1. Stacie M. Greby, DVM, MPH American Embassy School January 21, 2010
HIV in India
Stacie M. Greby, DVM, MPH
American Embassy School
January 21, 2010

2. Outline Epidemiology HIV HIV in India Definition Scope of work
HIV and AIDS
Natural history
HIV in India
Epidemic
Response
National AIDS Control Programme Phase III (NACP-III)

3. Epidemiology

4. Epidemiology Definition Scope of work Study of diseases in man.
Population based medicine.
Scope of work
Disease prevention and control programs
Vaccination programs, Outbreak investigation, Emergency response
Strategic Information
Monitor and evaluation, Surveillance, Operational Research
Capacity building and training
Infectious diseases, chronic diseases, injury prevention

5. Epidemiology and HIV Terminology
Prevalence and incidence
Prevalence
Number of cases of a disease in a population
Incidence
Number of new cases of a disease in a population
Rare disease, general and concentrated epidemic
Rare disease
Prevalence less than 0.5% of the population
Generalized HIV epidemic
Prevalence is greater than 1% in Antenatal Clinics.
Concentrated HIV epidemic
Prevalence is less than 1% in Antenatal Clinics but greater than 5% among Most at Risk Populations (MARP)
MARP
Female Sex Workers (FSW)
Men who have Sex with Men (MSM)
Injecting Drug Users (IDU)

6. HIV

7. HIV What is HIV? What is AIDS? What is the difference?
Human Immunosuppressive Virus
Virus discovered in mid-1980s
What is AIDS?
Acquired Immunodeficiency Syndrome
First reported in 1980 and designated in 1981
What is the difference?
How does it affect disease control?

8. HIV
Natural History
Virus
Reduces the effectiveness of the immune system
Symptoms
Opportunistic infections and tumors
Latency
Progressive
Transmission – through bodily fluids
Blood
Semen
Vaginal fluid
Preseminal fluid
Breast milk
What would you do to prevent transmission in a population?

9. Scenario of A Matured Epidemic

10. Dynamics of Transmission*
MARPs
FSW
Male Clients
MSM
IDUs
Males
Spouses/
Partners
Females
Stress the temporal order here as first noted by Weniger et al based on the early Thai epidemic.
General Population
Former MARP
Iatrogenic
Children
*Adapted from Tim Brown 10

11. Main Drivers of HIV Epidemic, Globally
Unpaid Heterosexual Intercourse
Between male and female in the general population (African epidemic)
Commercial Sex Work
Between a female or male sex worker and a client (Asian epidemic)
Men who buy sex are the main driving force in Asia and the largest infected population group.
An estimated 10 million Asian women sell sex and at least 75 million men buy it regularly.
Injecting Drug Use
Unprotected anal sex between MSM

12. HIV in India

13. HIV Prevalence in India

14. Modes of HIV Transmission, India
Not Specified
4.7%
MSM
1.4 %
Infected Syringe & Needles
1.3%
Unprotected heterosexual contact is the main route accounting for 85.6% of the total HIV transmission

15. Heterosexual HIV Transmission in India
86% of HIV cases attributed to heterosexual transmission
9% of males in the general population reported having sex with non-regular partner in the last 12 months
FSW
HIV Prevalence ranges from 5% to 40%
0.5% of adult female population but 7% of HIV infected females
Only 38% ever had an HIV test
Average 10 clients per week
50% reported at least one Sexually Transmitted Infection symptom
69% of FSWs were ever married
46% did not use condom during last sex with non-paying client
Male Clients
5% of sexually active urban males and 3% of sexually active rural males visited a Sex Worker in the last 12 months.
75% are in age group years
24 % had sex with more than three FSWs
64% of clients of Female Sex Workers are ever married
only 13% use condom with their spouse

16. MSM Transmission in India
3% of adult males reported ever indulged in MSM activities
10-30% had first sex with male partner before the age of 15 years
More than 50% of MSM are married and have female sexual partners
30-50% of MSM reported any one STI symptom in last 12 months
50-60% reported commercial male partners and more than 80% reported non-commercial male partners one month
Average 2-12 commercial male partners in a week
15% of MSM are at high risk for acquiring/transmitting HIV

17. HIV in India Type of epidemic Primary mode of transmission
General or concentrated?
Why be concerned?
Primary mode of transmission
Commercial sex work
How would you control the epidemic?

18. HIV in India How would you control the epidemic Goal? Focus?
What do you want to accomplish?
What is success?
Focus?
Limited resources and competing priorities
MARPs or general population
Resources?
Own resources or donor resources
Three Ones
Other benefits
Spillover

19. HIV in India National AIDS Control Organisation (NACO)
National AIDS Control Programme Phase III (NACP III)

20. NACP-III Overall goal Strategy: Specific objective
Halt and reverse the epidemic in India over the next 5 years by integrating programs for prevention, care, support and treatment.
Strategy:
Prevention of new infections in high risk groups and general population through:
Saturation of coverage of high risk groups with targeted interventions (TIs)
Scaled up interventions in the general population
Providing greater care, support and treatment to larger number of People Living with HIV/AIDS (PLHA).
Strengthening the infrastructure, systems and human resources in prevention, care, support and treatment programs at the district, state and national level.
Strengthening the nationwide Strategic Information Management System.
Specific objective
Reduce new infection as estimated in the first year of the program by:
60% in high prevalence states so as to obtain the reversal of the epidemic; and
40% in the vulnerable states so as to stabilize the epidemic.

21. NACP-III Programme Priorities and Thrust Areas
Learn from the lessons of the previous two phases
Prioritize preventive efforts
More than 99% of the population is free from infection
Integrate prevention with care, support and treatment.
MARPs will receive the highest priority (Sex workers, MSM, IDU)
Lower priority groups with high levels of exposure (long distance truckers, prisoners, migrants (including refugees) and street children).
Next priority general population services – STI treatment, voluntary counseling and testing and condoms.
Ensure all persons who need treatment would have access (prophylaxis, opportunistic infections, and first line ARV drugs).
Prevent vertical transmission through universal provision of PPTCT services and assure access to pediatric ART.
Address the needs of children infected and affected by HIV through agencies involved in child protection and welfare.
Invest in community care centers to provide psycho-social support, outreach services, referrals and palliative care.
Work with agencies involved in vulnerability reduction such as women’s groups, youth groups, trade unions etc. to integrate HIV prevention into their activities.
Facilitate a multisectoral response including private sector, civil society organizations, PLHA networks and government departments to provide prevention, care, support, treatment and services.