1. 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 dr.rajeshkumar@gmail.com

2. HIV Trends

3. 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

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

5. HIV Sentinel Surveillance 1998 19992000200120022003 2004 ANC 9494112174201272 396 STD 78 78105129165165 166 IDU 8 8 11 13 13 13 13 FSW - - 2 2 2 2 2 MSM - - 2 2 3 3 3 Total 180180232320384455 670

6. Sentinel Surveillance Data analysed from 2000-2004 2,94,050 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

7. 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

8. Age-standardised HIV-1 prevalence in women attending ANC clinic Trends in HIV-1 in young adults in south India from 2000-2004: A Prevalence Study. The Lancet, 8 April 2006

9. 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 2000-2004: A Prevalence Study. The Lancet, 8 April 2006

10. 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 2000-2004: A Prevalence Study. The Lancet, 8 April 2006

11. 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 2000-2004: A Prevalence Study. The Lancet, 8 April 2006

12. 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 2000-2004: A Prevalence Study. The Lancet, 8 April 2006

13. 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 2000-2004: A Prevalence Study. The Lancet, 8 April 2006

14. 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 2000-2004: A Prevalence Study. The Lancet, 8 April 2006

15. Sexual partners reported by general population in past 12 months Trends in HIV-1 in young adults in south India from 2000-2004: A Prevalence Study. The Lancet, 8 April 2006

16. Biases in ANC data ANC coverage only 50% in North versus 80% in South BUT little change in key demographic variables in South from 2000-2004 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

17. 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

18. 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

19. 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

20. 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.

21. Thanks