In 2002, US National Intelligence Council made a projection: About 20-25 million people will be living with HIV in India by 2010. They got it wrong. “The future of the global epidemic is really at stake in India,” said the then director, UNAIDS, Dr Peter Piot, who discovered the Ebola virus in Zaire in 1976. He was right, both about Ebola and HIV in India, where all the right things were done to stop the epidemic from spiralling out of control.
India being home to the world’s third largest HIV population — after South Africa (7.1 million) and Nigeria (3.2 million) — has more to do with its 1.32 billion population than high infection rates.
Adult HIV prevalence in India is 0.28%, compared to South Africa’s 18.9%, shows UNAIDS data for 2017.
The number of people living with HIV in India has more than halved from 5.1 million in 2003 to 2.1 million in 2016 — partly because the World Health Organisation’s revised and enhanced methodology halved HIV estimates for India to 2.5 million in 2007.
India’s revised estimates, combined with the five sub-Saharan African countries of Angola, Kenya, Mozambique, Nigeria, and Zimbabwe, led to a 70% reduction in the global HIV prevalence over the previous year, with global estimates falling to 33.2 million from 39.5 million in 2006. The epidemic, however, had started levelling off in the early 2000s as a result of a two-pronged strategy: intensive HIV prevention campaigns among the most affected; and free testing and treatment under the National AIDS Control Programme (NACP) since 2004.
Tracking the infection
How HIV estimates are calculated
* Counting everyone newly infected, living with HIV, or who have died from AIDS-related causes would require testing everyone regularly and investigating all deaths, which is logistically impossible and ethically challenging.
* India uses UNAIDS-supported software to provide modelled estimates to track HIV.
*Around 4.45 lakh blood tests were done at 1,323 sentinel sites across 650 districts to reach the estimates for 2017.
* 829 sites were at antenatal clinics ¡V infection in pregnant women is a proxy for prevalence in the general population -- and 494 among high-risk groups and bridge populations, who spread the infection to the general population.
* India’s HIV epidemic continues to be heterogenic, with varied prevalence across locations and populations.
* It also continues to be concentrated among people who inject drugs, transgenders, men who have sex with men, and female sex workers and their clients, except in some specific pockets where it is generalised
Lowering risk
Lowering infections among high-risk groups such as transgenders and female sex workers (FSW) — so called as they are considered likely to engage in high-risk behaviours that spread HIV, such as unprotected sex and sharing needles and syringes — is among the big successes of NACP, the first phase of which started in 1992.
By 2004, India had expanded targeted interventions for FSWs, injecting drug users, men who have sex with men, transgender people, single male migrants, long-distance truckers etc in the six high prevalence states of Tamil Nadu, Andhra Pradesh, Karnataka, Maharashtra, Nagaland and Manipur.
In 2003, around one in 10 FSWs in India had HIV, the virus that causes AIDS. The number fell to one in 64 in 2017.
Infection fell the most among transgender people, with HIV prevalence dropping from 29.6% in 2006 to 3.14% in 2017 (transgender was not surveyed as a distinct group before 2006), followed by homosexual men.
The hard work continues to show results. The National AIDS Control Organisation’s (NACO) biennial HIV Sentinel Surveillance 2017 reports declining HIV prevalence trends in traditional high-prevalence states such as Andhra Pradesh, Karnataka, Maharashtra, Tamil Nadu and Telangana, with sharp falls in prevalence in all high-risk groups other than injecting drug users.
“India began focusing on high-risk groups and working with communities and those most affected before many other countries. The persistent focus on a decentralised response that offered prevention coverage of high-risk groups to saturation level, testing and treatment services, evidence-based programming and building technical capacity helped has shown results,” says Ashok Alexander, founder-director, Antara Foundation and head of the world’s biggest private HIV-prevention programme — Bill & Melinda Gates Foundation’s Avahan — for a decade till 2012.
What also worked in lowering new infections is India’s ‘test and treat’ policy, which puts everyone who tests positive on antiretroviral therapy (ART) used to treat HIV. ART boosts CD4 count — a measure of the robustness of the body’s immune system — and protects against potentially fatal infections, such as tuberculosis and pneumonia. It keeps people healthy, lowers viral load, and with it, their risk of infecting others.
India has been providing free ART to people with low CD4 count since 2004 and second-line drugs since 2008 to the infected, but switched to treatment for all in 2015 on the World Health Organisation’s recommendation. ART prevented 1.5 lakh AIDS-related deaths every year between 2007 and 2011.
Rocky road
Despite successes, old challenges remain and new threats continue to emerge. New pockets of infection have emerged in the highly-populated states of Gujarat, Bihar, Delhi, Chhattisgarh Rajasthan, Odisha, Uttar Pradesh and Jharkhand.
Of the 14 sites with more than 2% prevalence, five were in Bihar, Chhattisgarh, Odisha, Rajasthan and Uttar Pradesh, while one-third of the 56 sites with more than 1% prevalence were in Bihar, Chhattisgarh, Delhi, Gujarat, Jharkhand, Odisha, Rajasthan and Uttar Pradesh.
“I see more new infections in migrants and the general population, who are more difficult to reach with interventions,” said Manoj Pardashi, general secretary of the Pune-based National Coalition of People Living with HIV and AIDS.
“Five to six young men under the age of 25 come to get tested and treated at our community clinic on Lakshmi Road near Budhwar Pet, which is near the traditional red-light area in the old city of Pune. They are young, literate, middle-class and very scared, and don’t want to go to government clinics for treatment, fearing breach of confidentiality,” said Pardarshi.
“Those who can afford it get treated in the private sector,” he said.
Less than half the people with HIV are on ART, which means not enough people have the infection under control.
An estimated 62,000 people died from AIDS-related illnesses in 2016, the last year for which death statistics are available.
Among people at risk, injecting drug users have the highest HIV prevalence.
“India needs a national review of its harm-reduction policies to offer substitution therapy for de-addiction to all drug users, and not just injecting drug users, because oral users graduate to injecting drugs. India must also decriminalise behaviours, such as drug use and homosexuality, to ensure that harm-reduction services and treatment reach those who need them,” said Dr Bilali Camara, UNAIDS country director in India.