HIV prevalence in India is declining, but some states — where new infections are on the rise — are bucking that trend.
By Harry Stevens | January 28, 2016
Samir Banik does not need to look at the data to know that more and more people have been testing positive for HIV in Tripura, India’s third smallest state. As general secretary of the Tripura State Network of Positive People, a support and advocacy group for people with HIV/AIDS, Banik sees the disturbing trend play out in clinics and hospitals every day.
“HIV-positive [cases] are increasing,” Banik said. “What I am seeing is that there are more cases than before.”
That’s what the data say too, according to the most recent report released by the National AIDS Control Organisation (NACO). Even as India's battle against HIV/AIDS has taken a turn for the better, some states, such as Tripura, are falling behind.
Between 2007 and 2015, India’s HIV prevalence — that is, the proportion of India’s adult population that is HIV-positive — fell by an estimated 24 percent. HIV prevalence in Tripura, however, more than doubled during that time.
Likewise, while new HIV infections and AIDS-related deaths plummeted across the country, they spiked in Tripura.
Tripura is bucking the national trend, and it’s not alone. The report also points to discouraging trends in Assam, Sikkim and, to a lesser extent, in Arunachal Pradesh, Delhi, Gujarat, Haryana, Jharkhand, Punjab, Rajasthan, and Uttarakhand.
To be sure, one must exercise caution when drawing conclusions based on NACO’s figures. “It is important to keep in consideration that these are estimates,” said Savina Ammassari, senior adviser for the Joint United Nations Programme on HIV and AIDS (UNAIDS) in India. “So you have confidence intervals. It's not exact science. That's absolutely a must to understand.”
In Tripura, for example, the report estimates that .31 percent of adults were HIV-positive in 2015. But that figure could be as low as .05 percent or as high as .89 percent.
Still, as far as estimates go, NACO’s are on solid footing. The agency bases its estimates on rigorously collected data and uses the statistical model favored by the United Nations.
“India is one of the most robust countries for data collection. It has a long history of collecting data and improving its data collection over time,” said Ammassari, who joined UNAIDS in India last August after a decade spent working for the organization in Cambodia and Myanmar. “The systems here are quite elaborate and robust.”
Leena Menghaney, a Medicins Sans Frontiers campaigner who advocates for greater access to HIV treatments in India, echoed Ammassari’s praise for NACO’s data collection.
“Among the communicable disease control programmes, NACO has the most reliable surveillance program,” Menghaney said. “It may not be perfect, but it gives you the broad trends for what's happening in the country.”
It may not be perfect, but it gives you the broad trends for what's happening in the country.
- Leena Menghaney, Medicins Sans Frontiers
NACO declined to comment for this story, but its annual progress report concedes that HIV prevalence is spreading in some areas.
“Overall trends of HIV portray a declining epidemic at national level, though regional variations exist,” the report says. “While some districts showed stable to declining trends, some districts showed rising trends of HIV prevalence warranting focused attention on these pockets.”
One such pocket is Assam, where 39-year-old Jahnabi Goswami has been an AIDS activist for much of her adult life. Over a decade ago, Goswami founded the Assam Network of Positive People, a support and advocacy group for people living with HIV. Since then, she said, she has seen an increasing number of people — truck drivers, pregnant mothers, drug addicts, teenagers, sex workers — show up at clinics and test positive for the virus.
“The government of India is declaring that the infection rate is declining,” said Goswami, who is also HIV-positive. “But it's not true.”
At least not in Assam. HIV prevalence among adults there jumped an estimated 50 percent — from .04 to .06 — between 2007 and 2015. The number of people living with HIV has nearly doubled in that time, from about 6,000 to 12,000. New infections and AIDS-related deaths are up, too.
Dr. Chiranjeev Bhattacharjya, the state epidemiologist for the Assam State AIDS Control Society, confirmed that Assam has recorded an increase in prevalence among pregnant mothers — considered a good proxy for the general population — and among certain high-risk groups, like female sex workers.
But Bhattacharjya also said that the statistical rise in prevalence may be the result, at least in part, of additional HIV testing around the state. “Whenever your testing increases, detection increases and the numbers will jump,” he said.
The AIDS epidemic has never been evenly distributed across India. Some states, particularly those in the south and those that border Myanmar, have long suffered from high infection rates.
While HIV continues to afflict these states more than others, a decades-long public health battle in historical HIV hotbeds like Maharashtra, Andhra Pradesh and Manipur has yielded success. In these states, HIV prevalence, new infections, and AIDS-related deaths have all fallen over the last decade.
How is it that India as a whole has turned the tide against HIV even as states such as Tripura and Assam struggle to keep their heads above water? Part of the answer lies with the way NACO uses the data it collects.
At NACO’s Delhi offices, statisticians work alongside public health experts to craft national HIV/AIDS policy. By collecting and analyzing data from every corner of India, NACO’s statisticians have been able to point public health programs to areas where their resources can do the most good.
NACO has found, for instance, that HIV/AIDS is far more common in the south and in some parts of the northeast. By targeting the epidemic in this handful of states — Andhra Pradesh, Telangana, Karnataka, Maharashtra, Manipur, Nagaland, and Tamil Nadu — the agency has slashed the national HIV prevalence rate.
“[NACO] is correctly determining, based on its analysis of the data from the states and down to the district level, where to focus on,” said Oussama Tawil, UNAIDS’s country coordinator in India.
But Tawil wondered whether NACO would be able to adapt its resources if the epidemic should shift geographically.
“They should reexamine their focus based on whatever evidence they have,” Tawil said. “In other words, the states and districts that were at risk in 2005 are not necessarily the same ones that are at risk in 2016. They still may be, but there may be something else that happened.”
India's HIV Prevalence Slowly Shifts
HIV remains most prevalent in the south and near the Myanmar border...
...but the epidemic is receding in those states, even as it progresses in the north.
Click on the states to explore the data. While HIV prevalence dropped nationwide by an estimated 24 percent from 2007 to 2015, Assam, Sikkim, and Tripura all recorded estimated prevalence increases of more than 50 percent. Meanwhile, the biggest prevalence drops were seen in Manipur, Maharashtra, Karnataka, Goa, Andhra Pradesh, Telangana, and West Bengal. (Source: National AIDS Control Organisation, India HIV Estimations 2015)
India’s historical HIV hotbeds continue to bear the brunt of the epidemic. Maharashtra, Andhra Pradesh, Telangana, and Karnataka still combine for nearly half of India’s more than 21 lakh HIV cases. Meanwhile, the states where HIV prevalence has increased the most — Sikkim, Tripura, and Assam — make up a tiny proportion (less than one-hundredth of a percent) of the country’s HIV cases.
NACO’s funds are limited (particularly since last year's budget cut). If you can only afford to set up so many antiretroviral therapy centres, or to distribute so many condoms, or launch so many public education campaigns, it makes sense to do that in places where the greatest number of people are likely to benefit. But that does little to ease the concern of HIV patients from low-prevalence states.
“[Government programs] are looking only at high-prevalence states,” said Goswami, speaking over the phone from Assam. “But there are low-prevalence states which are highly vulnerable. These are very poor states. They need to look after them, too.”
There are low-prevalence states which are highly vulnerable... They need to look after them, too.
- Jahnabi Goswami, Assam Network of Positive People
As of 2014, for example, Assam had only four government-run antiretroviral therapy centres, compared with 51 in Andhra Pradesh, 55 in Karnataka, 82 in Maharashtra (including 12 in Mumbai), and 52 in Tamil Nadu, according to NACO’s figures. That means someone with HIV who is living in Assam must often travel more than 100 kilometers to receive the treatment that can keep them alive.
In recognition of this, Bhattacharjya said, the Assamese government offers people with HIV free trips to the nearest antiretroviral treatment centre. But if they fail to make it to the centre by two o’clock in the afternoon, they are likely to find it closed, Goswami said.
“People have to travel for the full day sometimes to get to the centres,” Goswami said. “These people don't have any place to stay, and they are also very poor.”
If they still wish to be treated, they must wait until morning. A poor laborer would then have to choose between losing an extra day of wages or forgoing life-saving treatment.
Tawil, of UNAIDS, said the government ought to ensure that HIV patients in low-prevalence states are not overlooked.
“Every person who's infected, every person who's at risk, is of concern. There needs to be a response regardless of the state's size,” Tawil said. “Even if they have only 20 cases, those 20 cases have the right to services.”