Rural Indian HIV epidemic being neglected despite complex patterns, high
prevalence

Kelly Morris, Tuesday, April 03, 2007
Although HIV infection in India was thought to be mainly concentrated in
urban areas, a "rural epidemic" is beginning to be documented in the
southern Indian state of Karnataka. In the Bagalkot district, HIV prevalence
and associated factors were found to vary widely, even between villages, but
with the highest prevalence found in rural areas. These results have
important implications for prevention and care programmes to be implemented
in the area, report Marissa Becker, from the University of Manitoba, Canada,
and co-authors.

Antenatal surveillance data have suggested that the mainly agricultural
district of Bagalkot is a high prevalence area, so the district has been
selected for a demonstration project on HIV prevention in rural areas.

"Some potential explanations for why Bagalkot is particularly vulnerable to
HIV infection include a large volume of female sex work within the district
and the fact that sex workers tend to be younger, have higher rates of
illiteracy and receive more clients than their southern counterparts," note
the authors in the latest issue of the journal AIDS

This pattern is probably linked with a traditional system of religious sex
work called Devadasi. So, the team of researchers from Canada and Bangalore,
India, gathered baseline information in a community based study of 4949
individuals aged 15-49 years randomly selected from ten villages and six
towns.

Overall HIV prevalence was 2.9%, with 2.4% of respondents found HIV-positive
in urban areas and 3.6% in rural areas (odds ratio 0.65; 95% CI 0.45-0.95).
Significant differences in HIV prevalence were seen between the ten
villages, ranging from 0 to 8.2%. Reported multiple sexual partners,
receiving money for sex and a history of medical injections were
significantly associated with HIV infection, as were older age, being
widowed, divorced, separated or deserted, lower education levels and being a
woman of a lower caste.

The study also found that almost 70% of respondents had never seen a condom,
while only 9% of respondents had ever used a condom. As in other studies,
positive antibody testing for herpes simplex virus 2 was linked with
HIV-positivity.

A multiple logistic regression model found that men aged 30-39 years, people
in certain sub-districts, people whose marriage had dissolved, women who had
had more than five medical injections in the past year, respondents having
ten or more medical injections in the past year, and Hindus, especially
lower-caste individuals, were at greater risk of HIV infection.

Unmarried people and those with higher education levels had reduced risk.
The authors note that the association with marital status may be due to
infection through a spouse who has subsequently died, because of abandonment
due to serostatus, or because widowed women are more vulnerable to sexual
exploitation.

The association of HIV-positivity with lower-caste Hindus is possibly
explained by these respondents being more likely to be Devadasi sex workers
- this vulnerable group is very important in directing HIV prevention
efforts, the authors conclude.

The authors stress the need to deliver education programmes to rural,
largely non-literate populations, and the importance of further research to
understand the heterogeneity of the epidemic as well as to develop tools to
rapidly detect higher risk areas.

"An HIV epidemic as heterogeneous and diverse as India's will require a
response that is both comprehensive in terms of coverage of vulnerable
populations, and is of sufficient scale to address the epidemic in the vast
rural areas where the majority of the population lives, and which as yet are
largely neglected by prevention programs," the report concludes.

Reference

Becker M et al. Prevalence and determinants of HIV infection in South India:
a heterogeneous, rural epidemic. AIDS 21: 739-47, 2007.