India's response to the HIV epidemic . The lancet: Vol 364, No9442.09

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India's response to the HIV epidemic . The lancet: Vol 364, No9442.09

India's response to the HIV epidemic

J V R Prasada Rao, N K Ganguly, Sanjay M Mehendale, C

Bollinger. e-MAIL: secyhlth@...

The lancet: Comment. Volume 364, Number 9442,09 October 2004.

Feachem, Executive Director of the Geneva-based Global Fund

to Fight AIDS, Tuberculosis and Malaria, recently stated that India

now has the world's largest number of HIV-infected people,

surpassing South Africa, and that India is " on an African

trajectory " . He has characterised the Indian Government's response

to the HIV epidemic as " way short of what is necessary to turn

around the epidemic " .1 Recent estimates showing an increasing burden

of HIV-infected citizens necessitates that India sustain and

intensify its commitment to HIV prevention and treatment. However,

it is equally important to recognise that the HIV epidemic in India

is not " on an African trajectory " and that the response of the

Indian Government reflects a commitment to addressing this critical

public-health priority.

A high absolute number of HIV-infected individuals does not

necessarily indicate that India will follow Africa in epidemic

terms. The populations of ten Indian states individually exceed that

of South Africa. The Indian HIV epidemic is complex and challenging,

reflecting the diversity and uniqueness of India's society and

population. Despite the documentation of HIV in the Indian and South

African populations at the same time in 1985-86, current UNAIDS

estimates of adult HIV prevalence in India (0•5-1•5%) and South

Africa (18•5-24•9%) reflect very different epidemic trajectories.2-5

Despite similar low rates of prevalence in urban pregnant women in

South Africa and the state of Maharashtra in 1990,4,5 current HIV

prevalence rates in pregnant women in South Africa are about ten-

fold higher than in Maharashtra (figure).

Figure: HIV prevalence in urban pregnant women

*Median of 4 four urban South African antenatal clinics (UNAIDS/WHO

Epidemiological Fact Sheet-2004 Update).5 †Median of six urban

Maharashtran antenatal clinics (NACO HIV Sentinel Surveillance

Program).4

Factors that could be responsible for different epidemic patterns in

India and South Africa are not clear. The 2001 Indian National

Behavioural Surveillance Survey (NBSS) reported extramarital sexual

contact within the previous year by 8•6% of men and 1•7% of women.6

A recent randomised community-based study of adults in 28 Chennai

slums found that 2•9% of men and less than 1% of women reported

extramarital sexual contact, with 1% and 0•2% HIV-infected,

respectively.7 Although these finding suggest a large number of

Indian adults are at potential risk for HIV infection, the adult

population at high risk for HIV in India might represent a smaller

percentage of the general population than some African and western

countries, where adult men and women more commonly report a history

of extramarital sexual contact.8

The recognition that the trajectory of the HIV epidemic in India is

distinct from some African countries is no justification for

complacency, because a 1% increase in the HIV prevalence in adults

would result in an additional 5 million infected people. The annual

budget for the National AIDS Control Programme has doubled over the

past 3 years to Rs4700 billion in 2004-05. A 2002 pilot programme

offering antenatal counselling, testing, and antiretroviral

treatment to prevent mother-to-child transmission in 11 sites has

now been expanded to 225 antenatal clinics, and is the largest

national antenatal screening programme in the world. A recently

started programme to provide highly-active antiretroviral therapy to

100 000 HIV-infected patients in India is supported by a Rs2000

billion investment. A recently constituted National Parliamentarian

forum has generated strong political support for additional HIV

programmes, including a large school-based adolescent education

programme and a national campaign to raise awareness about sexually

transmitted diseases and treatments. Although more effort and

resources are needed, the Indian Government's response reflects a

sincere, intensive, and long-term commitment to effective HIV

prevention and care. These efforts show that India is not complacent

about the problem of HIV/AIDS. In fact, eradication of poliomyelitis

and HIV/AIDS prevention are the most highly visible public-health

programmes in India.

The accuracy of HIV-infection estimates and projections, based on

seroprevalence data, limited surveillance coverage, and invalidated

presumptions will always be considered questionable. With the same

raw data collected by the governmental surveillance programme,

different groups have produced widely varying estimates. HIV

estimates could be enhanced by expansion of national surveillance

and prevention programmes to reach vulnerable populations in rural

and low-prevalence areas, as well as the addition of programmes

designed to measure HIV incidence in population groups at risk.

Although the increase in HIV infections in India is following an

Indian rather than an African trajectory, the epidemic continues to

demand a serious and sustained national commitment. India has many

experienced, dedicated, and tireless governmental and non-

governmental HIV-prevention and treatment advocates, health

professionals, and researchers who will continue to ensure that this

will not happen, and that the national response to the HIV epidemic

will remain a top public-health priority.

*J V R Prasada Rao, N K Ganguly, Sanjay M Mehendale, C

Bollinger

________________________________________

Ministry of Health and Family Welfare, Government of India, , New

Delhi 110 011 (JVRPR); Indian Council of Medical Research (NKG);

National AIDS Research Institute, Pune, India (SMM); and s

Hopkins University, Baltimore, land, USA (RCB)

________________________________________

secyhlth@...

We thank D Celentano, M Ghate, S Godbole, N Gupta, L Kant, R S

Paranjape, M A Phadke, S Ranade, J Sastry, and S Trainer for their

help in the review and preparation of this commentary. We declare

that we have no conflicts of interest.

1 Mahapatra. India overtakes South Africa as country with most HIV

cases. Seattle Post-Intelligencer Sept 16, 2004.

2 Simoes EA, Babui PG, TJ, Nirmala S. S.

Lashiminarayana CS, Quinn TC. Evidence of HTLV-III infection in

prostitutes in Tamil Nadu (India). Indian J Med Res 1987; 85: 335-

38. [PubMed]

3 Becker WB. HTLV-III infection in the RSA. S Afr Med J 1986; Oct 11

(suppl): 26-27.

4 UNAIDS/WHO. India: epidemiological fact sheet on HIV/AIDS and

sexually transmitted infections 2004 update. http://www.unaids.org/

en/geographical+area/by+country/india.asp (accessed Sept 28, 2004).

5 UNAIDS/WHO. South Africa: epidemiological fact sheet on HIV/AIDS

and sexually transmitted infections 2004 update.

http://www.unaids.org/

en/geographical+area/by+country/south+africa.asp (accessed Sept 28,

2004).

6 National AIDS Control Organization, Government of India. National

baseline general population behavioural surveillance survey, 2001.

http://www.nacoonline.org/publication.htm (accessed Sept 28, 2004).

7 Celentano DD, Srikrishnan AK, Sivaram S, et al. The HIV epidemic

in Chennai (southern India) remains concentrated in high risk

groups. XV International AIDS Conference, Bangkok, Thailand, July 11-

16, 2004: MoPeC3469.

8 White R, Cleland J, Carael M. Links between premarital sexual

behaviour and extramarital intercourse: a multi-site analysis. AIDS

2000; 14: 2323-31. [PubMed]

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