India: country context
India is home to more than one billion people. With a birth rate of 25.4 per 1,000 population, and a death rate of 8.4 per 1,000, its population is growing at a rate of 1.93% (2001 census).
In 2007, new estimation methods* employed by the Government of India produced revised HIV prevalence estimates. The number of people estimated to be living with HIV has now reduced from 5.2 million to an estimated range of 2.0–3.1 million.
Current estimates place the national average adult HIV prevalence at 0.36%. Yet HIV infection varies greatly across the country. About two-thirds of reported HIV infections are in six of the country’s 28 states and seven union territories (Andhra Pradesh, Tamil Nadu, Maharashtra, Manipur, Nagaland and Karnataka), where prevalence is four to five times higher than in other Indian states.
Even in the four southern high prevalence states (Andhra Pradesh, Karnataka, Maharashtra and Tamil Nadu), HIV prevalence varies and the epidemic tends to be concentrated in certain districts. For example, data from the expanded 2006 sentinel surveillance shows stable or declining prevalence among pregnant women attending antenatal clinics in some states (notably Tamil Nadu). Yet prevalence remains above 1% in four of the high prevalence states.
2006 data indicates high HIV prevalence among sex workers (8.4% according to NACO 2005 data) and rising prevalence in injecting drug users and men who have sex with men. Injecting drug use (using non-sterile injecting equipment) is the main risk factor for HIV infection in the north-eastern states (especially Manipur, Mizoram and Nagaland) and is a feature of the epidemics of major Indian cities (Chennai, Mumbai and Delhi). New pockets of high HIV prevalence among injecting drug users have also been recorded in Punjab, Tamil Nadu, West Bengal, Kerala and Maharashtra states. The combination of injecting drug use and paid sex could lead to increasing infections in areas with serious injecting drug use-related epidemics.
Prevention programmes focusing on sex workers suggest that HIV infection is on the decline, particularly in areas that have been the focus of targeted prevention efforts (especially in the southern states). However, prevention efforts are often complicated by the varied nature of commercial sex and by law enforcement which can often act as a barrier against effective prevention.
Interventions for men who have sex with men remain limited and until recently, little research had been undertaken on the role of sex between men in India’s HIV epidemic. Data from a limited number of small-scale surveys has indicated HIV prevalence rates ranging from 10%–21% across all high prevalence states and Gujarat.
Only an estimated 10% to 20% of people living with HIV in India know that they have the virus. This impedes treatment and prevention efforts. Data from voluntary counselling and testing centres in 2005 indicate that 1,038,315 people were tested for HIV, among whom just 24% received their results. In Delhi, only 18% of survey respondents knew where to go to get an HIV test, despite 80% being aware that HIV tests existed. In Andhra Pradesh, over 20% of people in key populations were not sure if it was possible to obtain a test. In Manipur, one survey showed just 14.5% of urban respondents and 5.4% of rural respondents knew where to go for an HIV test.
Data also highlights a low level of knowledge, which perpetuates high-risk sexual behaviour: one national survey has shown that while 76.1% of the Indian population have heard of HIV and AIDS, only 46.8% indicated knowledge of the two important ways of avoiding transmission (consistent condom use and sex between uninfected partners).
Stigma and discrimination
HIV-related stigma and discrimination remain major barriers to curbing the epidemic in India. Early descriptions of HIV epidemiology created a general perception that HIV was largely restricted to sex workers, truck drivers and injecting drug users. Despite infection rates continuing to rise among the general population, the perception remains.
Experiences of and fears about discriminatory treatment cause many to conceal their status and deter many people from seeking care. Even sex workers, who tend to be well-informed about HIV and its modes of transmission, are often powerless to compel condom use.
Cultural expectations of masculinity in India lead to the stigmatisation of men who have sex with men and their subsequent marginalisation and social exclusion. And the well-documented increasing feminisation of epidemic in India is attributable to the low status of women, their economic dependence on men, a lack of information and power to negotiate safer sex, limited access to women’s services, and limited opportunities to acquire and exert knowledge about safe sexual practices.
Orphans
There are an estimated 25 million orphans in India – but no estimates exist for the number of children who have been orphaned as a result of AIDS. However, a report by the Alliance in India has drawn attention to the discrimination faced by orphaned children as well as the heavy burden that they face when deaths in the family force children to become heads of households.
Treatment
The Indian government committed to providing free antiretroviral treatment to 300,000 people living with HIV by the end of 2005. Due to initial constraints in rolling out the programme in the public sector, a revised target was set to reach 300,000 by 2011 (National AIDS Control Programme Phase III). 105,622 people are currently receiving free antiretroviral treatment through the public sector, including 7,414 children (NACO 2007). In addition, an estimated 35,000 people are receiving treatment through the private and NGO sectors (UNGASS Country Report 2008).
*The new methods included the expanded HIV sentinel surveillance system[1] and the National Family and Health Survey [NHFS-3] – complemented by data from the Integrated Behavioural & Biological Assessment (IBBA) and Behavioural Surveillance Survey.
[1] HIV prevalence data is collected from several groups including pregnant women, people attending sexually transmitted clinics, sex workers, men who have sex with men and people who inject drugs. The system was expanded in India from 155 sites in 1998 to 703 sites in 2005 and 1,164 sites in 2006 (UNAIDS India, June 2007)