Trends in HIV-1 in young adults in south India from 2000 to 2004: a prevalence s

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The Lancet Early Online Publication, 30 March 2006

The Lancet DOI:10.1016/S0140-6736(06)68435-3

Trends in HIV-1 in young adults in south India from 2000 to 2004: a

prevalence study

Rajesh Kumar a, Prabhat Jha b , Arora b, Prem Mony

c, Prakash Bhatia d, Peggy Millson b, Neeraj Dhingra b,

Madhulekha Bhattacharya e, S Remis b and Nico

Nagelkerke f, for the International Studies of HIV/AIDS (ISHA)

Investigators

Summary

Background

Major increases in HIV-1 prevalence in India have been predicted.

Incident infections need to be tracked to understand the epidemic's

course, especially in some southern states of India where the

epidemic is more advanced. To estimate incidence, we investigated

the prevalence of HIV-1 in young people attending antenatal and

sexually transmitted infection (STI) clinics in India.

Methods

We analysed unlinked, anonymous HIV-1 prevalence data from 294,050 women

attending 216 antenatal clinics and 58,790 men attending 132 STI clinics in

2000–04. Southern and northern states were analysed separately.

Findings

The age-standardised HIV-1 prevalence in women aged 15–24 years in

southern states fell from 1•7% to 1•1% in 2000–04 (relative

reduction 35%; ptrend<0•0001, yearly reduction 11%), but did not

fall significantly in women aged 25–34 years. Reductions in women

aged 15–24 years were seen in key demographic groups and were

similar in sites tested continuously or in all sites. Prevalence in

the north was about a fifth of that in the south, with no

significant decreases (or increases) in 2000–04. Prevalence fell in

men aged 20–29 years attending STI clinics in the south

(ptrend<0•0001), including those with ulcerative STIs

(ptrend=0•0008), but reductions were more modest in their northern

counterparts.

Interpretation

A reduction of more than a third in HIV-1 prevalence in 2000–04 in

young women in south India seems realistic, and is not easily

attributable to bias or to mortality. This fall is probably due to

rising condom use by men and female sex workers in south India, and

thus reduced transmission to wives. Expansion of peer-based condom

and education programmes for sex workers remains a top priority to

control HIV-1 in India.

Affiliations

a. School of Public Health, Post Graduate Institute of Medical

Education and Research, Chandigarh, India

b. Centre for Global Health Research, Public Health Sciences,

University of Toronto, Toronto M5C 1N8, Canada

c. Institute of Population Health and Clinical Research, St 's

National Academy of Health Sciences, Bangalore, India

d. Osmania Medical College, Hyderabad, India

e. National Institute of Health and Family Welfare, New Delhi, India

f. United Arab Emirates University, Al Ain, United Arab Emirates

Correspondence to: Dr Prabhat Jha (prabhat.jha@...)

[Guest guest]

[Moderators note: A review copy of the article " Trends in HIV-1 in young adults

in south India from 2000 to 2004: a prevalence study " is available from the

moderator]

Dear Forum ,

This article is probably well publicised and written as per the Lancets norms

hence i would like to see the full text before i can actually comment in

details.

But broadly some of the major anomalies ( which may have been answered in the

full text ) come to my mind in epidemiological parlance.

1) Unlinked anonymous testing but for data generation - which this study has

done to an extent must not be used and is unethical unless approved officially .

Imagine the ANC specially young women 15-24 who were positive and were not told

that they were positive or the young male STI cases who had a high risk

behaviour but were not told about their status ( If the study has been done

otherwise then the authors may kindly elaborate)

2) The prevalence rates of the ANC 15-24 studied over same areas where matched

controls were apparently from Northern India? The confounding variable being

studied was Condom usage? . Or was this an incidental finding not in the initial

design of the study?

3) Was condom usage in the North and South also quantified?? to actually come to

such conclusions??

4) The fact that in epidemiological trends world (Sub saharan Africa and south

east Asia) over younger women get a peak HIV prevalence compared to men seems

because of their vulnerability which is linked to many factors including

biological, cultural etc some how does not match with this study? or does it?

5) 216 ANC and 132 STI clinics do not in my opinion represent any standard which

can be extrapolated to the entire continent of India? Or has it been

mathematically derived at (I mean the actual nos of ANC and STI clinics?)

6) To my reasoning and to most experts who had carried out a met analysis of the

most at risk population ( FSW,IDU,MSM & transgender) at the national level there

is a big void or lack of data in the rural areas . Most of India is rural .Does

the distribution of the ANC /STI clinics ensure that rural India has been

covered?

Geographical and spatial considerations apart i feel More in depth analysis

should be carried out before commenting on prevalence being affected by condom

usage.

(I apologise if the study has taken care of the epidemiological parameters-- and

if possible i would like to see the whole text maybe the entire forum would like

to see it as well)

7) The variables which were not matched and studied in the original design may

also be kindly highlighted as this has generated many newspaper reports and

seems to be widely accepted as a validated trend in data or the way the epidemic

is shaping up in India.

(This hopefully will also raise more querries about such studies in the Forum

regarding scientfic validity as not just being published in Lancet)

Lt Col(DR) Anup Singh Gurung. Retd.AMC

E-mail: <anupsinghgurung@...>