HIV Declines in Young Adults in South India Rajesh Kumar, MD Prof. of Community Medicine School of Public Health Post Graduate Institute of Medical Education & Research Chandigarh India

HIV Trends

Background… Incidence is the BEST measure of trends Prevalence among young people especially young married women is a good proxy to study trends in HIV incidence

Is there a change in HIV? Can biases explain the change? Objectives

HIV Sentinel Surveillance ANC STD IDU FSW MSM Total

Sentinel Surveillance Data analysed from ,94,050 pregnant women at ANC clinics 58,790 men at STI clinics Age, Residence, Migration*, Education*, Some other sexually transmitted infections, Year, State and Site/Site Name*, * Not all years

Regions of Analysis <0.5% 0.5% to <1% 1% to <1.5% >=1.5% Based on state-level HIV-1 prevalence among ANC attendees Two regions of analysis: 1. ‘South’ 2. ‘North’ and other

Age-standardised HIV-1 prevalence in women attending ANC clinic Trends in HIV-1 in young adults in south India from : A Prevalence Study. The Lancet, 8 April 2006

Age-standardised HIV-1 prevalence in women aged 15–24 years attending ANC clinics by residence Trends in HIV-1 in young adults in south India from : A Prevalence Study. The Lancet, 8 April 2006

Age-standardised HIV-1 prevalence in women aged 15–24 years attending ANC clinics by migrant status Trends in HIV-1 in young adults in south India from : A Prevalence Study. The Lancet, 8 April 2006

Age-standardised HIV-1 prevalence in women aged 15–24 years attending ANC clinics by literacy Trends in HIV-1 in young adults in south India from : A Prevalence Study. The Lancet, 8 April 2006

Age-standardised HIV prevalence in women aged 15–24 years attending ANC monitored continuously and all sites Trends in HIV-1 in young adults in south India from : A Prevalence Study. The Lancet, 8 April 2006

Age-standardised HIV-1 prevalence in women aged 15–24 years attending ANC clinics in Andhra Pradesh, Karnataka, Maharasthra, and Tamil Nadu Trends in HIV-1 in young adults in south India from : A Prevalence Study. The Lancet, 8 April 2006

Age-standardised HIV-1 prevalence in men aged 20–29 years attending STI clinics and in those with genital ulcers Trends in HIV-1 in young adults in south India from : A Prevalence Study. The Lancet, 8 April 2006

Sexual partners reported by general population in past 12 months Trends in HIV-1 in young adults in south India from : A Prevalence Study. The Lancet, 8 April 2006

Biases in ANC data ANC coverage only 50% in North versus 80% in South BUT little change in key demographic variables in South from ANC captures young women better than older women ANCs don’t capture men who use FSWs and are not married (perhaps ½ of all such men) ANCs don’t capture FSWs

Summary 1/3 Decline in South Not due to major changes in women who go to antenatal clinics Not due to changes in sites chosen Not due to mortality Only changes in husband’s use of female sex work (less often or with condoms when done) is only plausible explanation Consistent with increased peer intervention programs to reach sex workers starting about 1999 Gaps exist in South however: esp Karnataka and Andhra Pradesh Goal: 100% coverage of TI in all 115 districts

Summary No Change in North Testing is not as complete: many districts don’t have a single site Can exclude only MAJOR changes It is early- only matter of time before increases occur Peer interventions are limited Rapid expansion of surveillance and scale up prevention in hot spots North is not immune: complacency is dangerous

Implications  Innovations in routine surveillance as a cost-effective, sustainable and relevant research resource  Enhanced ANC surveillance include STIs and behavioural surveillance  Central biorepository of HIV+ and random % of HIV-  VCTC populations  Training of surveillance officers for better use of their own data  Develop biomarker based methods relevant to control  Incidence measures that work and are cheap  Risk stratification with combination of STI/questions  Understand FSW and male clients better  Size and distribution of FSW and male clients  Measure HIV and STIs in FSW and clients

Acknowledgement International Studies of HIV/AIDS (ISHA) All Investigators P Jha D Phil, P Arora MSc, P Millson MD, N Dhingra MD, R S Remis MD Centre for Global Health Research, Public Health Sciences, University of Toronto, Toronto, M5C 1N8, Canada; P Mony MD Institute of Population Health and Clinical Research, St John’s National Academy of Health Sciences, Bangalore, India P Bhatia MD Osmania Medical College, Hyderabad, India M Bhattacharya PhD National Institute of Health and Family Welfare, New Delhi, India Prof N Nagelkerke PhD United Arab Emirates University, Al Ain, United Arab Emirates We thank NACO for providing access to the antenatal and STI data.

Thanks