|Year : 2007 | Volume
| Issue : 1 | Page : 1-5
Overview of HIV/AIDS in India
YS Marfatia, Archana Sharma, Megha Modi
Department of Skin and VD, Medical College and SSG Hospital, Vadodara, India
Y S Marfatia
Department of Skin and VD, Medical College and SSG Hospital, Vadodara
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Globally there are 40 million people living with human immunodeficiency virus (HIV)/ acquired immunodeficiency syndrome (AIDS). According to latest estimates based on National Family Health Survey (NFHS), released by National AIDS Control Organization (NACO), the National adult HIV prevalence in India is approximately 0.36% which corresponds to an estimated 2 to 3.1 million people living with HIV in the country. The new lower estimates are due to difference in surveillance method and do not mean a sharp decline in the epidemic. HIV prevalence has begun to decline in Tamil Nadu and other southern states with high HIV burden. There has been feminization of epidemic with an estimated 38.4% of infected adults being female. Eighty-six percent of the Indian population is unaware of their HIV status with only 57% population being aware of the preventive methods.
There are more than 4000 integrated counseling and testing centers (ICTCs) in the country. About 80,000 patients are accessing free antiretroviral treatment (ART) in 127 centers. PPTCT program has been scaled up in the county with Nevirapine as the regimen of choice. It has an efficacy rate of 48% in prevention of HIV transmission in the mother baby pair; there are chances of increased drug-resistance to ART in mothers who were treated with prophylactic single-dose Nevirapine.
These patients face a lot of stigma and discrimination. A 2006 study found that 25% of people living with HIV in India had been refused medical treatment on the basis of their HIV-positive status.
Keywords: Human immunodeficiency virus, India, prevalence, National AIDS Control Organization
|How to cite this article:|
Marfatia Y S, Sharma A, Modi M. Overview of HIV/AIDS in India. Indian J Sex Transm Dis 2007;28:1-5
| Global Estimates of HIV/AIDS|| |
The 40 million people now living with human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS), along with the families of the 20 million who have already died, are a stinging indictment of the world's collective failure to forestall a major and preventable epidemic. Over 15 million children - more than the total number of children in France or Germany or the United Kingdom - are orphans, their parents taken away from them at the most vulnerable point in their young lives. 
| History of HIV/AIDS in India|| |
India's first cases of HIV were diagnosed among sex workers in Chennai, Tamil Nadu. Most of the initial cases had occurred through heterosexual sex; but at the end of the 1980s, a rapid spread of HIV was observed among injecting drug users in Manipur, Mizoram and Nagaland.  In 1987, a National AIDS Control Programme was launched to coordinate national responses. Its activities covered surveillance, blood screening and health education.  In 1992, the government set up NACO (National AIDS Control Organisation), to oversee the formulation of policies, prevention work and control programs related to HIV and AIDS. In 2001, the government adopted the National AIDS Prevention and Control Policy.  NACP III was launched formally on 6 th July 2007. 
| Magnitude of HIV/AIDS in India|| |
According to the last year's estimates, India had 5.206 million HIV/AIDS patients (people aged between 15 and 49 years) in 2005. The UNAIDS later put it at 5.7 million, including the pediatric AIDS cases. For the first time, National Family Health Survey (NFHS), India's largest health survey, had specific questions on AIDS in its door-to-door survey conducted on 230,000 people.  The number of sentinel sites had gone up to 1,122 from 702.  Both sentinel site and NFHS data were integrated and a new internationally validated methodology was used to arrive at the new estimate. These new estimates released by the National AIDS Control Organization (NACO), supported by UNAIDS and WHO, indicate that national adult HIV prevalence in India is approximately 0.36%, which corresponds to an estimated 2.0-3.1 million people living with HIV in the country.  The new lower estimates do not mean a sharp decline in the epidemic.
In Tamil Nadu and other southern states with high HIV burden, where effective interventions have been in place for several years, HIV prevalence has begun to decline or stabilize. The 2006 surveillance data [Table - 2] has identified selected pockets of high prevalence in the northern states. There are 29 districts with high prevalence, particularly in the states of West Bengal, Orissa, Rajasthan and Bihar.  India's highest prevalence of HIV/AIDS cases has been observed in the Dharwad district of Karnataka. 
Feminization of the HIV/AIDS epidemic
The HIV/AIDS epidemic is increasingly affecting women and young girls, especially where heterosexual sex is the main mode of transmission.  Out of the estimated adults living with HIV, 38.4% were females.  Women are less educated, more overworked, underpaid and financially dependent on men. They fail to make use of protective measures (condoms) which are male driven, and also they lack the power to negotiate with their partner. Ironically, they are faithful but are infected by their single partner.
The greatest boon of nature to women is the capacity to conceive, and the greatest curse is her inability to control the same.
Trend of HIV prevalence among different population groups in India
The vast majority of infections occur through heterosexual sex, and most of those who become infected would not fall into the category of high-risk groups [Figure - 1]. HIV prevalence was >1% among antenatal mothers in 95 districts, including 9 districts in the low-prevalence states. Similarly, HIV prevalence was >10% in 34 STD sites across the country, indicating multiple heterogeneous epidemics. Year-wise trend of HIV prevalence in different population groups is shown in [Figure - 2]. 
The HIV/AIDS situation in different states
The vast size of India makes it difficult to examine the effects of HIV on the country as a whole. The HIV prevalence data for each state [Figure - 3] is established through antenatal clinics, where pregnant women are tested. The following states have recorded the highest levels of HIV prevalence at antenatal and sexually transmitted disease (STD) clinics over recent years.
The HIV prevalence at antenatal clinics was around 2% in both 2004 and 2005 - higher than in any other state. The vast majority of infections in Andhra Pradesh are believed to result from sexual transmission. HIV prevalence at STD clinics was 22.8% in 2005.
Goa is known as a tourist destination. Tourism is so prominent that the number of tourists almost equals the resident population, which is about 1.3 million. The HIV prevalence at antenatal clinics was found to be above 1% in both 2002 and 2004 but was 0.5% in 2003 and 0% in 2005. This variation is likely due to the small number of women tested; the 2005 survey included only two antenatal sites. Prevalence at STD clinics was 14% in 2005, indicating that Goa has a serious epidemic of HIV among sexually active people.
In Karnataka, the average HIV prevalence at antenatal clinics has exceeded 1% in all recent years. Districts with the highest prevalence tend to be located in and around Bangalore, in the southern part of the state, or in northern Karnataka's ' devadasi belt.' These days, this has evolved into sanctioned prostitution; and as a result, many women from this part of the country are supplied to the sex trade in big cities such as Mumbai. The average HIV prevalence among female sex workers in Karnataka was 18% in 2005.
Mumbai is the capital city of Maharashtra state and is the most populous city in India, with around 20 million inhabitants. The HIV prevalence at antenatal clinics in Maharashtra has exceeded 1% in all recent years, and surveys of female sex workers have found rates of infection above 20%.
The HIV prevalence at antenatal clinics in Tamil Nadu was 0.88% in 2002 and 0.5% in 2005, though several districts still have rates above 1%. Prevalence among injecting drug users was 18% in 2005. Tamil Nadu had reported 52,036 AIDS cases to NACO by July 2005, which is by far the highest number reported by any state.
The nearness of Manipur to Myanmar (Burma), and therefore to the Golden Triangle drug trail, has made it a major transit route for drug smuggling, with drugs easily available. HIV prevalence among injecting drug users is above 20%, and the virus is no longer confined to this group but has spread further to the female sexual partners of drug users and their children. The HIV prevalence at antenatal clinics in Manipur has exceeded 1% in all recent years.
The small northeastern state of Mizoram has fewer than a million inhabitants. In 1998, an HIV epidemic took off quickly among the state's male injecting drug users, with some drug clinics registering HIV rates of more than 70% among their patients. In recent years the average prevalence among this group has been much lower, at around 5%. HIV prevalence at antenatal clinics has exceeded 1% in most recent years but was 0.88% in 2005.
Nagaland is another small northeastern state, with a population of 2 million, where, again, injecting drug use has been the driving force behind the spread of HIV. In 2005, the HIV prevalence at antenatal clinics was 1.63%, and the rate among injecting drug users was 4.51%.
| Testing|| |
Facilities providing voluntary counseling and testing (VCT) and 'prevention of parent-to-child transmission' services (PPTCT) were remodeled as 'Integrated Counseling and Testing Centres' (ICTCs). Today, more than 10 million people have been counseled and tested in more than 4,000 ICTCs spread throughout the country. The NACP III now envisages expansion of testing sites to 5,000 and establishment of another 10,000.
| Access to Antiretroviral Treatment (ART)|| |
Highly active antiretroviral treatment (HAART) - a form of treatment involving antiretroviral drugs (ARVs), which significantly delays the progression from HIV to AIDS - has been available in rich countries since 1996. Unfortunately, as in many poor countries, access to this treatment is severely limited in India, with only 7% of those in need receiving them by the end of 2005.  Ironically, India is the major provider of cheap generic copies of ARVs to countries all over the world. While the coverage of treatment remains unacceptably low, improvements are being made. Today, about 80,000 patients are accessing free treatment in 127 centers. 
| Prevention of Parent to Child Transmission|| |
It has been estimated that out of 27 million pregnancies in India, nearly 189,000 occur in HIV-positive mothers, leading to an estimated cohort of 56,700 infected babies (Joint Technical Mission on PPTCT). PPTCT program using Nevirapine was initiated in the country in 2001. However, by 2004, only 3.94% of all pregnant women received HIV counseling and testing, and only 2.35% of the HIV-positive pregnant women received antiretroviral drug prophylaxis. 
PPTCT program has been scaled up in the country with Nevirapine as the regimen of choice. With single-drug regimen, there has been a reduction of perinatal transmission of HIV from 40% to 11-13%. With effective ART, elective cesarean section and exclusive breast feeding, it has fallen to 2%.  Although the regimen is simple to deliver and has an efficacy rate of 48% in prevention of HIV transmission in the mother-baby pair, data suggests that there is increased drug resistance to ART in mothers who were treated with prophylactic single-dose Nevirapine.  A preliminary report from South Africa suggested that reducing viral replication by combining single-dose Nevirapine with postnatal AZT/3TC may lower Nevirapine resistance in women to about 10%. 
| Awareness Regarding HIV/AIDS Status|| |
Eighty-six percent of the Indian population is unaware of their HIV status. Only 57% of the general population and 80% of commercial sex workers are aware of preventive methods [Figure - 4],[Figure - 5]. 
| Stigma and Discrimination in India|| |
A 2006 study found that 25% of people living with HIV in India had been refused medical treatment on the basis of their HIV-positive status. It also found strong evidence of stigma in the workplace, with 74% of employees not disclosing their status to their employer for fear of discrimination. Of the 26% who did disclose their status, 10% reported having faced prejudice as a result. People in marginalized groups - female sex workers, hijras (transgender) and gay men - are often stigmatized not only because of their HIV status but also because they belong to socially excluded groups.
There is an urgent need to do more and to do it better, so that the results of our efforts can be counted in millions of infections prevented; millions of people living with HIV/AIDS living more productive, healthy lives; and millions of children, so heartlessly orphaned by the disease, being properly cared for. - Paul Wolfowitz, President, World Bank, November 2005 
| Acknowledgment|| |
I am indebted to all the postgraduate students of the Department of Skin and V.D., Govt. Medical College, Vadodara, for their untiring efforts in bringing out the present issue and for their wholehearted support and help in carrying out editorial work.
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[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]
[Table - 1], [Table - 2]