Review
Containing HIV/AIDS in India: the unfinished agenda

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Summary

India's HIV epidemic is not yet contained and prevention in populations most at risk (high-risk groups) needs to be enhanced and expanded. HIV prevalence as measured through surveillance of antenatal and sexually transmitted disease clinics is the chief source of information on HIV in India, but these data cannot provide real insight into where transmission is occurring or guide programme strategy. The factors that influence the Indian epidemic are the size, behaviours, and disease burdens of high-risk groups, their interaction with bridge populations and general population sexual networks, and migration and mobility of both bridge populations and high-risk groups. The interplay of these forces has resulted in substantial epidemics in several pockets of many Indian states that could potentially ignite subepidemics in other, currently low prevalence, parts of the country. The growth of HIV, unless contained, could have serious consequences for India's development. India's national response to HIV began in 1992 and has shown early success in some states. The priority is to build on those successes by increasing prevention coverage of high-risk groups to saturation level, enhancing access and uptake of care and treatment services, ensuring systems and capacity for evidence-based programming, and building in-country technical and managerial capacity.

Introduction

The first instance of HIV in India was detected in Chennai in the southern state of Tamil Nadu in 1986.1 The National AIDS Control Programme was started in 1987 and focused mainly on surveillance in perceived high-risk areas, blood screening, and health education.2 By 1990, a medium-term plan was formulated that focused on four high-risk cities. The first HIV/AIDS project with support from the World Bank began in 1992.3 Programming has since expanded with assistance from several bilateral donors and, most recently, the Bill & Melinda Gates Foundation through its Avahan—India AIDS Initiative.4 The National AIDS Control Organization (NACO) estimated that adult HIV prevalence in India was 0·88% in 2005, which translates into about 5·2 million people infected with HIV, or one in eight of worldwide HIV cases.5 This number, however, masks distinct regional and subregional variations (figure 1) in a country with a population of 1 billion across 31 states and 593 districts.6 This review will explore what is known and yet to be understood about the current extent and features of the various Indian subepidemics and discuss the status, challenges, and needs of a national response. Given the early stage of the epidemic in India, the emphasis of the discussion on national response will be on prevention, although the growing importance of the need for treatment is clear.

Section snippets

Data sources and limitations

Data related to the HIV epidemic in India come from: (1) routine sentinel HIV surveillance from antenatal and sexually transmitted disease (STD) clinics, and from interventions with populations at greatest risk (high-risk groups), including female sex workers, men who have sex with men, and injecting drug users; (2) mapping and size estimation exercises of high-risk groups; (3) some behavioural surveys in high-risk groups and the general population; (4) limited biological surveys in high-risk

Drivers of India's subepidemics

In this section, we focus on what is known about (1) high-risk group presence, reported condom use, and HIV prevalence, (2) bridge and general population sexual networks, and (3) migration and mobility of both high-risk and bridge populations. The data reviewed came primarily from Group I, II, and to a lesser extent Group III states, since the states in Group IV are less studied and documented. The limited data indicates that India's epidemics seem to be largely driven and maintained through

Current national response to the epidemic

Table 2 provides a snapshot of select data related to HIV/AIDS programming in India. In 1992, the first Indian National AIDS Control Project (NACP-1) was launched under World Bank funding.3, 28 The project succeeded in establishing state AIDS control cells in all states and union territories but, due to substantial variations in state capacity and commitment, the resources were spent disproportionately by a few states—eg, Tamil Nadu, Maharashtra, and West Bengal.28 Over the next few years, more

Potential impact of the epidemic

The epidemic in India is difficult to classify given its scale and geographic diversity. Moreover, given the limited sources of systematic data, it is difficult to assess either the big picture or local epidemic patterns accurately. Minimum data required to realistically estimate past and current HIV infections, AIDS cases and deaths, or to project epidemic trends, are typically not available in most places in India.156 A recent analysis of aggregated antenatal clinic data across sites suggests

Ensuring an effective national response

Implementing an effective response to HIV in India presents extraordinarily complex challenges, due to the country's scale; the diversity, size, and mobility of the populations at risk; and the highly stigmatised nature of HIV. To mount a response capable of bringing HIV under control, India must address high-priority gaps in national HIV efforts, by (1) increasing prevention coverage of high-risk populations,164 (2) enhancing access and uptake of care and treatment services linked to these

Search strategy and selection criteria

We did a complete search of the National Library of Medicine for journal articles and abstracts for the year 1995 to the present using broad search terms such as “HIV”, “India”, “female sex workers”, “MSM”, “IDU”, and “migrant men”. We identified additional sources through a Google and Google Scholar search using the same terms and through review of reference lists of relevant publications. We obtained HIV/AIDS/STI surveillance reports from the Indian National Government or State

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