UNAIDS 2006 India AIDS Epidemic Update

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The following is the India section of the UNAIDS 2006 Update of AIDS

Epidemic. Due to formatting difficulty the fig 6 HIV prevalence in

India – by district, 2005 (Source: NACO. Sentinel Surveillance data,

ANC Sites (2005), is missing from this excerpt. [Moderator]

India

The world's second-most populous country, India, is experiencing a

highly varied HIV epidemic which appears to be stable or dimin¬ishing

in some parts while growing at a modest rate in others. Approximately

5.7 million [3.4 million–9.4 million] people, of which 5.2 million

were adults aged 15–49 years, were living with HIV in 2005.

As in China, the majority of HIV infections in India appear to be

occurring in a few regions. In the case of India, about two thirds of

reported HIV infections have been in six of the country's 28 states—

mainly in the industrialized south and west and in the north-eastern

tip. On average, HIV prevalence in those states is 4–5 times higher

than in the other Indian states. The highest prevalence rates are

found in the Mumbai-Karnataka corridor, the Nagpur area of

Maharashtra, the Nammakkal district of Tamil Nadu, coastal Andhra

Pradesh, and parts of Manipur and Nagaland (in the north-east of

India) (National AIDS Control Organization, 2005a; World Bank, 2005).

Notably, in the south of the country, infection levels in rural and

urban populations tend to be similar (World Bank, 2005).

A recent analysis of HIV data from 216 antenatal clinics and 132

sexually transmitted infection clinics for 2000–2004 suggest that HIV

preva¬lence among women aged 15–24 years in southern states declined

from 1.7% in 2000 to 1.1% in 2004 (Kumar et al., 2006). HIV infection

levels also fell among men aged 20–29 years who attended sexually

transmitted infection clinics in the south. (There was no evidence of

declining prevalence in northern states.) The authors have attributed

the trends to a postulated rise in condom use by men and female sex

workers in southern India, which is presumed to have reduced the

transmission of HIV (Kumar et al., 2006). However, further analysis

of the data collected suggests that the apparent reduction in HIV

prevalence in the south is due mainly to a decline in HIV prevalence

in Tamil Nadu (, 2006). Other analysts contend that insuf¬ficient

evidence exists to support the attribution of a decline in HIV

prevalence in the south to behaviour change (Hallett and Garnett,

2006).

The bulk of HIV infections in India are occurring during unprotected

heterosexual inter¬course (National AIDS Control Organization,

2005b). Consequently, women account for a growing proportion of

people living with HIV (some 38% in 2005), especially in rural areas.

HIV infection levels of over 1% have been found among pregnant women

in Andhra Pradesh, Maharashtra and Karnataka (National AIDS Control

Organization, 2004a). In 2004, mean HIV prevalence of 1.6% was found

in pregnant women in Karnataka, with AIDS the leading reported cause

of death in some northern districts; in some rural sub-districts,

prevalence ranged between 1.1% and 6.4% among adults, underlining the

highly varied character of the epidemic (Moses et al., 2006).

A large proportion of women with HIV appear to have acquired the

virus from regular partners who were infected during paid sex

(Lancet, 2006). In Mumbai and Pune (in Maharashtra), for example,

where 54% and 49% of sex workers, respectively, have been found to be

HIV-infected (NACO, 2005c), the likelihood of transmit¬ting HIV to

clients and their partners can be high. Indeed, in the higher-

prevalence states of the south, most HIV transmission appears to be

occurring between sex workers and their clients, and their other sex

partners (Kumar et al., 2005). In Karnataka, for example, almost one

quarter (23%) of 1100 female sex workers taking part in a recent

study were HIV-infected, as were almost one half (47%) of the women

operating out of brothels (Ramesh et al., 2006).

HIV prevention efforts targeted at sex workers are being implemented

in India. However, the law enforcement context of sex work is complex

and often acts as a barrier against effective HIV prevention and

treatment efforts (Dandona et al., 2006b). In addition, the

interventions tend to mostly target brothel-based sex workers, who

represent a minority of sex workers. Some prevention programmes run

by sex workers—in Sonagachi, Kolkata, for example—have encour¬aged

safe paid sex practices and have been associated with lower HIV

prevalence (Kumar, 1998; Jana et al., 1998). Building on those

experi¬ences, sex workers organizations have expanded their primary

prevention programme throughout the state of West Bengal to reach

some 28 000 sex workers in almost 50 areas (Roy et al., 2006).

However, risk-taking during paid sex is still commonplace in other

parts of India. In Andhra Pradesh, for example, one in four sex

workers canvassed in 13 districts had never used a condom, and one in

two used them inconsistently. More than half the street-based sex

workers said they never or seldom used condoms. Notably, those women

who knew that HIV infection could be prevented and who had access to

free condoms were significantly more likely to be using condoms

consistently (Dandona et al., 2005).

Injecting drug use is the main risk factor for HIV infection in the

north-east (especially in the states of Manipur, Mizoram and

Nagaland), and features increasingly in the epidemics of major cities

elsewhere, including in Chennai, Mumbai and New Delhi (MAP, 2005a;

National AIDS Control Organization, 2005). Products injected include

pharmaceuticals that are not illegal (such as buprenorphine,

pentazocine and diazepam), in addition to heroin. In Chennai, 31% of

injecting drug users were found to be HIV-infected in a recent study

(Srikrishnan et al., 2006).

Using contaminated injecting drug equipment is the main risk factor

for HIV infection in the north-east of India (especially in Manipur,

Mizoram and Nagaland), and features increasingly in the epidemics of

cities such as Chennai, Mumbai and New Delhi.

Currently, interventions among injecting drug users tend to be

inconsistent, and too small and infrequent to yield demonstrable

results (Basu and Koliwad, 2006). Harm reduction programmes need to

be extended and expanded as a matter of urgency in those parts of

India with serious drug injecting-related HIV epidemics. Failing

that, there is a possibility that the combination of injecting drug

use and paid sex could lead to larger HIV epidemics. A recent study

among men seeking treatment for sexually transmitted infec¬tions in

Mumbai clinics showed that among those patients who injected drugs,

12% were HIV-positive, 80% of whom had recently (in the past three

months) paid for sex and 27% of whom had themselves sold sex (Yu et

al., 2006). As of 2006, several needle exchange programmes were

operating in the North East, West Bengal and Delhi; however, only one

project using substi¬tution therapy has been started, in the state of

Manipur.

There has been little research on the role of sex between men in

India's HIV epidemic. In the two states where such data have been

collected, HIV prevalence of 6.8% and 9.6% were found among men who

have sex with men in Chennai and Mumbai, respectively (NACO, 2004b).

More recently, HIV prevalence of 12% was found among men who have sex

with men seeking voluntary counselling and testing services in

Mumbai, and 18% prevalence was found at 10 clinics in Andhra Pradesh

(Kumta et al., 2006; Sravankumar, Prabhakar, Mythri STI/HIV Study

Group, 2006). Those HIV infection levels were comparable to the 16%

prevalence found in that state in sentinel surveillance conducted

among men who have sex with men in 2004 (Andhra Pradesh State AIDS

Control Society, 2004). In some areas, a substantial proportion of

men who have sex with other men also sell sex: in a large study in

Andhra Pradesh, for example, one in four of the men sold sex to other

men (Dandona et al., 2006a). Poor knowledge of HIV has been found in

groups of men who have sex with men. In Bangalore, for example, three

in four men who have sex with men did not know how the virus is

transmitted, and a large proportion of them engaged in unprotected

sex with other men ( et al., 2006).

The extent and effectiveness of India's efforts to increase safe sex

practices between sex workers and their clients, and between men who

have sex with men (and their other sex partners) will likely

determine the scale and development of India's HIV epidemic (Kang et

al., 2005). In the north-east states, as well as in major cities

elsewhere, extensive harm reduction programmes are equally vital.

Amid all this, more must be done to combat stigma—which remains rife

in all walks of Indian society, including among health-care workers

(Mahendra et al., 2006)—and to reduce the gender and other

inequalities that make HIV prevention and treatment such a huge

challenge in this country (Lancet, 2006).

The highest national HIV infection levels in Asia continue to be

found in south-east Asia, where combinations of unprotected paid sex

and sex between men, along with unsafe injecting drug use, are

fuelling the epidemics in most countries.

ASIA 2006 AIDS Epidemic update

http://data.unaids.org/pub/EpiReport/2006/05-

Asia_2006_EpiUpdate_eng.pdf