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HIV & AIDS in India
India has the third largest HIV epidemic in the world. 1 In 2013, HIV prevalence in India was an estimated 0.3 percent. This figure is small compared to most other middle-income countries but because of India's huge population (1.2 billion) this equates to 2.1 million people living with HIV. In the same year, an estimated 130,000 people died from AIDS-related illnesses. 2
Overall, India’s HIV epidemic is slowing down, with a 57 percent decline in new HIV infections between 2000 and 2011, and a 29 percent decline in AIDS-related deaths between 2007 and 2011. 3
HIV prevalence in India varies geographically. The four states with the highest numbers of people living with HIV (Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu) are in the south of the country and account for 53 percent of all HIV infections. However, HIV prevalence is falling in these states. By comparison, in some states in the north and northeast of the country, the number of new HIV infections is rising. 4
Key affected groups
Among key affected groups, sex workers and men who have sex with men have experienced a recent decline in HIV prevalence while the number of people who inject drugs living with HIV has remained stable. 5
However, transgender people are emerging as a group at high risk of HIV transmission. Moreover, in certain parts of the country, migrants and long distance truckers continue to act as bridge populations between certain groups and the general population, fuelling the HIV epidemic. 6
Sex workers and HIV in India
- Number of female sex workers: 868,000
- HIV prevalence: 2.7 percent
- HIV prevention activities coverage: 84.5 percent 7
HIV prevalence among female sex workers varies both between and within states. For example, one study found HIV prevalence among sex workers ranged between 2 percent and 38 percent (averaging at 14.5 percent) among districts in the four high prevalence south Indian states of Andhra Pradesh, Maharashtra, Tamil Nadu and Karnataka. 8
Although sex work is not strictly illegal in India, associated activities - such as running a brothel – are. This means that the authorities can justify police hostility and brothel raids. Stigma and discrimination against sex workers restrict their access to healthcare. 9
Male sex workers are a group particularly vulnerable to HIV who engage in high-risk behaviours. One study in suburban Mumbai reported an HIV prevalence of 33 percent among this group with all of the individuals in the study engaging in anal sex while 13 percent had never used a condom. 10
Men who have sex with men (MSM) and HIV in India
- Number of MSM: 427,000
- HIV prevalence: 4.4 percent
- HIV prevention activities coverage: 70.6 percent 11
In 2009, the Delhi High Court decriminalised same sex conduct. 12 However, in December 2013, India's Supreme Court re-criminalised adult consensual same sex sexual conduct raising fears about access to HIV prevention and treatment for MSM. 13
Indeed, stigma and discrimination act as significant barriers that make this group hard to reach with HIV information. Moreover, outreach workers and peer educators working with MSM have frequently been harassed or arrested by the authorities. 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 14
In India, many MSM have female partners. A large study in Andhra Pradesh found that 42 percent of MSM were married, while 50 percent had sexual relations with a woman in the previous three months. Just under half reportedly had not used a condom during their last sexual encounter. 15
Hijras / transgender people and HIV in India
- Number of transgender people: unknown
- HIV prevalence: 8.8 percent
- HIV prevention activities coverage: unknown 16
Hijras, (also know as Aravani, Aruvani or Jagappa in other areas) are names given to individuals in South Asia who are transgender. In India, past surveillance and monitoring of groups at a high risk of HIV transmission have not considered transgender people as a distinct group, often including them in MSM data. However, since 2012, the National AIDS Control Programme has collected data and surveillance about hijras separately. 17
The traditional background of hijras is linked to high-risk behaviours such as alcohol and substance use. Lower literacy levels act as a barrier to accessing HIV information. Many hijras also report unfair treatment in healthcare settings with staff lacking education on their specific needs. Indeed, there is a need for HIV interventions targeting this group. 18
In April 2014, the Indian Supreme Court recognised transgender people as a distinct gender. Many hope this ruling will lead to a decline in the stigma and discrimination faced by hijras and increase their access to HIV services. 19
People who inject drugs (PWID) and HIV in India
- Number of PWID: 177,000
- HIV prevalence: 7.1 percent
- HIV prevention activities coverage: 80.7 percent 20
HIV prevalence among PWID in India has remained largely unchanged since 2007. 21 30 percent of PWID reside in north-eastern states where injecting drug use is the major route of HIV transmission. However, HIV prevention efforts in this region have reduced the number of new infections. 22 By contrast, HIV prevalence among PWID in north-western states is increasing. 23
Research has emphasised the need for early interventions for PWID in India. Indeed, many embark on a 'drug career' in their early teens using widely available substances such as tobacco and alcohol before progressing on to illegal drugs through a non-injecting route (e.g. orally or smoking) and eventually using shared needles and syringes putting them at risk of HIV transmission. It is only at this point that PWID are typically reached by harm reduction services. 24 25
Migrant workers and HIV in India
- Number of migrants: 7.2 million
- HIV prevalence: 1 percent
- HIV prevention activities coverage: 41.3 percent 26
Research worldwide has linked migration to increases in HIV transmission. In India, migrants act as a bridge population spreading HIV between urban and rural areas, and between high-risk and low-risk groups. 27
“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." 28
Despite being an important driver of the HIV epidemic in India, data on migrant sexual behaviour is limited. Moreover, migrants have been found to have low risk perception of HIV transmission compared with other high-risk groups. For example, one study in Andhra Pradesh found that 60 percent of female sex workers acknowledged their risk to HIV infection compared with just 5 percent of male migrants. 29 One study from south-west India has suggested targeting migrants locally as well as at their destination could have 1.6 times the impact of only targeting migrants at their destinations. 30
Truck drivers and HIV in India
- Number of truckers: 2 million
- HIV prevalence: 2.6 percent
- HIV prevention activities coverage: 48.4 percent 31
A number of studies from India have reported the high vulnerability of truckers to HIV transmission with many engaging in high-risk behaviours - an estimated 36 percent of sex worker clients are truckers. Time away from home on the road, marital status, alcohol use, and income level have all been associated with visiting sex workers. 32 33
"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." 34
Moreover, knowledge of how HIV is transmitted is low among this group. One study from Uttar Pradesh reported a number of misconceptions including HIV transmission by mosquito bites, living in the same room, shaking hands and sharing food. 35
These factors, in combination with inconsistent condom use, mean truckers act as a bridge population transmitting HIV to their regular sexual partners and into the general population. 36
HIV testing and counselling (HTC) in India
In 1997, there were just 67 HIV testing and counselling (HTC) sites in India. By 2014, there were nearly 15,000 healthcare facilities offering HTC. In the same year, 13 million general users and 9.7 million pregnant women accessed HTC respectively against a target of 10.2 million for each group. 37 Despite this progress, only 13 percent of people living with HIV in India are aware of their status. 38
In order to address this issue, one study has proposed universal testing of the general population and more intensive testing of high-risk groups on a 5-year cycle. It is argued this would be cost-effective with models indicating that up to $1900 would be saved per year of life (YLS) in general and $1300 YLS among key affected groups. Additionally, more people would know their status and therefore actively seek treatment before developing AIDS-related illnesses encouraging behaviour change and decreasing viral load. 39
HIV prevention in India
The National AIDS Control Organisation (NACO) is the body responsible for formulating policy and implementing programmes for the prevention and control of the HIV epidemic in India.
In 1992, India's first National AIDS Control Programme, NACP-I (1992-1999) was launched with NACO responsible for its delivery. NACP-II (1999-2006) oversaw the formation of a National Council on AIDS mainstreaming HIV and AIDS as a development issue as opposed to a public health one. 40 NACP-III (2007-2012) focussed on targeted interventions to dramatically increase coverage among high-risk groups. 41
The current programme, NACP-IV (2012-2017), aims to reduce annual new HIV infections by 50 percent through the provision of comprehensive HIV treatment, education, care and support for the general population and build on targeted interventions for key affected groups and those at a high risk of HIV transmission. 42
Targeted interventions for key affected groups
A key component of the National AIDS Control Programme is the prevention of new HIV infections by achieving an 80 percent coverage of key affected groups with targeted interventions (TIs). 43
TIs are implemented on the premise that prevention of HIV transmission from key affected groups such as sex workers to their male clients (for example) will lower HIV transmission among their sexual partners - e.g. women in the general population. 44
Some of the most high profile interventions are listed below.
- Project Pehchan
Project Pehchan was launched in October 2010 in order to tackle the HIV epidemic among MSM, Transgender people and Hijra (MTH) in India. 45 Supported by the Global Fund, the 5-year project works with roughly 200 community based organisations across 17 states to reach over 450,000 MTH members. 46
The project enables MTH communities to access HIV and other sexual and reproductive health services. A community-driven project, Pehchan advocates for policy to create an enabling environment where MTH can easily access these types of services. 47
Since 2003, the Avahan project has worked to reduce HIV transmission among sex workers, MSM and transgender people through the provision of education as well as condom promotion, sexually transmitted infection (STI) management, behaviour change communication, community mobilisation and advocacy. 48
The programme has been highly effective with 36-68 percent of new HIV infections averted across the four focus states in a seven-year period. 49 In 2013, it was announced that over the previous 10 years, Avahan had averted 57 percent of HIV infections in southern India. 50 Avahan is internationally recognised as a cost-effective, successful, targeted HIV prevention programme. 51
- The Sonaguchi Project
Launched in 1992, the Sonaguchi Project promotes the use of healthcare services by sex workers to reduce HIV prevalence among this group. The project employs peer educators to provide information, distribute condoms, promote behaviour change and refer sex workers to health clinics. 52
Sex workers participate in all areas of the project and since 1999, have been responsible for its operation. In the same year, the Durbar Mahila Samanwaya (DMSC) evolved out of the project as a union representing sex worker rights. 53 The project has been promoted as a model of ‘best practice’ for other sex worker projects around the world. 54
- Project Kavach
Since 2004, the Kavach project has been working to stop the spread of HIV among truckers and other high-risk populations. The project reaches out to 21,000 truckers annually in Punjabi Bagh and Mangol Puri and encourages behaviour change through street plays, magic shows and peer education. It also provides healthcare services such as HIV and STI treatment, HIV testing and counselling as well as condom promotion. 55
HIV education and awareness in India
- Link Worker Scheme
Specifically, the scheme provides information resources on HIV and STI prevention, condom promotion and distribution, HTC and referral to treatment. Since the introduction of HTC in 2003, there has been a ten-fold increase in those identified as living with HIV in rural Chhattisgarh. 57 The project currently operates in 163 districts across 17 states. 58
- The Red Ribbon Express
Launched in 2007, the Red Ribbon Express is an HIV and AIDS awareness campaign train run by Indian Railways.
By 2013, the train had visited 23 states reaching more than 10 million people with messages about HIV prevention in rural parts of India. The train now also provides HIV testing and counselling (HTC) services and treatment for sexually transmitted infections (STIs) Most recently, the campaign has targeted young people. 59 60
- The Condom Social Marketing Programme (CSMP)
The Condom Social Marketing Programme (CSMP) aims to promote safer sex by improving the availability of condoms and by utilising multimedia to encourage behaviour change. To date, two mass media campaigns have been launched in Hindi as well as other regional languages. By 2014, the CSMP had distributed over 560 million condoms across 15 states from over 50,000 outlets. 61
Harm reduction in India
Under the National AIDS Control Programme, harm reduction in India is delivered through a number of means including needle and syringe programmes (NSPs), opioid substitution therapy (OST) and peer education in a variety of healthcare settings. These interventions are typically delivered by non-government organisations (NGOs) but are financially supported by the Indian government. Roughly 80 percent of an estimated 186,000 PWID are thought to be covered by existing programmes. 62
NACO actively distributes free needles and syringes to PWID through peer educators working for a number of TIs. PWID are strongly encouraged to return used injecting equipment and exchange it for new, clean equipment. In 2012, 44 percent of equipment was returned. 63
Opioid Substitution Therapy (OST) was incorporated into the harm reduction programme in 2008. To date, there are 150 OST centres supporting nearly 18,000 PWID. There are plans to increase this number to over 300 equating to a 20 percent OST coverage for PWID. 64 One of the first pilot programmes was set up in the largest prison complex in South Asia - Tihar prisons in Delhi. 65
Preventing mother-to-child transmission (PMTCT) in India
The Indian government is committed to eliminating new HIV infections among children by 2015. India's Prevention of Parent to Child Transmission of HIV/AIDS (PPTCT) programme started in 2002. To date, there are over 15,000 sites offering PMTCT services. 66 Based on 2013 WHO Guidelines, the programme initiates antiretroviral treatment for all pregnant and breastfeeding women living with HIV regardless of CD4 count or stage of HIV infection. 67
In 2013-2014, 9.7 million pregnant women accessed HIV testing against a target of 13.2 million - a coverage of 74 percent. Of the 12,000 pregnant women found to be living with HIV, 84 percent were provided antiretroviral drugs (ARVs) to prevent mother-to-child transmission of HIV. 68
Antiretroviral treatment (ART) in India
Free antiretroviral treatment (ART) has been available in India since 2004. At Indian ART clinics, people living with HIV can access testing and counselling (HTC), nutritional advice and treatment for HIV and opportunistic infections. Patients are required to take a CD4 count test every six months. 69 Moreover, the country is now rolling out reminders to people about their testing appointments with the aim of increasing overall attendance. 70 NACP-IV aims to make second-line ART free. 71
However, in 2012, only 55 percent of those eligible for ART received treatment (1.1 million). Indeed, many people living with HIV have difficulty accessing the clinics emphasising the importance of initiatives such as the Link Workers Scheme to link people to healthcare. 72 The introduction of the new 2013 WHO treatment guidelines is expected to make many more people eligible for ART, making treatment access a priority area. 73 Moreover, shortages of both first-line and second-line ARVs have become a feature in recent years. 74
HIV stigma and discrimination in India
In India, as in many other parts of the world, people living with HIV and AIDS face stigma and discrimination in a variety of settings including households, the community and workplaces. For example, parents and in-laws can blame women for infecting their husbands, while children can be denied the right to go to school. Key affected groups such as sex workers, hijras and MSM are stigmatised for being members of a socially marginalised group as well as their HIV status. 75
Stigma and discrimination is also very common within the healthcare sector. Negative attitudes among healthcare staff prevent many people from disclosing their status, while others will not seek treatment altogether.
"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." 76
Establishing an HIV and AIDS management policy, sensitising healthcare workers, mainstreaming HTC and making post-exposure prophylaxis available to staff have all been suggested as ways of reducing stigma and discrimination among healthcare workers in India. 77
NACP-IV has made the elimination of stigma and discrimination a major focus up until 2017, aiming to utilise mass media campaigns and existing interventions such as the Red Ribbon Express. 78
Funding the HIV response in India
Previously, efforts to tackle the HIV epidemic in India relied heavily on multilateral and bilateral funding. 79 However, India has increasingly taken responsibility for financing its HIV response and in 2012, committed to financing 90 percent of its HIV and AIDS programmes. 80
The proposed budget for NACP-IV is an estimated $2.5 billion with $1.6 billion from the Indian government and $0.6 billion coming from external sources such as the World Bank and the Global Fund. 82
The future of HIV and AIDS in India
Over the past decade, India has made significant progress in tackling its HIV epidemic, especially in comparison with other countries in the region. For example, while new HIV infections have fallen by more than half since 2001, the number of new HIV cases in neighbouring Pakistan has increased eight-fold. 83
A major reason for the country's success has been the sustained commitment of the Indian government through NACO and its National AIDS Control Programme. NACP III has been particularly effective at targeting high-risk groups such as MSM, sex workers and PWID to stem the wider epidemic. However, better HIV surveillance and targeted interventions are needed for groups such as transgender people, migrants and truckers with the latter acting as gateways for HIV into the general population.
While antiretroviral treatment is free, uptake remains low and requires a dramatic scaling up especially in the wake of the new 2013 WHO treatment guidelines. Moreover, stigma and discrimination remains a significant barrier preventing key affected groups and those at high risk of HIV transmission from accessing vital healthcare services.
However, hope has arrived in the form of an "HIV/AIDS Bill" submitted to NACO in 2006 and finally introduced to parliament in early 2014. The Bill prohibits discrimination in employment, education, healthcare, travel and insurance and calls for a legal commitment by the government to provide free antiretroviral treatment (ART). Moreover, it recognises a person living with HIV right to privacy and confidentiality about their HIV status. 84 85
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