Trends in HIV incidence in India from 2000 to 2007

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Trends in HIV incidence in India from 2000 to 2007

The Lancet 2008; 372:289-290. DOI:10.1016/S0140-6736(08)61105-8

Arora a, Rajesh Kumar b, Madhulekha Bhattacharya c, Nico

JD Nagelkerke a d and Prabhat Jha a

India's HIV epidemic is of global interest. 2 years ago, we showed

that HIV prevalence in young women declined by about a third between

2000 and 2004 in the southern states of Andhra Pradesh, Karnataka,

Maharashtra, and Tamil Nadu.1 HIV prevalence at young ages (15–24

years) is a useful proxy for trends in HIV incidence. We now present

trends up to 2007.

Among 423 842 women aged 15–24 years tested nationally at antenatal

clinics, prevalence declined by 54% (95% CI & #8722;45 to & #8722;63; p<0•0001)

between 2000 and 2007 in south India, and there was no significant

change in north India (3%, & #8722;47 to 53; p=0•73) where HIV is less

prevalent (figure).

Declines in south India were similar if we analysed individual age-

groups, if we excluded Tamil Nadu, or restricted the analyses to each

individual state or to the sites tested continuously for at least 4

years. Women who use antenatal clinics differ from those who do not

in education, residence, and migration, but these demographic factors

remained similar from year to year. More research is needed to

understand why incidence has fallen in south India.

The most probable reason is reduced contacts with female sex work by

the husbands of tested women or increased condom use in sex work.

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Figure. Age-adjusted HIV prevalence among antenatal attendees aged 15–

24 years from 2000 to 2007 in high-prevalence southern states (Andhra

Pradesh, Karnataka, Maharashtra, and Tamil Nadu) and northern states

of India

Logarithmic trend line; test for trend by logistic regression, with

age adjustment to the entire study population, n=202 254 for south,

n=221 588 for north.

Although useful for estimating trends in HIV incidence, data from

antenatal clinics cannot estimate community prevalence reliably.

The National Family Health Survey of 2005–06 (NFHS-3)2 yielded lower

HIV prevalence nationally in adults (0•28%, 95% CI 0•25–0•31 at ages

15–49 years) than seen among women at antenatal clinics in our study

(0•60%, 0•57–0•63 at ages 15–49 years).

A study in one district3 suggested that women with HIV were over-

represented in public antenatal clinics, but we found that HIV

infection was associated with lower use of public antenatal clinics

within the NHFS-3. Among 8743 eligible women, survival analyses with

's regression of time since last antenatal clinic use yielded a

hazard ratio for HIV of 0•44 (0•22–0•90; p=0•02), after adjustment

for age and sampling unit.

The halving of new infections in south India and the lack of

demonstrable increases in the north would, at first glance, seem to

be consistent with India's downward revision of HIV prevalence in

2006 from 5•1 million to 2•5 million (range 2•0–3•1 million).

However, the revised prevalence estimates are based largely

on " hybrid " analyses that combine antenatal clinic and NFHS-3 data,

whereas earlier estimates were based on antenatal clinic data. The

NFHS-3 has biases also, including the under-representation of high-

risk groups.4

In conclusion, although the estimation of HIV trends is reasonably

robust, we caution that prevalence estimates remain uncertain.

Reliable estimation of prevalence requires combining various sources

of data, including information on AIDS mortality.5

We declare that we have no conflict of interest.

References

1. Kumar R, Jha P, Arora P, et al. Trends in HIV-1 in young adults in

south India from 2000 to 2004: a prevalence study. Lancet 2006; 367:

1164-1172. Abstract | Full Text | Full-Text PDF (172 KB) | CrossRef

2. International Institute for Population Sciences and Macro

International. National Family Health Survey (NFHS-3), 2005–2006.

India Volume I. Mumbai: IIPS, 2007:.

3. Dandona L, Lakshmi V, Sudha T, Kumar GA, Dandona R. A population-

based study of human immunodeficiency virus in south India reveals

major differences from sentinel surveillance-based estimates. BMC Med

2006; 4: 31. MEDLINE | CrossRef

4. Kumar R, Jha P, Arora P, Dhingra N for the Indian Studies of

HIV/AIDS Working Group. HIV-1 trends, risk factors and growth in

India In: National Commission on Macroeconomics and Health.

Background papers: burden of disease in India. New Delhi: Ministry of

Health and Family Welfare, 2005: 58-74

https://www.who.int/macrohealth/action/NCMH_Burden%20of...

accessed June 24, 2008)..

5. Jha P, B, Gajalakshmi V, et alfor the RGI-CGHR

Investigators. A nationally representative case-control study of

smoking and death in India. N Engl J Med 2008; 358: 1137-1147.

CrossRef

Affiliations

a. Centre for Global Health Research, St 's, Hospital,

University of Toronto, Ontario M5B 2C5, Canada

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

Education and Research, Chandigarh, India

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

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