HIV (Human Immunodeficiency Virus) and AIDS (Acquired Immunodeficiency Syndrome) have had the misfortune of being associated with more stigma than they deserve. This very impenetrable wall of myth and stigma around the disease has made treating the condition and curbing its spread an exhausting challenge for the world organizations and governments.
India has the third largest number of People Living with HIV (PLHIV) in the world after South Africa and Nigeria. In 2013, the HIV prevalence in India was an estimated 0.3%, which amounts to around 2.1 million people.
But the good news is that India’s HIV epidemic is slowing down, with a 19% decline in new HIV infections from 3.2 million people in 2007 to 2.1 million in 2013. In addition, there has been a 38% decline in AIDS-related deaths between 2005 and 2013.
These significant changes could not have been made possible by taking a shot in the dark. The Government of India has been taking well-measured, wisely-directed initiatives to reduce the prevalence and spread awareness around of HIV/AIDS.
The Approach to AIDS and HIV in India
The National AIDS Control Program (NACP) is a completely centre-sponsored scheme. First launched in 1992, NACP is India’s first national health program for the prevention and control of AIDS. The National AIDS Control Organisation (NACO) was constituted by the Ministry of Health and Welfare to implement this program. More programs (NACP-II and NACP-III) were launched in consecutive years to continue the work started by the initial scheme.
The current version of NACP is NACP-IV, which takes effect from 2012 to 2017. NACP-IV aims to reduce new infections and provide comprehensive care and support to all People Living with HIV (PLHIV), as well as treatment services for anyone who requires it.
After a little over two decades of this organized battle against AIDS and HIV, India currently seems to be making good progress. From gauging the problem to identifying susceptible locations and high-risk populations, NACP has utilized data very effectively.
Targeted Interventions for High Risk Groups
Considering the fact that more than 99% of the population is HIV negative, prevention is the main approach of NACO. However, identification of high-risk behavior populations is crucial for directing treatment and follow-up initiatives as well as curbing fast HIV growth.
Female Sex Workers (FSW), Men who have Sex with Men (MSM), Transgender (TG) or hijras, and Injecting Drug Users (IDU) have been identified as the high-risk groups (HRGs) in India. Truck drivers and migrants were identified as Bridge populations since they tend to transfer HIV from HRGs to the general population.
Identifying these high-risk groups has allowed for the creation of effective targeted interventions. Targeted interventions include efforts directed towards a particular high-risk group in a fixed geographical location. These are implemented by various Non-Governmental Organizations (NGOs) and Community-Based Organizations (CBOs). Linkages to Integrated Counseling and Some of these targeted interventions include building testing centers for HIV testing, providing care and support services for HIV-positive HRGs, peer counseling, distribution of clean needles and syringes, Opioid Substitution Therapy, community mobilization and ownership building.
Being able to target these interventions at relevant populations or locations has been highly effective, as is evident from the numbers. HIV prevalence has gone from 5.06% in 2007 to 2.67% in 2011 among FSW and from 7.41% in 2007 to 4.43% in 2011 among MSM.
HSS: The Main Tool for Collecting Data on HIV in India
HIV Sentinel Survey (HSS) is NACO’s HIV epidemic monitoring tool. It helps NACO understand the levels and trends of the HIV epidemic among the general population, bridge populations and high-risk groups in different states. HSS allows for the collection of concrete data, which is used to prioritize resources, evaluate program impact and estimate the prevalence and burden of HIV/AIDS.
Over the last 15 years, HSS has expanded greatly to cover a huge population. HSS 2012-13 was implemented in 556 districts across 34 states and union territories in India. A total of 741 sentinel surveillance sites (where HSS data is collected) were selected. These surveillance sites focus on HRGs, including FSWs, truckers, migrants, fisher folk/seamen, injecting drug users etc. In addition, the surveillance sites include antenatal clinics, since data from the pregnant women at antenatal clinics is considered a marker for the prevalence of HIV among the general population.
HSS uses both consecutive sampling and unlinked anonymous testing to improve the quality of collected data. Consecutive sampling, which reduces sampling and response bias, is a method in which every subject meeting the inclusion criteria is sampled till the sample size is met. In unlinked anonymous testing, the data is not linked to the individual participant and even the investigator does not know the characteristics of the individual being surveyed.
Despite an overall increase in the number of surveillance sites, the total number of surveillance sites that recorded an HIV prevalence of 1% or more has been on a consistent decline. In 2008-09, 133 of 639 sites had a prevalence of 1% or more. In 2012-13, this number fell to 80 of 741 sites.
Using HSS Data to Prioritize State Implementation
In NACP-III, India’s districts were categorized into 4 groups for the ease of planning and implementation of the program. This categorization was based on data from HSS from 2003, 2004 and 2005. Prevalence rates among Antenatal Clinic attendees and people in HRGs in each district were the criteria for classification.
After adding sentinel sites, there are 156 Category A districts and 39 Category B districts (Total of 195 districts) that call for priority attention. 122 of 156 Category A districts fall in the six high-prevalence states of Andhra Pradesh, Karnataka, Tamil Nadu, Maharashtra, Manipur and Nagaland.
Besides allowing focused intervention, these results help us keep a track of district-wise performance and new emerging pockets.
IBBS: Collecting Further Data on HIV-Related Behaviors
National Integrated Biological and Behavioral Surveillance (IBBS) is an ancillary program being implemented by NACO as a strategic focus to strengthen surveillance among high-risk groups and the migrant population. It continues to generate evidence on prevalence and risk behaviors to support prioritization of program planning.
IBBS follows the key risk populations in specific regions and tracks HIV-related behaviors and HIV prevalence. This allows NACO to analyze behavioral data and link certain behaviors with HIV biological findings. IBBS also helps NACO report about changes in HIV-related risk behaviors among the key risk groups.
Other Initiatives for HIV in India
Project Kavach, The Sonaguchi Project, Avahan, Link Worker Scheme, The Condom Social Marketing Programme etc are some of the many successful targeted interventions for HIV prevention and control. A majority of these are funded by NACO, UNDP or other global organizations. In general, these projects are low-cost initiatives that work for rights advocacy, community mobilization, awareness and behavior change. They are very closely associated with the high-risk groups.
NGOs working with groups such as TG and MSM often face non-cooperation and even harassment by government and non-government organizations due to the taboo associated with these populations. However, these organizations play a major role in bringing about a difference at the grassroots level.
The Way Forward
India has come a long way in terms of our approach to the disease. The development of Anti-Retroviral Therapy has positively impacted the quality of life and reduced mortality rates significantly for PLHIV.
Back in the early 1990s, universal precautions for the control of AIDS was thought as the mainstay solution for curbing the spread of HIV and AIDS. Data has had a major role to play in the changed approach to the disease. Now we are attacking the active loci that act as sources of growing cases.
The well-prioritized, evidence-based health programs are yielding better results with fewer resources. Hopefully the road ahead will be less stigmatizing and uncertain for people with HIV/AIDS.