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HIV & AIDS Impact in India
HIV and AIDS affect all segments of India’s population, from children to adults, female sex workers to housewives, and gay men to heterosexual people. However, HIV prevalence among certain groups (sex workers, injecting drug users, men who have sex with men, transgender women, truck drivers, and migrant workers) remains high; injecting drug users recorded the highest HIV prevalence in 2011 of 7.14 percent, compared to the national average of 0.27 percent. 1
It is thought that HIV in India has spread by first occurring among the most vulnerable populations (such as injecting drug users and female sex workers), then spreading to 'bridge' populations (clients of sex workers, migrants and truckers) and then finally entering the general population. 2
Women now account for around 39 percent of adult infections, and 86 percent of all infections are in the sexually active and economically productive 15 to 49 age group. 3 This means that most people living with HIV are in the prime of their working lives. Many are supporting families.
The fourth phase of India's National AIDS Control Programme (NACP IV) 2012-2017 aims to heighten targeted interventions for high risk groups and 'bridging populations', alongside ensuring treatment and care for all people living with HIV. 4
Key statistics 2011:
- Number of female sex workers: 8.68 lakh
- HIV prevalence: 2.67%
- HIV prevention activities coverage: 84.5%
Although sex work is not strictly illegal in India, associated activities - such as running a brothel – are. This means that police hostility and brothel raids can be justified by the authorities. Stigma and discrimination against sex workers restricts their access to healthcare, even if they actively seek it. 5
HIV prevalence among female sex workers (FSW) varies widely between districts and states: one study found prevalence ranged between 2 percent and 38 percent (averaging at 14.5 percent) among districts in the four high prevalence south Indian states Andhra Pradesh, Maharashtra, Tamil Nadu and Karnataka. 6
Despite statistics like this, sex workers in India are renowned for being successful at mobilising HIV prevention efforts that are run by sex workers, for sex workers. For example:
The Sonagachi project - central Kolkata (Calcutta)
This project was started in 1992 and its approach is based around three R’s: Respect, Reliance and Recognition – respecting sex workers, relying on them to run the program, and recognising their professional and human rights. In 1999 the project was handed over to the female sex workers themselves, creating the organisation ‘Durbar Mahila Samanwaya Committee’, a collectivisation of 65,000 sex workers that still runs today. 7 These women are peer-educators who teach others about HIV and AIDS in brothels, including the importance of using condoms with clients. 8
Between 1992 and 1995, condom use among Sonagachi sex workers rose from 27 percent to 82 percent. 9 HIV prevalence among sex workers in the area fell from 11 percent in 2001 to less than 4 percent by 2004. 10
The Sonagachi project has become internationally famous for its achievements, and the UN has used the project as a ‘best practice’ model for other sex worker projects around the world. 11
The Avahan prevention programme in South India
Since 2003 the project has been providing HIV prevention information and handing out free condoms, contributing to a rise in condom use as swiftly as 2004, coupled with a decline in HIV infections. Alongside sex workers, the project also tailors its HIV prevention work for MSM and the general population. It was estimated that in the four districts with the greatest rise in consistent condom use, 36-68 percent of new infections were prevented across a seven-year period. 12 In 2013 it was announced that during the last 10 years, Avahan's work has prevented 57 percent of HIV infections in the area. 13 This shows the success of targeted HIV prevention programmes when data collection is routinely monitored.
SANGRAM, in the state of Maharashtra
SANGRAM operates with a similar approach to the Sonagachi project: a peer education initiative trains sex workers about their rights and relys on them to manage the outreach programme. About 120 peer educators distribute more than 350,000 condoms to sex workers in the area every month. SANGRAM also runs a peer support network for men who have sex with men. 14 15
Another scheme benefitting FSWs is the Female Condom (FC) Scale Up Pilot Programme, which began in August 2012. In two districts in each of nine different states, the programme is handing out free FCs to women, particularly female sex workers. The FC allows women to have greater decision over condom use, and over 35,000 sex workers in theses districts are benefiting from the project. 16
Male sex workers (MSW) are a particularly neglected group in India. One study in suburban Mumbai reported an HIV prevalence of 33 percent among the study group (17 percent in men and 41 percent in transgenders). 17 All of the individuals in the study had reported anal sex and 13 percent had never used a condom, highlighting the need for increased attention and prevention efforts among this group.
Key statistics 2011:
- Number of transgender women: unknown
- HIV prevalence: 0.99%
- HIV prevention activities coverage: unknown
Indian Hijras, (or Aravanis in some areas) are men who have adopted a feminine gender. Hijras have a long history of culture and tradition in India. Past surveillance and monitoring of groups at high risk of HIV have not considered hijras and transgender women a group on their own, and instead have grouped them with men who have sex with men. NACP-IV recognised the faults with this, and since 2012 collects data and surveillance about hijras separately. 18 This was followed by a landmark decision in April 2014, in which the Indian Supreme Court recognised transgender people as a distinct gender. 19 It is hoped this new ruling will lead to a decline in the discrimination faced by hijras and increase their access to HIV services.
The traditional background of hijras is linked to higher alcohol and substance use than the general Indian population. This is coupled with lower levels of literacy, which is a barrier to accessing HIV information in itself. There is subsequently a need for Targeted Interventions for hijras to be delivered in a spoken word and image format. 20
Many hijras report unfair treatment in healthcare settings, due to the healthcare professional’s lack of education on their specific needs. Sex reassignment surgery (SRS) is only available free in a few government hospitals in Tamil Nadu. Due to the expense of private medical care, many people seeking SRS have seen unqualified practitioners and experienced problems in their aftercare. 21
Injecting drug users
Key statistics 2011:
- Number of IDUs: 1.77 lakh
- HIV prevalence: 7.14%
- HIV prevention activities coverage: 80.7%
HIV prevalence among Indian IDUs has remained relatively unchanged since 2007. 22 However the location of IDUs has changed. Thirty percent of IDUs reside in north-eastern states where injecting drugs is the major route of HIV transmission; many IDUs report sharing needles with friends. 23 However HIV prevention efforts have sought to reduce the number of new infections here. Instead, rising HIV prevalence among IDUs is now noted in north-western areas. 24
The Indian government adopted a harm reduction strategy as part of the third phase of its National AIDS Control Programme (NACP III), in 2008/09. 25 This strategy contains five components, including opioid substitution therapy (OST), 26 which is currently being scaled up. As of 2013, 107 government healthcare facilities provide OST, 45 of which were opened in in 2012/2013, which almost doubled the number in existence the previous year. Around 11,500 IDUs are currently benefiting from free OST. 27
“Harm reduction is the urgent, practicable and feasible HIV prevention method among Injecting Drug Users and their sex partners.”
The alarming levels of infection occurring through sharing needles and syringes have implications that extend beyond networks of drug users. Some of those who inject drugs are also sex workers or truck drivers, and many are sexually active, which can result in infection being passed on to their partners.
To address this, NACO provides free needles and syringes to IDUs through peer educators working for the various Targeted Intervention strategies. People are encouraged to return the used injecting equipment and swop it for new clean equipment; 44 percent of equipment was returned in 2012. 28 This will help prevent the spread of the HIV virus both within and beyond the IDU network.
In 2008 an opioid substitution therapy pilot programme was set up in the largest prison complex in South Asia, Tihar prisons. According to the UNODC in 2009, ‘the OST centre in Tihar is being viewed as a model by other countries in South Asia.’ 29 A scientific report found that the OST was beneficial for all the programme’s participants, both inmates and staff, during the 2008-2012 study. 30 But the pilot ended in 2012, and the Indian law still prevents IDUs from accessing harm reduction services whilst in prison. 31
Men who have sex with men
Key statistics 2011:
- Number of MSM: 4.27 lakh
- HIV prevalence: 4.43%
- HIV prevention activities coverage: 70.6%
Consensual same sex sexual conduct is illegal in India, since the Supreme Court of India's recriminalisation in December 2013. 32 Between 2009 and 2013, same sex conduct was legal, due to its decriminalisation in 2009 by the Delhi High Court. 33 34 The decriminalisation heightened access to HIV prevention and HIV treatment in the country for MSM. 35 Prior to 2009, the illegality forced MSM to hide their sexuality and prevented them from feeling comfortable accessing healthcare services. There is concern that the 2013 law will further hamper India's HIV response amongst MSM.
Around 11 percent of NACO’s Targeted Interventions are specifically for MSM. These interventions are important, especially in the years following the recriminalisation of sex between men when people are more reluctant to actively seek help. 36
In India, many MSM do not consider themselves homosexual, and many have female partners. A large study in Andhra Pradesh found that 42 percent of MSM in the sample were married, that 50 percent had had sexual relations with a woman within the past three months and just under half had not used a condom. 37 As such, unprotected sex between men can also present a risk to any women that they may subsequently have sex with.
The stigma surrounding MSM makes it hard for both the government and NGOs to reach them with information about HIV. Outreach workers and peer educators working with MSM have frequently been harassed by police, and in some cases arrested. In 2001, four members of the Naz Foundation Trust (an Indian NGO that works with MSM and other groups affected by HIV) were jailed for 47 days after police raided their offices:
“I was arrested for promoting homosexuality. The leaflets we use for our outreach work were dubbed obscene. The police claimed that the replica of a penis used to demonstrate the proper use of condoms was actually a sex toy!” - Arif Jafar, Naz Foundation 38
Funding provided by the Global Fund has allowed the Pechan programme to flourish. Pechan works with community-based organisations (CBOs) that focus on MSM, to build their capacity across 17 states. The aim of the 2010-2015 phase is to establish 90 new CBOs and strengthen 110 existing ones. Each CBO is linked with a government Targeted Intervention, and is awarded funds that they would not have received from the government budget. Pechan’s dedication helps to support MSM to access HIV services around the country. 39
Key statistics 2011:
India has one of the largest road networks in the world. Truck drivers spend long periods of time away from home; studies have shown that around a quarter to a third of long-distance truckers pay for sex whilst away working. 40
"There is no entertainment. It is day-in-day-out driving... When they stop, they drink, dine and have sex with women. Then they transfer HIV from urban to rural settings." 41
Sometimes, relations with sex workers occur at roadside ‘dhabas’, which act as both brothels and hotels for truck drivers. In other cases, drivers stop to pick up women by the side of the road, and transport them to another area after they have had sex with them. Both truck drivers and sex workers move from area to area, often unaware that they are infected with HIV.
In 2000, various State AIDS Control Societies tried to implement HIV prevention programmes for truckers, but it was swiftly realised that a national approach was needed to coordinate the effort. ‘Kavach’ was set up to run this intervention and to overcome the challenges of truckers crossing state boundaries. 42 A number of halt and transhipment locations across the country provide HIV education and awareness, free condoms and leaflets, and behaviour change communication. A 2013 study found that 76 percent of truckers who received targeted interventions consistently used condoms with paid female partners, compared to 65 percent of those who received no intervention.
As part of the fourth phase of the National AIDS control programme (2012-2017) 60 truckers interventions have been set up at major trans-shipment locations tasked with providing behavioural change education, condom and STI services to truckers. So far these interventions reach about 1.4 million out of an estimated 3 million truck drivers. 43
Other campaigns have targeted the wives and partners of truck drivers, who often become infected when their partner returns home after a long absence. The HIV epidemic is found to be the highest among women whose spouses work in the transport industry. 44
Key statistics 2011:
- Number of migrants: 72.0 lakh
- HIV prevalence: 0.99%
- HIV prevention activities coverage: 41.3%
A large number of people move around India for work. Studies from across the world have linked migration to multiple sexual partners and increased HIV transmission. 45 It has been said that migrants and other mobile individuals are bridge populations for HIV transmission between urban and rural areas, and between high-risk and low-risk groups.
NACP-IV is revising its Targeted Interventions for migrants. Previously, HIV interventions for migrants were focused at destination points. However it is increasingly being recognised that areas of high out-migration - the villages that migrants originate from - are vital places to spread messages about HIV prevention. This is because migrants return here to see family, or attend festivals periodically, and as a result HIV is spreading from high prevalence destination areas, to these low prevalence source areas. NACP-IV is organising awareness campaigns and health camps in these areas, where the Link Workers Scheme is also being scaled up. 46
Phase three of the Red Ribbon Express train has a focus on reaching migrant populations who are particularly at risk of HIV. Its strategy involves using its strength as an HIV service that migrates to focus on reaching places with high out-migration. 47
“Being mobile in and of itself is not a risk factor for HIV infection. It is the situations encountered and the behaviours possibly engaged in during mobility or migration that increase vulnerability and risk regarding HIV/AIDS.”UNAIDS 48
Migrants have the lowest perception of risk in all high prevalence states. For example, in Andhra Pradesh, 60 percent of female sex workers believe they are at risk of HIV infection, compared with only 5 percent of male migrants. 49 This suggests that the migrant population is not receiving enough HIV education, and that more effort needs to be made to reach these people.
As a result, NACO has recommend targeted HIV prevention programmes primarily for men who are both migrants and part of high risk sex networks, due to the extremely large size of the migrant population in India. 50
There is evidence that some prevention strategies have been successful in reducing HIV prevalence among certain groups in India. However despite these successes, there are still around 2.1 million people living with HIV. 51
The new recognition of transgender women and hijras as separate from the category of men who have sex with men should allow HIV interventions to become more specific and relevant to these people. As well as addressing high prevalence groups, more attention is needed for people perceived to be at low risk, such as married women, as HIV spreads amongst the general population.
"HIV prevention and intervention strategies need to focus on married, monogamous Indian women whose self-perception of HIV risk may be low, but whose risk is inextricably linked to the behaviour of their husbands". 52
AVERT has more information about prevention, stigma, treatment and the future of the HIV/AIDS epidemic in India.
- 1. NACO (2013) ' India: Annual Report 2012-13'
- 2. UNGASS (2008) 'India - Country progress report'
- 3. NACO (2013) ' India: Annual Report 2012-13'
- 4. NACO (2013) ' India: Annual Report 2012-13'
- 5. Shetty, Priya (2010, July 3rd) ' Meena Saraswathi Seshu: tackling HIV for India's sex workers' Lancet 376(9734)
- 6. Ramesh. B.M. et al (2008) 'Determinants of HIV prevalence among female sex workers in four south Indian states: analysis of cross-sectional surveys in twenty-three districts', AIDS 22(5):35-44
- 7. Durbar Mahila Samanwaya Committee (2013) ‘ History’
- 8. Mukerjee M., 'The prostitutes union', Scientific American, April 2006
- 9. Dutta et al. (2002) 'Strategizing peer pressure in enhancing after safer sex practices in brothel setting', Abstract TuPeF5332, The XIV International AIDS Conference
- 10. UNAIDS, AIDS Epidemic Update December 2005
- 11. UNAIDS (2000), ' Female sex worker HIV prevention projects: Lessons learnt from Papua New Guinea, India and Bangladesh '
- 12. Lippincott Williams & Wilkins (2013) ' Positive impact of a large-scale HIV prevention programme among female sex workers and clients in South India'
- 13. Michael Pickles et al (2013, September) ' Assessment of the population-level effectiveness of the Avahan HIV-prevention programme in South India: a preplanned, causal-pathway-based modelling analysis'
- 14. The Communication Initiative Network (2008) ' SANGRAM'
- 15. SANGRAM (2013) ‘ The Peer Intervention’
- 16. NACO (2013) ' India: Annual Report 2012-13'
- 17. Shinde. S. et al (2009) 'Male sex workers: are we ignoring a risk group in Mumbai, India?', Indian Journal of dermatology, venereology and leprology, Jan-Feb;75(1): 41-6
- 18. NACO (2013) ' India: Annual Report 2012-13'
- 19. BBC News (2014, 15 April) ' India court recognises transgender people as third gender'
- 20. UNDP, Venkatesan Chakrapani (2010) ‘ Hijras/transgender women in India: HIV, human rights and social exclusion’
- 21. UNDP, Venkatesan Chakrapani (2010) ‘ Hijras/transgender women in India: HIV, human rights and social exclusion’
- 22. NACO (2013) ' India: Annual Report 2012-13'
- 23. Rajatashuvra Adhikary et al (2013) ‘ Spatial distribution and characteristics of injecting drug users (IDU) in five Northeastern states of India’ BMC Public Health
- 24. NACO (2013) ' India: Annual Report 2012-13'
- 25. The Times of India, (2008, 17th June) ‘ A pill a day for substance abusers’
- 26. NACO (2008) ‘ Annual Report NACO 2008-09’
- 27. NACO (2013) ' India: Annual Report 2012-13'
- 28. NACO (2013) ' India: Annual Report 2012-13'
- 29. UNODC (2009, 23rd June) ‘India: Tihar Prisons – Looking Beyond the Bars’
- 30. UNODC (2013) ‘ Rolling out of Opioid Substitution Treatment (OST) in Tihar Prisons, India’
- 31. Harm Reduction International (2013) ‘ Support don’t punish: Experiences of community advocacy and harm reduction programmes’
- 32. UNAIDS (2013, December) ' UNAIDS calls on India and all countries to repeal laws that criminalize adult consensual same sex sexual conduct'
- 33. UNAIDS (2009, 7th July) 'Landmark Delhi High Court decision recognizes inappropriate criminalization as a barrier to health, human rights and dignity'
- 34. UNDP (2012, December) ‘ HIV and men who have sex with men: Country snapshots, India’
- 35. ILGA (2013) ‘ State-sponsored homophobia, A world survey of laws: Criminalisation, protection and recognition of same-sex love’
- 36. UNDP (2012, December) ‘ HIV and men who have sex with men: Country snapshots, India’
- 37. Dandona L., Dandona R. et al. (2005), 'Sex behaviour of men who have sex with men and risk of HIV in Andhra Pradesh, India', AIDS 2005: 19:611-19
- 38. Chatterjee P. (2006), ' AIDS in India: police powers and public health', The Lancet, Vol. 367 No. 9513, March 11-17 2006
- 39. India HIV/AIDS Alliance (2013) ‘ HIV Prevention: Pechan (2010-2015)’
- 40. Arvind Pandey et al (2011) ‘ Heading towards the Safer Highways: an assessment of the Avahan prevention programme among long distance truck drivers in India’ BMC Public Health
- 41. Global Health Council (2002) 'Truckers carry dangerous cargo', May 1
- 42. Sachin Juneja et al (2013, March) ‘ Impact of an HIV Prevention Intervention on Condom Use among Long Distance Truckers in India’, AIDS and Behaviour
- 43. Department of AIDS Control (2010, March) ' National AIDS Control Organisation (NACO) Annual Report 2009-2010'
- 44. NACO (2008) ‘ Annual Report NACO 2008-09’
- 45. Saggurti, N. et al (2008) 'HIV risk behaviours among contracted and non-contracted male migrant workers in India: potential role of labour contractors and contractual systems in HIV prevention', AIDS 2008, 22(5):127-136
- 46. NACO (2013) ' India: Annual Report 2012-13'
- 47. The Times of India (2012, 12th January) ' HIV 10 times more prevalent among migrants than general population'
- 48. UNAIDS (2001) ' Population Mobility and AIDS', Technical Update, February, p.5
- 49. UNGASS (2010, March 31st) ' India - Country Progress Report
- 50. NACO (2007, October) 'Targeted interventions under NACP III: Operational guidelines'. Vol II: Migrants and truckers
- 51. NACO (2013) ' India: Annual Report 2012-13'
- 52. Newmann. S. et al (2000) 'Marriage, monogamy and HIV: a profile of HIV-infected women in south India', International Journal of STD & AIDS 2000; 11:250-253