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HIV & AIDS in India
The adult HIV prevalence in India is 0.27 percent, as of 2011. 1 Whilst this figure is small relative to other middle-income countries, 2 the large population of 1.2 billion inhabitants means there are still around 2.1 million people living with HIV in India. 3
Overall, India’s HIV epidemic is slowing down, with a 57 percent decline in new infections between 2000 and 2011, and a 29 percent decline in AIDS-related deaths between 2007 and 2011. 4
India’s HIV epidemic varies across its 28 states. The four states with the highest number of people living with HIV (Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu) are all in the south, and account for 53 percent of all HIV infections in India. Despite this, the adult HIV prevalence is falling in these high prevalence states. However, in a few states in the north and northeast, HIV infections are rising. 5
Who is affected by HIV and AIDS in India?
Of all people living with HIV in India, 39 percent are women, and 7 percent are children. 6 In many low- and middle- income countries women are disproportionately affected by HIV, but men are more affected in India. This is because HIV transmission here is concentrated among high-risk groups that are predominantly male, such as truck drivers, migrants and clients of sex workers. The vast majority of infections occur through heterosexual sex. See our page on affected groups in India for more information.
Educating people about HIV/AIDS can be a challenge in India, as there are a number of major languages and hundreds of different dialects. This means that, although some HIV/AIDS prevention and education can be provided at the national level, many of the efforts are best carried out at the state and local level, via tailored programmes.
The Indian Government’s current National AIDS Control Programme, NACP-IV, is coordinating the 2012-2017 national response to the HIV epidemic. NACP-IV will focus on:
- Reducing new infections, especially maintaining low prevalence in areas where it is already low
- Targeting high-risk groups and vulnerable populations with prevention campaigns
- Promoting and improving access to treatment and care
- Preventing mother to child transmission (PMTCT)
- Reducing stigma and discrimination
- Building the capacities of state and district level facilities.
The Condom Social Marketing Programme (CSMP): was set up to get people talking about condoms and not be embarrassed to buy them. To increase uptake, condoms are being supplied in unusual places like petrol stations, wine shops and barbers, with 228 million condoms distributed by the end of 2012. This idea runs alongside the ‘Condom Bindas Bol!’ (Condom-Just say it!) campaign, a government initiative which started in 2006. 7
The Red Ribbon Express: is a train that began its journey on World AIDS Day 2007. 8 A year later the journey was completed, having travelled to 180 stations and reaching 6.2 million people with HIV/AIDS education and awareness. 9 The journey began for a second time in December 2009 and a third time in February 2012 reaching 11,400,000 people and training 100,000 in HIV knowledge and prevention. 10 The train now includes counselling and training services, HIV testing, treatment of sexually transmitted diseases (STDs) as well as HIV/AIDS education and awareness. 11
Link Workers Scheme: launched under NACP III, the scheme ensures rural communities are connected to the HIV support available around them. Rural communities around the world can be missed by HIV initiatives due to poor infrastructure and a lack of outreach work. Link workers liase between rural communities and HIV prevention services, HIV testing, HIV treatment and care, and support groups such as those for people infected and affected by HIV. Migrants particularly benefit from this scheme when they return home to rural areas, as they can now access services they may find difficult to access whilst away working. 12
Preventing mother-to-child transmission of HIV is high on the NACP-IV agenda. During 2012, about 63 percent of pregnant women in India had been tested for HIV, and 0.17 percent were diagnosed as HIV-positive. 13 Testing for HIV is important when pregnant, so that if positive, necessary measures can be taken towards preventing HIV being passed to the baby.
Of those who tested positive, 96 percent of mothers and babies received single-dose nevirapine (NVP) to prevent the transmission of HIV from mother to baby in 2012. 14 However, this form of PMTCT is no longer recommended by WHO. 15 In line with the 2010 WHO treatment recommendations for HIV prophylaxis among pregnant women, India have opted for Option B; providing mothers with effective triple antiretroviral regimens from 14 weeks of pregnancy, and either stopping after birth or breastfeeding, unless mothers are eligible to continue them (based on their own CD4 count). 16 17 Roll out of Option B began across Andhra Pradesh and Karnataka in September 2012.
In 2013, a study recommended providing voluntary counselling and testing to all Indian inhabitants once every five years. Having an HIV test is important to ensure you access essential HIV treatment early and counselling about how to prevent onward transmission of the infection. This would additionally expand lifespans, and be a cost-effective move for India. 18
In 2012, over 7 million people tested for HIV; of these, 2.5 percent received a HIV-positive test result. 19 India has certainly made progress in expanding HIV testing to its large population. However, too many people currently infected with HIV remain unaware of their status and there is still significant work to be done in this area. 20
HIV testing should be carried out voluntarily, with the consent of the individual concerned. The Indian government and NACO have established thousands of integrated counselling and testing centres (ICTCs) in India. By the end of 2012 there were 12,897 ICTCs in India, 21 compared to just 62 in 1997. 22
Treatment for people living with HIV
Antiretroviral drugs (ARVs) for HIV treatment have been free to people living in India since 2004. 23 Despite this, only 1.1 million, or 55 percent of those eligible for ARVs were receiving them in 2012. 24 WHO’s new 2013 treatment guidelines mean that even more people are now eligible for ARVs, emphasising the need for treatment access to be a priority area. 25
There are 380 ART clinics across the country in Medical Colleges and District Hospitals, however many people living with HIV have difficulty accessing the clinics. This highlights the importance of initiatives such as the Link Workers Scheme to link people in rural areas to healthcare facilities. 26 There are now also:
- 840 Link ART Centres which can administer certain ART services
- Link Plus ART Centres where ART eligibility and care can be determined
- 24 ART Plus Centres where second line treatment is available
- 239 Community Care Centres for advice and support. 27
At ART clinics, people living with HIV can access counselling, nutrition advice, HIV prevention education, and treatment for opportunistic infections; patients are also asked to come for a CD4 count test every six months. 28 In order to monitor the effectiveness of treatment regimens it is important that follow-up appointments are attended. India is beginning to roll out reminders to people about their CD4 testing appointments, with an aim to increase attendance. 29
For some patients, first line ART may become ineffective, especially if treatment adherence is poor. In this case, second line ART is recommended. As of 2012, many ART clinics across the country are providing second line ART; those that do not are linked to better-equipped clinics that do provide this kind of treatment and support. 30 31 NACP-IV aims to provide all second line ART free.
Stigma and discrimination in India
In India, as elsewhere, AIDS is often seen as “someone else’s problem”. Even as it moves into the general population, the HIV epidemic is still misunderstood among the Indian public. People living with HIV have faced violent attacks, been rejected by families, spouses and communities, been refused medical treatment, and even, in some reported cases, denied the last rites before they die. 32
While such strong reactions to HIV and AIDS exist, it is difficult to educate people about how they can avoid infection. In 2009, NACO carried out a population based survey in Nagaland, where it was shown that 72.8 percent of people surveyed believed HIV could be transmitted by sharing food with someone. 33 Education is therefore vital; however AIDS outreach workers and peer-educators have reported harassment, 34 and teachers sometimes face negative reactions from the parents of children that they teach about AIDS:
“When I discussed with my mother about having an AIDS education program, she said, ‘you learn and come home and talk about it in the neighbourhood, they will kick you’. She feels that we should not talk about it.” - Female student, Chennai 35
Stigma and discrimination is also alarmingly common in the health care sector. Negative attitudes from health care staff have generated anxiety and fear among many people living with HIV and AIDS. As a result, many keep their status secret. It is not surprising that for many HIV positive people, AIDS-related fear and anxiety, and sometimes denial of their HIV status, can be traced to traumatic experiences in health care settings.
"There is an almost hysterical kind of fear ... at all levels, starting from the humblest, the sweeper or the ward boy, up to the heads of departments, which make them pathologically scared of having to deal with an HIV positive patient. Wherever they have an HIV patient, the responses are shameful." 36
NACP-IV has made the elimination of stigma and discrimination a major focus for the next 5 years, using mass media campaigns such as the Red Ribbon Express, and television adverts. 37
Funding for the HIV epidemic in India
India’s NACP-IV aims to raise 90 percent of its funds domestically. 38 This would enable India to have a reliable source of funding that can be used for tackling the HIV epidemic.
- In 2011-2012 around $215 million was spent on the HIV/AIDS epidemic.
- Spending had fluctuated between 2007 and 2012. 39
- In 2006-07 $171 million was spent, which represented an increase of 28 percent from the previous year. 40
In financial year 2011-12, NACO spent 67 percent of its budget on prevention, and 17 percent on care and treatment. 41 The ratio of these figures is important to primarily stop new infections. Bridge populations such as migrants and truck drivers are still not receiving adequate HIV prevention information, meaning spending on the prevention budget needs to be kept high.
Continual investment in HIV/AIDS is important in a struggling health sector that faces a growing multitude of health challenges including malaria, diabetes, heart disease and cancer.
The HIV/AIDS situation in different states
The majority of states within India have a higher population than most African countries, so a more detailed picture of the crisis can be gained by looking at each state individually.
The following states have recorded the highest levels of HIV prevalence among the general population over recent years.
Andhra Pradesh in the southeast of the country has a total population of around 84 million. The adult HIV prevalence is around 4.52 percent as of December 2012; this figure remains the highest out of all states. 42 HIV prevalence at antenatal clinics was 0.3 percent in the same year. Acknowledging high-risk groups, there are a great number of targeted interventions for female sex workers, men who have sex with men (MSM) and migrants in this state. Along with Karnataka, these two states were the first to roll out Option B for PMTCT in September 2012. 43
As the third largest state, Bihar is emerging as one with high HIV prevalence at 3.76 percent among the general population and 0.16 percent among pregnant women. 44 Despite having the second highest adult HIV prevalence in India, the state is so large that the number of people living with HIV is smaller than in other states. There is high out-migration from this north-eastern state, and the HIV epidemic is spreading as migrants return home. NACP-III rolled out targeted prevention initiatives for returnee migrants during festivals in the area to try and avert new infections. The state is also a growing pocket for IDU transmitted HIV infections. 45
Goa, a popular tourist destination, is a very small state in the southwest of India (population 1.5 million). In 2012, HIV prevalence amongst general clients and antenatal clients was 1.59 percent and 0.16 percent respectively. 46 The Goa State AIDS Control Society reported that in 2008, a record number of 26,737 people were tested for HIV, of which 1018 (3.81%) tested positive. 47 Although HIV prevalence had declined by 2012, the number of people getting tested for HIV reduced over the 4 years too suggesting more is needed to promote HIV testing.
Karnataka, a diverse state in the southwest of India, has a population of around 61 million. HIV prevalence among general clients exceeded 3 percent in 2012, and was 0.16 percent among pregnant women. 48 Districts with the highest prevalence tend to be located in and around Bangalore in the south, or in northern Karnataka's "devadasi belt". Devadasi women have historically been dedicated to the service of gods. Despite being made illegal in 1988, the system has evolved into sanctioned prostitution, and as a result many women from this part of the country are supplied to the sex trade in big cities such as Mumbai. 49 Targeted interventions for sex workers are succeeding: the average HIV prevalence among female sex workers in Karnataka was just over 5 percent in 2011, a huge decrease on the 21.6 percent in 2004. 50
Maharashtra is a very large state with a total population of around 112 million. The capital city Mumbai (Bombay) is the most populous city in India, with around 14 million inhabitants. The HIV prevalence at antenatal clinics was 0.23 percent, and 3.45 percent among general clients in 2012. 51 At 6.89 percent, the state has the highest reported HIV prevalence among female sex workers as of 2011. 52 High prevalence was also found among injecting drug users (14.17%) and men who have sex with men (9.91%). 53
Manipur is a small state of some 2.5 million people in northeast India. Manipur borders Myanmar (Burma), one of the world's largest producers of illicit opium. In the early 1980s drug use became popular in northeast India and it wasn't long before HIV was reported among injecting drug users in the region. 54 Although NACO report a state-wise HIV prevalence of 12.89 percent among IDUs in 2010/11, studies from different areas of the state found prevalence to be as high as 32 percent in 2008. 55 56 Targeted interventions for female IDUs and sex partners of male IDUs are being rolled out in this state and three other north-east states. 57
The small north-eastern state of Mizoram has just over a million inhabitants. In 1998, an HIV epidemic took off quickly among the state's male injecting drug users, with some drug clinics registering HIV prevalence of more than 70 percent. 58 In recent years the average prevalence among this group has been much lower, at around 4-7 percent, until 2010/11 when prevalence doubled to 12 percent. 59 HIV prevalence at antenatal clinics was 0.59 percent in 2011, one of the highest in the country. 60
Nagaland is another small north-eastern state where injecting drug use is the driving force behind the spread of HIV. In 2003 HIV prevalence among IDUs was 8.43%, but has since fluctuated between 1-4 percent, recording 2.21 percent in 2010/11. 61 HIV prevalence amongst the general population and pregnant women was 2.12 percent and 0.84 percent respectively in 2011. 62
The Punjab, a state in northern mainland India, has shown an increase in prevalence among injecting drug users (13.8% in 2007, 26.4% in 2008-9) until declining to 21.1% in 2010-11. 63 However in 2010 it was reportedly thought that HIV prevalence among IDUs in the capital of the state, Amritsar, had reached 30 percent. 64 Denis Broun, head of UNAIDS in India has stated, "the problem of IDUs has been underestimated in mainland India, as most of the problem was thought to be in the northeast." 65
The future of HIV and AIDS in India
Various groups have made predictions about the effect that HIV and AIDS will have on India and the rest of
Asia in the future, and there has been a lot of dispute about their accuracy. For instance, a 2002 report by the CIA's National Intelligence Council predicted 20 million to 25 million AIDS cases in India by 2010 - more than any other country in the world.
66 India's government responded by calling these figures
completely inaccurate, and accused those who cited them of
67 The government has also disputed predictions that India’s epidemic is
on an African trajectory, although it claims to acknowledge the seriousness of the crisis.
According to UNAIDS, there has been improvement over time. Between 1996 and 2010 the rate of new HIV infections fell by 56 percent. 69 This trend is mainly due to a drop in infections in southern states; in other areas there has been no significant decline.
“The challenges India faces to overcome this epidemic are enormous. Yet India possesses in ample quantities all the resources needed to achieve universal access to HIV prevention and treatment… defeating AIDS will require a significant intensification of our efforts, in India, just as in the rest of the world” - Peter Piot, former Executive Director of UNAIDS. 70
The History of HIV/AIDS in India
- 20,000 reported AIDS cases worldwide, 71 but no reported cases of HIV or AIDS in India. 72
- A medical journal in January 1986, stated:
“Unlike developed countries, India lacks the scientific laboratories, research facilities, equipment, and medical personnel to deal with an AIDS epidemic. In addition, factors such as cultural taboos against discussion of sexual practices, poor coordination between local health authorities and their communities, widespread poverty and malnutrition, and a lack of capacity to test and store blood would severely hinder the ability of the Government to control AIDS if the disease did become widespread.” 73
- Later in the year, India’s first cases of HIV were diagnosed among sex workers in Chennai, Tamil Nadu. 74 Contact with foreign visitors thought to have transmitted HIV among sex workers, and there were calls for visitors to be screened for HIV. 75 76
- A National AIDS Control Programme was launched to co-ordinate national responses. Its activities covered surveillance, blood screening, and health education. 77
- By the end of 1987, out of 52,907 who had been tested, around 135 people were found to be HIV positive and 14 had AIDS. 78
- Most of these initial cases had occurred through heterosexual sex, but at the end of the 1980s a rapid spread of HIV was observed among injecting drug users (IDUs) in Manipur, Mizoram and Nagaland - three north-eastern states of India bordering Myanmar (Burma). 79
- In 1992 the government set up NACO (the National AIDS Control Organisation), to oversee programmes relating to HIV and AIDS. 80 It was able to make a number of important improvements in HIV prevention such as surrounding blood safety.
- By this stage, cases of HIV infection had been reported in every state of the country. 81
- Throughout the 1990s, it was clear that although individual states and cities had separate epidemics, HIV had spread to the general population. Increasingly, cases of infection were observed among people that had previously been seen as ‘low-risk’, such as housewives and richer members of society. 82
- In 1998, one author wrote:
“HIV infection is now common in India; exactly what the prevalence is, is not really known, but it can be stated without any fear of being wrong that infection is widespread… it is spreading rapidly into those segments that society in India does not recognise as being at risk. AIDS is coming out of the closet.” 83
- In 1999, the second phase of NACP-II aimed to reduce the spread of HIV through promoting behaviour change.
- The prevention of mother-to-child transmission (PMTCT) programme and the provision of free antiretroviral treatment were implemented for the first time. 84
- In 2001, the government adopted the National AIDS Prevention and Control Policy and former Prime Minister Atal Bihari Vajpayee referred to HIV/AIDS as one of the most serious health challenges facing the country. 85
- NACP III began in 2006, aiming to reach 80 percent of high-risk groups including sex workers, men who have sex with men, and injecting drug users with targeted interventions. 86 NACP III also sought to decentralise the HIV effort to the most local level, and engage more non-governmental organisations in providing welfare services to those living with HIV/AIDS. 87
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