Each year since 1998, NACO, the National Institute of Health and Family Welfare and the National Institute of Medical Statistics (a body under ICMR) bring out estimates of India’s population living with HIV and AIDS. Released this year in July, the figures for 2006 represent the most accurate reading yet (see box “Methodology”) of India’s HIV and AIDS numbers. The process of enumeration and the results have been attested to and backed by international agencies – UNAIDS and WHO.
The 2006 estimates suggest national adult HIV prevalence in India is approximately 0.36 percent, amounting to between 2 and 3.1 million people. If an average figure is taken, this comes to 2.5 million people living with HIV and AIDS; almost 50 percent of the previous estimate of 5.2 million.
More men are HIV positive than women. Nationally, the prevalence rate for adult females is 0.29 percent, while for males it is 0.43 percent. This means that for every 100 people living with HIV and AIDS (PLHAs), 61 are men and 39 women. Prevalence is also high in the 15-49 age group (88.7 percent of all infections), indicating that AIDS still threatens the cream of society, those in the prime of their working life.
While adult HIV prevalence among the general population is 0.36 percent, high-risk groups, inevitably, show higher numbers. Among Injecting Drug Users (IDUs), it is as high as 8.71 percent, while it is 5.69 percent and 5.38 percent among Men who have Sex with Men (MSM) and Female Sex Workers (FSWs), respectively.
Breaking Down the Numbers
In terms of geographical break-up, 118 districts have HIV prevalence more than 1 percent among mothers attending ante-natal clinics. The 2006 estimates indicate that the epidemic has stabilised or seen a drop in Tamil Nadu and other southern states with a high HIV burden. Yet, new areas have seen a rise in HIV prevalence, particularly in the northern and eastern regions. Twenty-six districts have been identified with high prevalence, largely in the states of Madhya Pradesh, Uttar Pradesh, West Bengal, Orissa, Rajasthan and Bihar.
HIV prevalence continues to be higher among vulnerable groups. For instance, there is a significant population living with HIV and AIDS among IDUs in four of India’s biggest cities – Chennai, Delhi, Mumbai and Chandigarh. Young people are at greater risk, with the under-15 category accounting for 3.8 percent of all HIV infections, as against 3 percent in 2002.
Between 2005 and 2006, prevalence has fallen in some major states – Maharashtra from 0.80 to 0.74 percent, in Tamil Nadu from 0.47 to 0.39 percent – for instance. Yet, new areas of concern have emerged. In West Bengal, prevalence has gone up from 0.21 to 0.30 percent and in Rajasthan from 0.12 to 0.17 percent.
The Big Picture
In terms of treatment and prevention interventions, lower estimates for HIV positive people are both heartening and challenging for NACO. At one level, the need for treatment and the need to access ART may be lower. Yet, this makes it is all the more imperative that an effective and universal roll-out of the ART program is completed at the earliest.
More accurate data is a sort of force-multiplier and allows the country to fine-tune and pinpoint its responses. New AIDS estimates will allow NACO, its partners and State AIDS Control Societies (SACS) to focus on emerging districts of concern even if these be located within states that show low prevalence overall. Indeed, this is also the strategy being followed in the Third National AIDS Control Program (NACP-III), which makes the district, the unit of intervention. As the new numbers indicate, national figures alone are not enough; they have to be seen in the context of local and district-level HIV and AIDS situation.
Though overall trends are encouraging, injecting drug use and homosexual route among men have emerged as important routes of HIV transmission in different parts of the country. In the North East, besides IDU, HIV prevalence among the FSW is increasing, suggesting a dual nature of the epidemic. Rising HIV prevalence among ANC clinic attendees in North Indian states is an alarming signal for focused attention.
Yet it is important to understand that a more accurate model indicating lower estimates than before does not mean a decline in the epidemic. It only points out that the epidemic is under control because of enormous effort and mobilization over the past decade. This guard cannot be lowered. While the percentage of adult population affected by HIV and AIDS may have dropped, in absolute numbers, India’s AIDS figure is still substantial. It is the third largest in the world, and remains the largest in Asia.
That is a sobering indicator of the challenges still before us. The imperatives of NACP-III beckon.
Why are these numbers more accurate?
The credibility of the new HIV prevalence figures is very high because they are derived from not one but three authoritative sources.
- An expanded and upgraded Sentinel Surveillance spread over 1,122 sentinel surveillance sites and covering all districts in the country. This represents an increase of 400 sites since the last time, and an eight-fold increase from the 180 surveillance sites NACO began with in 1998.
- The National Family Health Survey or NFHS-3, a population- based survey conducted in 2005-06, with a sample size of over 100,000 people for HIV testing.
- An integrated behavioral and biologic assessment – the National Behavioral Surveillance Survey and the Integrated Biological Behavioral Assessments Survey. This is a targeted surveillance system focusing on high-risk groups in high-prevalence states.
It may be pointed out that NFHS-3 is a household survey among the general population, and excludes high-risk groups such as sex workers, MSM, IDUs, truckers and so on. Seen in isolation, NFHS-3 suggests a prevalence figure of 0.28 percent. If the high-risk groups are also taken into account – as they have been by NACO – then the prevalence estimate rises.
The new, composite methodology represents the most modern and accurate system in the world and, indeed, the Indian survey could now be the template for estimating HIV and AIDS figures in other countries. It was the result of protracted discussion and consultation with national and international agencies and experts. It incorporated the WHO/UNAIDS Workbook Approach, which consisted of two panels: one for high-risk groups and the other for the low-risk general population. The new estimation process was overseen by the Technical Resource Group on Surveillance, jointly chaired by the Director-Generals of NACO and ICMR.
The new methodology allows for a “back calculation” of prevalence figures since 2002, based on the new assumptions and measures. The previous data for India offered a wide range – 3.4 million to 9.4 million – within which AIDS prevalence figures actually lay. The new estimation process has severely contracted that range, to between 2 and 3.1 million people.
International validation of both the numbers and the process has been swift. This would indicate NACO’s estimation methodology would probably be replicated in other countries to gauge the spread of the HIV and AIDS epidemic there. As Paul Delay, Director of Evidence Monitoring and Policy at UNAIDS, Geneva, pointed out at a background briefing to contextualize the new Indian numbers, “India now really represents the state-of-the-art methodology, as far as combining different data sources is concerned. And now the analysis that is taking place will hopefully provide us with a most accurate picture that we have ever had on India.”