The target of wiping out AIDS by 2030 not easy

The first cases of HIV infection in India were detected in 1986 among female sex workers in Chennai. A rapid increase followed in many states. The current national prevalence is about 0.26% compared with a global average of 0.2%, but the figure in most high-risk groups including female sex workers is much higher (up to 7%). Overall, India’s HIV epidemic is slowing down. Between 2010 and 2017 new infections declined by 27% and AIDS-related deaths more than halved, falling by 56%. However, in 2017, new infections increased to 88,000 from 80,000 and AIDS-related deaths increased to 69,000 from 62,000.3 UNAIDS (2017) ‘UNAIDS data 2017’ 

Key points:

India has the third largest HIV epidemic in the world, with 2.1 million people living with HIV. India’s epidemic is concentrated among key affected populations including sex workers and men who have sex with men. The National AIDS Control Programme, however, has made particular efforts to reach these two high-risk groups with HIV interventions. Compared to neighbouring countries, India has made good progress in reducing new HIV infections by half since 2001. Despite free antiretroviral treatment being available, uptake remains low as many people face difficulty in accessing clinics.

• India’s long battle against AIDS is not likely to end any time soon, if the latest figures released by the National AIDS Control Organisation (NACO) on Friday is any indication.
• The data revealed that, as of 2017, there were still around 21.40 lakh people living with HIV in India, with the prevalence among adults stood at 0.22 per cent.
• “HIV Estimations 2017 corroborates the previous rounds in terms of the characteristic of the HIV epidemic in India -- national prevalence and incidence remains low, but the epidemic is high in some geographical regions and population groups. The report has noted that the rate of decline in annual new HIV infections has been relatively slower in recent years,” noted a release from the Health Ministry.
• The 2017 estimation report also indicates that there is no place for complacency as the country aims to achieve the ambitious goal of ending AIDS in India by 2030. It adds, however, that the impact of the HIV/AIDS control programme has been significant, with more than an 80 per cent decline in estimated new infections from the epidemic’s peak in 1995.
• Estimations of adult HIV prevalence, annual new infections (HIV incidence), AIDS-related mortality, and prevention of mother-to-child transmission (PMTCT) needs are produced as outcomes of HIV estimations. The modelled estimates are needed because there is no direct reliable way of measuring these core indicators, which are used to track the epidemic monitor and evaluate response around the world.

Barriers to the HIV response in India

Stigma and discrimination:

India’s NACP-IV has made the elimination of stigma and discrimination a major focus. In 2018, implementation on the HIV AIDS (prevention and control) Act 2014 began. The law criminalises discrimination against people with HIV and AIDS, including within employment, healthcare, education, public facilities and public office, as well as protecting property and insurance rights. Despite this, people living with HIV continue to experience high levels of discrimination. In 2016, 27% of adults demonstrated a discriminatory attitude towards people living with HIV, a slight improvement on the 2006 level of 35%. The study recommended further intervention programmes targeting healthcare providers to address fear of transmission, improve universal precaution skills, and involve people living with HIV at all stages of the intervention to reduce symbolic stigma and ensure that relevant patient interaction skills are taught.

Gender inequality is also an issue:  Women, particularly in rural areas, have little control or decision-making powers over important aspects of their lives. This means they are often unable to negotiate protection from risk of infection. This is an issue for the female partners of men from key populations particularly, given the concentrated nature of the epidemic. Women living with HIV are reluctant to access health care for fear of discrimination and marginalisation, leading to a disproportionate death rate in HIV women. India is also home to arguably the largest number of orphans of the HIV epidemic. These children endure stigma and face an impenetrable barrier in many Indian societies. This situation encourages children and their guardians to hide HIV and discourages access to essential treatment services (if available).

Data issues:

There is a need for greater access, analysis and applied use of data within the national HIV response. This is due to a lack of integrated quality data systems, which limit availability and use plus a lack of structure for case-based reporting, a lack of district HIV and key population size estimates, and inadequately trained staff to monitor the epidemic. There are also challenges associated with tracking people through the continuum of HIV diagnosis to care and treatment due to a lack of unique patient identifier records and different monitoring and reporting systems used within facilities.86

Strutural and resource barriers

In recent years, there have been shortfalls in the procurement, management and distribution of ARVs, HIV testing kits and other HIV commodities, mainly due to supply chain bottlenecks.

India needs a national review of its harm-reduction policies to offer substitution therapy for de-addiction to all drug users, and not just injecting drug users since oral users graduate to injecting drugs. India must also decriminalize behaviors, such as drug use and homosexuality, to ensure that harm-reduction services and treatment reach those who need them,

By: Jasmeet Singh