With an estimated 5.7 million people living with HIV/AIDS, India has the highest HIV/AIDS prevalence in the world, according to UNAIDS.1 Among 15-49 year olds, an estimated 5.2 million are living with the disease, according to India’s National AIDS Control Organisation (NACO).2 Still, India’s prevalence rate (the percent of the adult population estimated to be infected with HIV) is relatively low. However, India is considered to be a “next wave” country; that is, it stands at a critical point in its epidemic, with HIV poised to expand, but where large-scale prevention and other interventions today could help to contain a more serious epidemic in the future.3,4 As the second most populous nation in the world,5 even a small increase in India’s HIV/AIDS prevalence rate would represent a significant component of the world’s HIV/AIDS burden.
• The first case of HIV disease was documented in India in 1986.
• Later that year, the Government of India (GOI) established a National AIDS Committee under the Ministry of Health & Family Welfare to formulate a strategy for responding to HIV/AIDS in the country. It launched a National AIDS Control Programme (NACP) in 1987.
• NACO, established in 1992 by the Ministry with major support from the World Bank, is the implementing entity of the National AIDS Control Programme. Phase I of the Programme started that year; Phase II followed in 1999. Phase III is slated to begin in 2006.
• NACO has facilitated the development of 38 State AIDS Control Societies (SACS), which operate in all states and Union Territories and in three cities.
• The GOI’s overall HIV/AIDS budget for NACO in FY 2005-2006 was US $103 million, and is expected to total US $138 million in FY2006-2007.
Current National Estimates
NACO, UNAIDS, and other international experts develop estimates of HIV prevalence (people living with the disease) and incidence (new HIV infections) in India:
• As of the end of 2005, UNAIDS estimates that there were 5.7 million people of all ages living with HIV/AIDS in India. NACO estimates that there were 5.2 million adults, aged 15-49, at this same point in time.
• HIV/AIDS prevalence among adults in India is still relatively low, at 0.9%, as estimated by both UNAIDS and NACO(once a country’s prevalence rate is greater than 1%, it is considered to have a “generalized epidemic” and HIV may spread more rapidly).
• India accounts for 75% of HIV/AIDS prevalence in South/South East Asia and 15% of global prevalence.1 By comparison; India represents 20% of the world’s population.
• National prevalence rates mask variations by region and subpopulation. In 2005, five Indian states had high HIV/AIDS prevalence (>1% in antenatal clinics)—Andhra Pradesh, Karnataka, Maharashtra, Manipur, and Nagaland—as did 95 districts within states. HIV prevalence of >10% was found at 34 STD sites.
• Most HIV infections in India are due to heterosexual transmission.4,6 In the North East, however, injection drug use is the main mode of transmission. Commercial sex work and sex between men also drive the HIV epidemic in parts of India. Large-scale population mobility and migration, primarily through male migrant labour, further contribute to the spread of disease.
• NACO estimates that women accounted for 38% of India’s adult HIV/AIDS prevalence in 2005.
• The majority of people living with HIV/AIDS in India are from rural areas (57% in 2005).
• Young adults, aged15-29, account for 32% of AIDS cases reported in India over the course of the epidemic.39 Among those aged 15-24, the number of young women living with HIV/AIDS has been estimated to be almost twice that of young men.
• Tuberculosis (TB) and HIV are intersecting epidemics. Those infected with HIV are more susceptible to TB infection, and TB disease may progress more quickly in those infected with HIV. TB is the most common opportunistic infection among people living with HIV/AIDS in India.
• According to NACO, the number of adults (15-49) living with HIV/AIDS in India has increased by 35% since 2000, although it has been relatively stable for the past two years, increasing by 2% between 2003 and 2005. UNAIDS estimates that overall HIV/AIDS prevalence among those 15 and older increased by 8% between 2003 and 2005. Both UNAIDS and NACO estimate that the prevalence rate remained stable, at 0.9%, over this same period.
• NACO also collects AIDS case surveillance data from SACS but these data only provide a snapshot of the epidemic, given the delay in progression from HIV infection to an AIDS diagnosis and the large number of people living with HIV who do not know their status. This is the case in every country, including the United States.
• Data on new HIV infections in India are not currently available. One way to approximate this figure is to apply India’s share of the global total of people estimated to be living with HIV/AIDS (15%) to the global total of estimated new HIV infections (4 million), yielding an estimate that approximately 600,000 Indians may have been newly infected with HIV last year.
Several different projections have been developed to model the potential impact of the epidemic in India over time, including:
• U.S. National Intelligence Council (NIC): in 2002, NIC projected that by 2010, India could have 20 to 25 million people living with HIV/AIDS, the highest number of any country in the world.
• Eberstadt: Researcher Nicholas Eberstadt modeled several scenarios to project the epidemic’s impact between 2000 and 2025. For example, he projected that life expectancy in India in 2025 could fall by 3-13 years, depending on epidemic severity.
• World Health Organization (WHO) and United Nations: The WHO estimated that HIV/AIDS caused 3% of all deaths and 17% of deaths due to infectious diseases in India in 2002. If current HIV/AIDS trends continue, by 2033, HIV could account for 17% of all deaths and 40% of deaths from infectious disease. They are expected to be lower due to HIV/AIDS.
• India’s Office of the Registrar General and Census Commissioner recently released demographic projections, estimating that there could be 11 million deaths due to HIV in India between 2001 and 2026.
• Asian Development Bank/UNAIDS: A 2004 report by ADB/UNAIDS estimates that HIV/AIDS could slow poverty reduction goals by 23% every year between 2003 and 2015.
• National Council of Applied Economic Research: NCAER analyzed the likely impact of HIV/AIDS over the period between 2002/2003 and 2015/2016 finding that if left unchecked, India’s economic growth could fall by 0.86 percentage points each year over the period.
• World Bank: A recent World Bank report examines alternate scenarios for expanding antiretroviral therapy (ARV) in India, concluding that such an expansion is cost effective. However, without strengthened prevention efforts, the epidemic will not substantially slow.
• Support Groups and Networks: As of 2003, there were 51 community care centres run by NGOs in India. NACO supports 17 networks of people living with HIV/AIDS. The Indian Network for People Living with HIV/AIDS, one of the largest associations of HIV-positive people in the world, has more than 20,000 members.
• HIV Counselling and Testing: There were 1,110 voluntary counselling and testing (VCT) centres in India as of December 2005, most of which are supported by NACO through the SACS. These centres served over 970,000 clients in 2005.
• HIV Prevention: The GOI, and donors including the United States, the United Kingdom, the Gates Foundation, and others, support a network of targeted interventions aimed at reducing transmission among those at highest risk. In August 2005, there were 965 interventions targeting female sex workers, injection drug users, men who have sex with men, migrant workers in slums, prisoners, street children, truckers, and individuals that meet multiple risk factor criteria.
• Antiretroviral Therapy (ART): As of December 2005, an estimated 52,000 people were receiving ART in India, less than 7% of the estimated 785,000 people in need of ART in the country. In November 2003, the GOI set a national target of providing free ART to 100,000 people through the public sector by 2007. By August 2005, 12,000 people were reported to be receiving treatment through the public sector. India is one of six countries which together comprise more than half of treatment need in low- and middle-income countries.
• Public Education Initiatives: The Heroes Project, a national initiative co-chaired by Richard Gere and Parmeshwar Godrej in partnership with the Kaiser Family Foundation and supported by a grant from the Gates Foundation’s Avahan India AIDS Initiative, works with a cross-section of Indian media and societal leaders on a coordinated HIV/AIDS campaign. Population Services International (PSI) conducts social marketing activities on HIV/AIDS that span 22 States and Union Territories as well as the national highway system. The BBC World Service Trust has a co-production partnership with NACO and Doordarshan, the government-supported broadcaster, on HIV/AIDS programming. There are other national and regional efforts to work with media on HIV/AIDS, including journalism programs developed by the Kaiser Family Foundation and others.
Generic Drugs: India is one of the key manufacturers of generic ARVs in the world which are sold within India and in other countries, including those in sub-Saharan Africa. There is some concern that India’s recent compliance with the World Trade Organization’s requirements to protect product patents on medicines may drive up prices and affect supplies, particularly for second and third-line ARV treatment.
• HIV Vaccine Trials: The first Phase I clinical trial for an HIV vaccine recently began in India. Conducted by NACO, the Indian Council of Medical Research, and the International AIDS Vaccine Initiative (IAVI), the trial is taking place at the National AIDS Research Institute in Pune.
Major Donors/Other External Support
• Currently, more than 30 donor government agencies work with NACO, including: the Australian Agency for International Development; Canadian International Development Agency; Danish International Development Agency; Swedish International Development Cooperation Agency; UK Department for International Development; and U.S. Government.
• The U.S. Government provides bilateral assistance to India for HIV/AIDS, and support through its contributions to the Global Fund. USAID has supported activities in India since 1995 and CDC since 2001. India is not one of the 15 focus countries of the President’s Emergency Plan for AIDS Relief (PEPFAR), but has been identified as a country of “concern outside of the focus countries.” U.S. bilateral aid for India was over $26 million in FY 2005, the largest outside of the 15 focus countries.
• The World Bank has been a main financier of NACO, providing $84 million for Phase I of the National AIDS Control Project and $191 million for Phase II.
• The Global Fund to Fight AIDS, Tuberculosis, and Malaria has approved two HIV/AIDS grants in India totaling $118,533,024 and one HIV/TB grant for $2,667,346.
• UNAIDS, UNDP, UNICEF, WHO, and the other UNAIDS co-sponsors provide technical assistance and other support, through in-country offices and partnerships.
• The Gates Foundation has committed $200 million in India through its Avahan Initiative.
Source: The Kaiser Family Foundation