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Hsin-Yu Ou
Dr. Kasprzyk and Dr. Montano
HONORS 391 B
June 1, 2014
The AIDS Epidemic and AIDS-Free Policy in India
According to the India National AIDS Control Organization, the HIV prevalence
rate in India is estimated to be 0.27% in 2011. With 2.1million people living with HIV,
India is the country with the third largest number of people living with HIV in the
world (The World Fact Book). The huge population of people living with HIV makes
India an important country in controlling the global AIDS epidemic and reaching the
global vision of an AIDS-free generation. With a low HIV prevalence in the general
population, the AIDS epidemic in India is mainly driven by high-risk groups, meaning
Indias success in containing the epidemic will depend largely on its ability to carry
out the interventions for these populations. This paper will describe the AIDS
epidemic in India, starting from its history and government response and followed by
a discussion of its current epidemiological situation, the epidemic among high-risk
groups and current government interventions. Finally, the paper will give an
assessment and recommendation of Indias policies on whether it will reach the
UNAIDS goals set for an AIDS-free generation by 2015.
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History of the Epidemic and Government Response
The first AIDS cases in India were diagnosed among sex workers in Tamil Nadu
in 1986 (Simoes et al. 336). The National AIDS Control Organization, or NACO, was
established in 1992 to implement the National AIDS Control Program (NACP). The
first phase of the National AIDS Control Program (NACP-I) was launched between
1992 and 1999. The objective for this phase was to slow down the spread of HIV
infections so as to reduce the morbidity, mortality and impact of AIDS in the country
(NACO 2012-13 Annual Report 1). NACP-II was implemented between 1999 and
2006, with the focuses of changing behavior, decentralizing the program
implementation to the state level and increasing nongovernmental organizations
involvement (NACO 2012-13 Annual Report 1). NACP-III ran between 2006 and
2011. The main strategies under NACP-III were scaling up prevention services for
high-risk populations and the general public and integrating the prevention with care
and treatment services for those who are infected and affected by HIV (NACO
2012-13 Annual Report 1). India is currently at NACP-IV, which is planned for the
period between 2012 and 2017. The strategies and polices under NACP-IV will be
discussed later in this paper.
Current Epidemiological Situation
According to the NACO 2012-13 Annual Report, the HIV prevalence rate among
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adults is 0.27% in 2011. The number of annual new HIV infections among adults is
estimated to be 0.116 million, of which 39% are among women, and children under
15 years old account for 7% of total new infections (NACO 2012-13 Annual Report
6). Indias HIV prevalence is relatively low compared to other developing countries.
However, with its huge population, a low prevalence rate still makes it account for a
large proportion of the global AIDS epidemic.
There is an uneven geographic distribution of the epidemic among Indian states,
with high-prevalence states such as Manipur (1.22%), Andhra Pradesh (0.75%) and
Karnataka (0.52%) accounting for half of the new infections in 2011(Technical
Report India HIV Estimates 2012 42). The AIDS epidemic in the high-prevalence
states are mainly driven by populations that engage in risky behaviors, for example
injecting drug use. At the national level, the HIV prevalence rate in India has been
declining over the past decade, from 0.41% in 2000 to 0.27% in 2011; the annual new
HIV infections has also decreased from 0.274 million in 2000 to 0.116 million in 2011
(NACO 2012-13 Annual Report 7). However, some states with low prevalence
showed increasing trends in HIV prevalence (Technical Report India HIV Estimates
2012 41). Therefore, besides targeting on the high-prevalence states, India will need
to direct some attention on containing the new epidemic that is occurring in
low-prevalence states, which used to be less noticed, in order to achieve the global
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goal of an AIDS-Free Generation.
Epidemic among High-Risk Groups
The AIDS epidemic in India is concentrated in certain populations. This is
reflected on the disproportional distribution of HIV prevalence as seen in the NACO
2012-13 Annual Report: the HIV prevalence among antenatal clinic attendee, which
represent the general population, is 0.40% while that among populations such as
transgender women (8.82%) and injecting drug users (7.74%) is much higher. The
AIDS epidemic in India is mainly spread through sexual route, with most of the
infections caused by unprotected sex, and a smaller proportion through drug injection
(National AIDS Control Organization). The main driving force of the epidemic also
varies across different Indian states. For example, injecting drug users are identified to
be the main driver in the northern states. The populations that have higher tendency to
engage in risky behaviors are defined as high-risk populations, which are divided into
the core and the bridge populations by NACO. The core high-risk groups include
injecting drug users (IDU), female sex workers (FSW), men who have sex with men
(MSM) and transgender women. The bridge populations, which link the core groups
with the general population, consist of migrant workers, truck drivers and the sexual
partners of those in the core high-risk groups. Although these populations are
categorized into distinct groups, there are a lot of overlaps among them, for example,
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transgender women who work as commercial sex workers. The following sections
will discuss each of the high-risk population in terms of its relationship with the AIDS
epidemic in India.
As of 2011, transgender women, or Hijras, have the highest HIV prevalence
(8.82%) of all the high-risk groups. Transgender women are people who were born
biologically male but identify themselves as females. Several studies have found high
prevalence in HIV and other sexually transmitted infections (STI) among transgender
women. Some behavioral research reported high-risk behaviors, such as low level of
condom use, and also a higher use of alcohol and substances among transgender
women (Chakrapani 4). Higher use of alcohol and substances poses problems with
controlling the AIDS epidemic because it is correlated with higher tendency to engage
in unsafe sex. Transgender women receive a lot of discrimination and treatments that
violate human rights in the Indian society. A report written by the United Nations
Development Programme, India on transgender women points out that most families
do not accept sons that identify themselves as women and that sometimes transgender
women end up leaving their families. This results in limited access to education and
healthcare services. Transgender women are often excluded from employment and
receive limited protection from the police because they are considered different,
resulting in many transgender women to work as sex workers. Most transgender
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women lack the access to health insurance plans because they cannot afford it.
Additionally, healthcare providers usually lack the knowledge about the specific
conditions that transgender women have. Therefore, there are several barriers for
transgender women to access services such as HIV screening (Chakrapani 8).The
transgender group used to be included in the group of men who have sex with men
instead of categorized as a separate group. In recent years, NACO has started to
recognize transgender women as a core high-risk group that is separated from MSM.
Especially after the recognition of the Indian Supreme Court that transgender is a
third gender in 2014 (BBC News), discrimination against the transgender and barriers
in containing the AIDS epidemic among them are expected to decline, which leads to
the discussion of another population that also faces the similar kind of societal
pressure.
Similar to transgender women, men who have sex with men (MSM) are difficult
for HIV-related services to reach due to discrimination and stigma. The HIV
prevalence MSM is estimated to be 4.43% in 2011 at the national level. According to
NACO, the national HIV prevalence among MSM shows a declining trend since 2007
(7.41%). Studies find that MSM are more likely to engage in unsafe sex. This may be
due to their higher tendency of substance use, having multiple sex partners and having
contact with commercial sex workers (Go et al. 316). Studies also find that the
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knowledge level about HIV is low among MSM. For example, there are
misconceptions that HIV is transmitted through vaginal sex with commercial sex
workers and thus individuals believe that they would be safe if they have unprotected
sex with men (Asthana and Oostvogels). Many MSM are married to women due to
social intolerance of homosexuality; however, the level of condom use between MSM
with females (spouse or prostitutes) is low and a lot of these MSM also are having
unprotected sex with other men (Dandona et al.). This means that MSM have a
substantial effect on the spread of the HIV epidemic because they can transmit HIV
through both hetero and homosexual routes. Moreover, same sex sexual conduct is
made illegal by Section 377 of the Indian Panel Code. Although MSM was
de-criminalized between 2009 and 2012, the Indian government re-criminalized
consensual same sex sexual conduct in 2013 (UNAIDS Calls on India). The
criminalization of same sex sexual conduct is a challenge for the prevention of HIV
because MSM may hide their sexuality and may not feel comfortable about accessing
healthcare services. Another population that is similar to MSM in its likelihood of
causing the widespread the epidemic is the female sex workers.
The HIV prevalence among female sex workers (FSW) is 2.67% in 2011 and the
prevalence at the national level has been declining since 2007 (5.06%) (NACO
2012-13 Annual Report 7). Sex workers are at risk because of the lack of condom
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use and because they are engaged in large and complicated sexual network.
Transmission among sex workers and their clients and among the clients and their
regular partners may therefore be the fuel for the spread of the epidemic. Over the
past few years, the rate of condom use among sex workers has been increasing. A
study done in southern India finds that that rate of condom use rose significantly
(from 3%-36% in 2004 to 56%-96% in 2008) due to the increase of condom
availability (Bradly et al.). The increase of condom use is a desirable trend. However,
reports show that sex workers often have difficulty accessing HIV services because of
fear of discrimination and the hostility of healthcare services: they may be refused
treatment or threatened to disclose their HIV status (Amin 2). This means the
discrimination sex workers are facing complicates Indias approach in fighting the
epidemic because they may be less willing to attend HIV services. While HIV
transmission through sexual route is the major driver for the Indian AIDS epidemic,
transmission through needle sharing among injecting drug users is responsible for the
high HIV prevalence in several states.
Injecting drug user (IDU) is the main epidemic driver in the northern Indian
states. Injecting drug use started to increase in the northeastern states in the 1980s and
due to the sharing of needles and syringes, the HIV prevalence among IDUs increased
rapidly. The epidemic later spread to larger populations through the transmission from
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the IDUs to their sexual partners (Medhi et al. 2). A study conducted in 2004 in the
northeastern region finds that many IDUs have large networks and that a large number
of drug users share or reuse needles because they cannot afford buying new ones
(Medhi et al. 8). The study also finds that many IDU sites are located in rural areas
(Medhi et al. 8), meaning that the challenge for HIV prevention programs targeted at
IDUs is to reach the rural sites, where the healthcare system is weaker and there is
more stigma toward the disease. Additionally, the study finds a significant number of
female IDUs and that some of them are also involved in commercial sex work (Medhi
et al. 9). The HIV epidemic can therefore spread rapidly not only among IDUs
through sharing needles but also to the general population through IDU sex workers.
In recent years, the HIV prevalence among IDUs at the national level has remained
relatively stable (7.23% in 2007 and 7.14% in 2011) (NACO 2012-13 Annual Report
8). While declining trends in HIV prevalence among IDUs is observed in some
northeastern states in the past few years, some states with low prevalence reported
increasing trends.
The increasing trend in HIV prevalence in some low-prevalence states is linked
to migrant workers and truck drivers, which are categorized as the bridge populations.
The bridge populations play an important role in the spread of the epidemic because
they link the high-risk groups with the general population (NACO 2012-13 Annual
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Report 10). They have more encounter with the core high-risk groups and are the
main clients of sex workers and because of their mobility, they are able spread the
epidemic from high-prevalence areas to low-prevalence areas (NACO 2012-13
Annual Report 10). Studies have found positive relationship between migration and
HIV infections and that more HIV-positive women have migrant husbands than
HIV-negative women (Saggurti et al. 45). This may be due to their engagement in
extramarital sex, in which condoms are rarely used (Saggurti et al. 46). Truck drivers
are considered driving force of the HIV epidemic because many of them have
multiple sexual partners and are involved with commercial sex workers; moreover,
condom use is not common (Chaturvedi et al. 155). Additionally, their contact with
sex workers happens not only at their work location but also places such as train
stations or roadsides. Because both the drivers and the sex workers are mobile, the
epidemic can spread to other areas. The truck drivers or migrant workers also put their
partners at home at risk. Thus, truck drivers and migrant workers are thought of as the
bridge population that link low-prevalence areas with high-prevalence areas
(NACO 2012-13 Annual Report 9).
Current Policies and Status
India is currently at the fourth phase of the National AIDS Control Program
(NACP-IV). The phase is planned for the period between 2012 and 2017, with the
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goals of reducing new infections and providing people living with HIV
comprehensive care and treatment. NACP-IV plans to achieve the goals through
strategies such as scaling up targeted interventions, increasing access to care and
treatment, raising awareness and behavioral change among general and high-risk
populations and building capacities for evidence-based planning (NACO 2012-13
Annual Report 2).
HIV prevention among high-risk populations is carried out by programs called
targeted interventions, which provide prevention services through peer-led approach
(NACO 2012-13 Annual Report 11). Peer-led approach means that members in the
high-risk communities provide their peers with information regarding HIV prevention,
such as promoting safe behavior. Condom promotion and distribution are carried out
through social marketing programs, especially in high-prevalence communities.
Targeted interventions also work on linking high-risk groups with treatment and
counseling services. There are specific interventions that are targeted at each high-risk
group. For example, opioid substitution treatment and needle exchange program for
the IDUs (NACO 2012-13 Annual Report 11). Additionally, to increase the
intervention coverage of the bridge populations (migrant workers and truck drivers),
intervention sites are set up not only at the source (hometowns) and the destination
but also at places such as train and bus stations, where a lot of migrants gather.
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NACO launches mass media campaigns to raise the knowledge level and
awareness for HIV among the general public, particularly women and children. These
campaigns send messages that promote safe behaviors, eliminate AIDS-related stigma
and provide information about HIV and other STIs through TV and radio networks
(NACO 2012-13 Annual Report 64). There is also the Red Ribbon Express (RRE)
project, in which trains travel across the country to send HIV-related information and
to provide services such as HIV testing. Additionally, there are interventions that
target specifically at the youth, including adolescence education program, which
provide sex education at secondary schools, and red ribbon clubs in colleges that
encourage peer-led education about HIV prevention (NACO 2012-13 Annual Report
65). NACO launched the Link Worker Scheme to provide high-risk and vulnerable
populations in rural areas with information about HIV and STI prevention on a
community base (NACO 2012-13 Annual Report 23). The importance of the
community-based scheme is that it can fulfill the specific need of each village and
reach more people who are at risk.
With a huge population of 2.1 million living with HIV, India aims at providing
quality care and treatment for all those who are living with HIV. Under NACP-IV,
services such as free ART, psycho-social support and treatment for opportunistic
infections are provided through different levels of health facilities (NACO 2012-13
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Annual Report 50). Besides services for high-risk populations, integrated counseling
and testing services for the general populations are also scaled up and increased
mobility to reach rural communities. Since tuberculosis (TB) is one of the main
causes of death among people living with HIV, HIV-TB collaborative programs that
work on TB detection and HIV/TB treatment is another focus of NACP-IV.
Additionally, to contain the epidemic among children, program for prevention of
parent to child transmission is a key component of NACP-IV. The program consists of
HIV screening and counseling for pregnant women and provision of ART for pregnant
women and children who are HIV-positive. Free first-line antiretroviral therapy (ART)
for people eligible for ART was provided first in six high-prevalence states in 2004
and has since been scaled up and the provision of second-line ART began in 2008. As
in 2012, there are 380 ART centers across the country (NACO 2012-13 Annual
Report 51). ART centers are mostly located in medical colleges or district hospitals
and in order to reach patients in rural areas, NACO has set up link ART centers that
are located in sub-district level hospitals (NACO 2012-13 Annual Report 52).
Other initiatives that NACP-IV is taking are building HIV prevention capacity at
the state and district level and for evidence-based program planning. NACO provides
training for the people involved in different aspects of the implementation of HIV
prevention plans. The trainees include not only the personnel that are on site, such as
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counsellors, and lab technicians, but also those at research institutes that work on
HIV-related research (NACO 2012-13 Annual Report 76). Increasing the capacity
of states and districts can ensure that the implementation of the plans fit the specific
situation of each state and district so that interventions can be more effective. To
strengthen the capacity for evidence-based programming, systems that provide the
surveillance of the epidemic, which include data collecting and program monitoring,
will direct more focus to tracking emerging epidemics (NACO 2012-13 Annual
Report 85).
At the end of 2012, targeted interventions coverage for high-risk groups was
around 80% for FSW and IDUs, 70% for MSM and around 40% among bridge
populations (NACO 2012-13 Annual Report 17). Counseling and HIV testing
services for pregnant women achieved 63% coverage against the annual target and
96% of the women who were detected HIV-positive were given treatment to prevent
vertical transmission (NACO 2012-13 Annual Report 42, 44). Other programs such
as Link Worker Scheme, condom distribution and opioid substitution treatment were
scaled up. In 2012, the estimated antiretroviral therapy (ART) coverage in India was
55% and that among children under 15 was 40% (WHO 16, 25).
Assessment and Recommendation of Indias Current Policies
UNAIDS has a global target of an AIDS-Free Generation with visions of Zero
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New Infections, Zero AIDS Related Deaths and Zero Discrimination. To achieve the
visions, UNAIDS has goals that are set to be done by 2015. The goals that are set for
2015 include: reducing sexual transmission of HIV and AIDS-related mother
mortality by half, eliminating vertical transmission, preventing new HIV infections
among people who use drugs, universal ART access for those who are eligible, access
for care and support for those infected or affected by HIV and reducing the
criminalization for high-risk behaviors (Getting to Zero 7). The following section
will discuss whether India will achieve those goals by 2015 based on its current
polices.
The declining trends in HIV prevalence and overall new HIV transmission
suggest that India is on the track of reaching the global target; however, it is unlikely
that India will hit the goals by 2015. One reason is the criminalization same-sex
sexual behavior and the discrimination that high-risk groups receive remain the main
barrier for interventions to reach them. Although NACO reported high coverage of
interventions among the core high-risk groups, a lot of these populations may still
remain hidden from the services due to discrimination and fear of criminalization. For
example, MSM who are married to women may not be reached by the targeted
interventions for MSM. MSMs heterosexual partners may also be unaware of their
vulnerability. Reaching these hidden high-risk populations will be Indias main
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challenge in combatting the AIDS epidemic. Minimizing social discrimination against
the high-risk populations and revoking the laws that criminalize high-risk behaviors is
what India will need to focus on in order to close the gaps in the coverage of targeted
interventions.
Another thing to notice is that the HIV prevalence among IDUs remains high in
the past few years and partners of IDUs, who are also susceptible for HIV infections,
are less noticed. The interventions coverage and condom distribution among IDU are
the lowest among the core high-risk groups. Therefore, in order to reach the Zero
Transmission goal, India will need to address the criminalization and discrimination
against the high-risk populations and scale up services such as Link Worker Scheme
and mobile testing and counseling centers to reach the populations in rural areas.
Additionally, to lower the HIV transmission among IDUs, NACO will need to
develop interventions targeted at the partners of IDUs and scale up not only needle
exchange program but also condom distribution. Indias large scale and the high
population concentration in rural areas add complexity to increasing intervention and
prevention coverage.
Rural areas do not have infrastructures and healthcare systems that are as well
developed as urban areas, giving them less capacity in controlling the epidemic. Rural
areas are also more difficult to reach due to reasons such as geographical barriers.
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Given that a large proportion of the population resides in rural areas, India must work
on building HIV prevention capacity in these areas. Although the number of districts
that are covered by Link Worker Scheme is increasing, the coverage is still low
compared to the number of districts there are to cover. Besides scaling up programs
such as Link Worker Scheme and mobile testing and counseling centers, increasing
the knowledge level of the healthcare providers that tailors to the specific need of the
district are measures India can take.
India has a large number of children who are infected with HIV and most of
these children acquire it from vertical transmission. Given that parent to child
transmission is highly preventable by ART, providing pregnant women who are
HIV-positive with ART is the main solution to containing the epidemic among
children. India has a high ART coverage for HIV-positive mothers and babies, which
is a good achievement in approaching the Zero-AIDS goal. However, the main
challenge for India in eliminating vertical transmission is the low percentage of
pregnant women who get HIV-testing. Therefore, increasing HIV-testing coverage
among pregnant women is a priority for the prevention policies. Besides scaling up
testing services for pregnant women, preventing HIV infections among women,
especially partners of the high-risk populations, will also be a strategy to take.
While NACO aims at providing free ART for all people living with HIV, it has
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been putting efforts in expanding ART program coverage, which can be seen in the
significant increase of ART centers across the country. However, there are only half of
the people who are eligible for ART are on treatment. The low coverage may be due
to reasons such as discrimination that prevent HIV patients from accessing ART
services. Another challenge for increasing ART coverage is the economic burden it
will bring. The World Trade Organization (WTO) introduced The Agreement on Trade
Related Aspects of Intellectual Property Rights (TRIPS), which grant patent
protection for products including drugs, in 1995 (Zaidi 9). Developing countries were
given a ten-year period before they had to comply with TRIPS, which enabled India
to produce generic drugs at a lower cost (350 dollars per person per year) (Zaidi 10).
However, given the huge population of people living with HIV in India, the economic
burden is still heavy even with generic drugs. Moreover, because India is now TRIPS
compliant, companies cannot manufacture generic drugs for newer second-line HIV
medications, which are much more expensive. Therefore, ensuring good adherence for
those who are on treatment so that drug resistance is less likely to happen and
providing second-line drugs only to those who really need it become especially
important for India to be able to support such a huge demand for ART. This means
that community-based care centers will need to be scaled up along with ART
programs.
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Conclusion
As a country that contains a huge population of people living with HIV, India has
a crucial role in the global effort to achieve an AIDS-free generation. The AIDS
epidemic in India is mainly transmitted via sexual route and is highly concentrated in
the high-risk groups. India has made significant progress in containing the AIDS
epidemic; however, it is unlikely that it will achieve UNAIDS goals for 2015 with its
current plans and status. Reducing the discrimination around high-risk populations,
reallocating more resources to the vulnerable populations that were less noticed and
elevating the knowledge level regarding HIV among the general public and high-risk
populations are the priorities for India as it works toward reaching an AIDS-free
generation.
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