnosis - January 2010 20

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Technical guidelines on second line ART for children- October 2009

Training manual for ART Medical Officers May 2007, Updated: December 2010 Training Manuals for specialists- May 2007, Updated: December 2010

Training module for Link ART Centre doctors

Guidelines for Community Care Centres: October 2010

Draft guidelines for HIV care for prisoners: September 2009

Guidelines for Air Borne infection control: September 2009

Scheme for Centres of Excellence in HIV Care: January 2012

Scheme for Paediatric Centres of Excellence in HIV Care: December 2011

(CST), NACO Head of the Division (CST), NACO Head of the Division (CST), NACO Head of the Division (CST), NACO Head of the Division (CST), NACO Head of the Division (CST), NACO Head of the Division (CST), NACO Head of the Division (CST), NACO Head of the Division (CST), NACO Head of the Division (CST), NACO

Evaluation reports Tour reports

Respective Programme Head All Officers

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ACRONYMS
AAP AIDS ANC ART ARV BCSU BSD CCC CMIS CST DAPCU DD DDG EOI FSW HIV HRD HRG HSS ICTC IDU IEC JD LWS M&E MSM NACP NGO NIHAR NRHM OI PLHA PO PPTCT RCH RFP RNTCP RRC RTI SACS SIMU SMO STI TI TO TRG US Annual Action Plan Acquired Immuno Deficiency Syndrome Ante Natal Clinic Antiretroviral Therapy Anti Retro Viral Blood Component Separation Unit Basic Services Division Community Care Centres Computerised Management Information System Care, Support and Treatment District AIDS Prevention and Control Unit Deputy Director Deputy Director General Expression of Interest Female Sex Worker Human Immuno-deficiency Virus Human Resource Development High Risk Group HIV Sentinel Surveillance Integrated Counseling & Testing Center Injecting Drug User Information, Education and Communication Joint Director Link Worker Scheme Monitoring & Evaluation Men having Sex with Men National AIDS Control Programme Non-Governmental Organisation Network of Indian Institutes of HIV/AIDS Research National Rural Health Mission Opportunistic Infection People Living with HIV/AIDS Programme Officer Prevention of Parent to Child Transmission Reproductive & Child Health Request for Proposal Revised National TB Control Programme Red Ribbon Club Reproductive Tract Infection State AIDS Control Society Strategic Information Management Unit Social Marketing Organisation Sexually Transmitted Infection Targeted Intervention Technical Officer Technical Resource Group Under secretary