India's response to the HIV epidemic

J V R Prasada Rao, N K Ganguly, Sanjay M Mehendale, Robert C
Bollinger. e-MAIL: secyhlth@...


The lancet: Comment. Volume 364, Number 9442,09 October 2004.

Richard Feachem, Executive Director of the Geneva-based Global Fund
to Fight AIDS, Tuberculosis and Malaria, recently stated that India
now has the world's largest number of HIV-infected people,
surpassing South Africa, and that India is "on an African
trajectory". He has characterised the Indian Government's response
to the HIV epidemic as "way short of what is necessary to turn
around the epidemic".1 Recent estimates showing an increasing burden
of HIV-infected citizens necessitates that India sustain and
intensify its commitment to HIV prevention and treatment. However,
it is equally important to recognise that the HIV epidemic in India
is not "on an African trajectory" and that the response of the
Indian Government reflects a commitment to addressing this critical
public-health priority.

A high absolute number of HIV-infected individuals does not
necessarily indicate that India will follow Africa in epidemic
terms. The populations of ten Indian states individually exceed that
of South Africa. The Indian HIV epidemic is complex and challenging,
reflecting the diversity and uniqueness of India's society and
population. Despite the documentation of HIV in the Indian and South
African populations at the same time in 1985-86, current UNAIDS
estimates of adult HIV prevalence in India (0•5-1•5%) and South
Africa (18•5-24•9%) reflect very different epidemic trajectories.2-5
Despite similar low rates of prevalence in urban pregnant women in
South Africa and the state of Maharashtra in 1990,4,5 current HIV
prevalence rates in pregnant women in South Africa are about ten-
fold higher than in Maharashtra (figure).


Figure: HIV prevalence in urban pregnant women
*Median of 4 four urban South African antenatal clinics (UNAIDS/WHO
Epidemiological Fact Sheet-2004 Update).5 †Median of six urban
Maharashtran antenatal clinics (NACO HIV Sentinel Surveillance
Program).4

Factors that could be responsible for different epidemic patterns in
India and South Africa are not clear. The 2001 Indian National
Behavioural Surveillance Survey (NBSS) reported extramarital sexual
contact within the previous year by 8•6% of men and 1•7% of women.6
A recent randomised community-based study of adults in 28 Chennai
slums found that 2•9% of men and less than 1% of women reported
extramarital sexual contact, with 1% and 0•2% HIV-infected,
respectively.7 Although these finding suggest a large number of
Indian adults are at potential risk for HIV infection, the adult
population at high risk for HIV in India might represent a smaller
percentage of the general population than some African and western
countries, where adult men and women more commonly report a history
of extramarital sexual contact.8

The recognition that the trajectory of the HIV epidemic in India is
distinct from some African countries is no justification for
complacency, because a 1% increase in the HIV prevalence in adults
would result in an additional 5 million infected people. The annual
budget for the National AIDS Control Programme has doubled over the
past 3 years to Rs4700 billion in 2004-05. A 2002 pilot programme
offering antenatal counselling, testing, and antiretroviral
treatment to prevent mother-to-child transmission in 11 sites has
now been expanded to 225 antenatal clinics, and is the largest
national antenatal screening programme in the world. A recently
started programme to provide highly-active antiretroviral therapy to
100 000 HIV-infected patients in India is supported by a Rs2000
billion investment. A recently constituted National Parliamentarian
forum has generated strong political support for additional HIV
programmes, including a large school-based adolescent education
programme and a national campaign to raise awareness about sexually
transmitted diseases and treatments. Although more effort and
resources are needed, the Indian Government's response reflects a
sincere, intensive, and long-term commitment to effective HIV
prevention and care. These efforts show that India is not complacent
about the problem of HIV/AIDS. In fact, eradication of poliomyelitis
and HIV/AIDS prevention are the most highly visible public-health
programmes in India.

The accuracy of HIV-infection estimates and projections, based on
seroprevalence data, limited surveillance coverage, and invalidated
presumptions will always be considered questionable. With the same
raw data collected by the governmental surveillance programme,
different groups have produced widely varying estimates. HIV
estimates could be enhanced by expansion of national surveillance
and prevention programmes to reach vulnerable populations in rural
and low-prevalence areas, as well as the addition of programmes
designed to measure HIV incidence in population groups at risk.

Although the increase in HIV infections in India is following an
Indian rather than an African trajectory, the epidemic continues to
demand a serious and sustained national commitment. India has many
experienced, dedicated, and tireless governmental and non-
governmental HIV-prevention and treatment advocates, health
professionals, and researchers who will continue to ensure that this
will not happen, and that the national response to the HIV epidemic
will remain a top public-health priority.

*J V R Prasada Rao, N K Ganguly, Sanjay M Mehendale, Robert C
Bollinger
________________________________________
Ministry of Health and Family Welfare, Government of India, , New
Delhi 110 011 (JVRPR); Indian Council of Medical Research (NKG);
National AIDS Research Institute, Pune, India (SMM); and Johns
Hopkins University, Baltimore, Maryland, USA (RCB)
________________________________________
secyhlth@...

We thank D Celentano, M Ghate, S Godbole, N Gupta, L Kant, R S
Paranjape, M A Phadke, S Ranade, J Sastry, and S Trainer for their
help in the review and preparation of this commentary. We declare
that we have no conflicts of interest.

1 Mahapatra. India overtakes South Africa as country with most HIV
cases. Seattle Post-Intelligencer Sept 16, 2004.

2 Simoes EA, Babui PG, John TJ, Nirmala S. Solomon S.
Lashiminarayana CS, Quinn TC. Evidence of HTLV-III infection in
prostitutes in Tamil Nadu (India). Indian J Med Res 1987; 85: 335-
38. [PubMed]

3 Becker WB. HTLV-III infection in the RSA. S Afr Med J 1986; Oct 11
(suppl): 26-27.

4 UNAIDS/WHO. India: epidemiological fact sheet on HIV/AIDS and
sexually transmitted infections 2004 update. http://www.unaids.org/
en/geographical+area/by+country/india.asp (accessed Sept 28, 2004).

5 UNAIDS/WHO. South Africa: epidemiological fact sheet on HIV/AIDS
and sexually transmitted infections 2004 update.
http://www.unaids.org/
en/geographical+area/by+country/south+africa.asp (accessed Sept 28,
2004).

6 National AIDS Control Organization, Government of India. National
baseline general population behavioural surveillance survey, 2001.
http://www.nacoonline.org/publication.htm (accessed Sept 28, 2004).

7 Celentano DD, Srikrishnan AK, Sivaram S, et al. The HIV epidemic
in Chennai (southern India) remains concentrated in high risk
groups. XV International AIDS Conference, Bangkok, Thailand, July 11-
16, 2004: MoPeC3469.

8 White R, Cleland J, Carael M. Links between premarital sexual
behaviour and extramarital intercourse: a multi-site analysis. AIDS
2000; 14: 2323-31. [PubMed]

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