Magnitude of HIV/AIDS in India - Overview of HIV/AIDS in India
According to the last year’s estimates, India had 5.206 million HIV/AIDS patients (people aged between 15 and 49 years) in 2005. The UNAIDS later put it at 5.7 million, including the pediatric AIDS cases. For the first time, National Family Health Survey (NFHS), India’s largest health survey, had specific questions on AIDS in its door-to-door survey conducted on 230,000 people.  The number of sentinel sites had gone up to 1,122 from 702.  Both sentinel site and NFHS data were integrated and a new internationally validated methodology was used to arrive at the new estimate. These new estimates released by the National AIDS Control Organization (NACO), supported by UNAIDS and WHO, indicate that national adult HIV prevalence in India is approximately 0.36%, which corresponds to an estimated 2.0-3.1 million people living with HIV in the country.  The new lower estimates do not mean a sharp decline in the epidemic.
In Tamil Nadu and other southern states with high HIV burden, where effective interventions have been in place for several years, HIV prevalence has begun to decline or stabilize. The 2006 surveillance data [Table - 2] has identified selected pockets of high prevalence in the northern states. There are 29 districts with high prevalence, particularly in the states of West Bengal, Orissa, Rajasthan and Bihar.  India’s highest prevalence of HIV/AIDS cases has been observed in the Dharwad district of Karnataka.
Feminization of the HIV/AIDS epidemic
The HIV/AIDS epidemic is increasingly affecting women and young girls, especially where heterosexual sex is the main mode of transmission.  Out of the estimated adults living with HIV, 38.4% were females.  Women are less educated, more overworked, underpaid and financially dependent on men. They fail to make use of protective measures (condoms) which are male driven, and also they lack the power to negotiate with their partner. Ironically, they are faithful but are infected by their single partner.
The greatest boon of nature to women is the capacity to conceive, and the greatest curse is her inability to control the same.
Trend of HIV prevalence among different population groups in India
The vast majority of infections occur through heterosexual sex, and most of those who become infected would not fall into the category of high-risk groups [Figure - 1]. HIV prevalence was >1% among antenatal mothers in 95 districts, including 9 districts in the low-prevalence states. Similarly, HIV prevalence was >10% in 34 STD sites across the country, indicating multiple heterogeneous epidemics. Year-wise trend of HIV prevalence in different population groups is shown in [Figure - 2]. 
The HIV/AIDS situation in different states
The vast size of India makes it difficult to examine the effects of HIV on the country as a whole. The HIV prevalence data for each state [Figure - 3] is established through antenatal clinics, where pregnant women are tested. The following states have recorded the highest levels of HIV prevalence at antenatal and sexually transmitted disease (STD) clinics over recent years.
The HIV prevalence at antenatal clinics was around 2% in both 2004 and 2005 - higher than in any other state. The vast majority of infections in Andhra Pradesh are believed to result from sexual transmission. HIV prevalence at STD clinics was 22.8% in 2005.
Goa is known as a tourist destination. Tourism is so prominent that the number of tourists almost equals the resident population, which is about 1.3 million. The HIV prevalence at antenatal clinics was found to be above 1% in both 2002 and 2004 but was 0.5% in 2003 and 0% in 2005. This variation is likely due to the small number of women tested; the 2005 survey included only two antenatal sites. Prevalence at STD clinics was 14% in 2005, indicating that Goa has a serious epidemic of HIV among sexually active people.
In Karnataka, the average HIV prevalence at antenatal clinics has exceeded 1% in all recent years. Districts with the highest prevalence tend to be located in and around Bangalore, in the southern part of the state, or in northern Karnataka’s ‘ devadasi belt.’ These days, this has evolved into sanctioned prostitution; and as a result, many women from this part of the country are supplied to the sex trade in big cities such as Mumbai. The average HIV prevalence among female sex workers in Karnataka was 18% in 2005.
Mumbai is the capital city of Maharashtra state and is the most populous city in India, with around 20 million inhabitants. The HIV prevalence at antenatal clinics in Maharashtra has exceeded 1% in all recent years, and surveys of female sex workers have found rates of infection above 20%.
The HIV prevalence at antenatal clinics in Tamil Nadu was 0.88% in 2002 and 0.5% in 2005, though several districts still have rates above 1%. Prevalence among injecting drug users was 18% in 2005. Tamil Nadu had reported 52,036 AIDS cases to NACO by July 2005, which is by far the highest number reported by any state.
The nearness of Manipur to Myanmar (Burma), and therefore to the Golden Triangle drug trail, has made it a major transit route for drug smuggling, with drugs easily available. HIV prevalence among injecting drug users is above 20%, and the virus is no longer confined to this group but has spread further to the female sexual partners of drug users and their children. The HIV prevalence at antenatal clinics in Manipur has exceeded 1% in all recent years.
The small northeastern state of Mizoram has fewer than a million inhabitants. In 1998, an HIV epidemic took off quickly among the state’s male injecting drug users, with some drug clinics registering HIV rates of more than 70% among their patients. In recent years the average prevalence among this group has been much lower, at around 5%. HIV prevalence at antenatal clinics has exceeded 1% in most recent years but was 0.88% in 2005.
Nagaland is another small northeastern state, with a population of 2 million, where, again, injecting drug use has been the driving force behind the spread of HIV. In 2005, the HIV prevalence at antenatal clinics was 1.63%, and the rate among injecting drug users was 4.51%.
Facilities providing voluntary counseling and testing (VCT) and ‘prevention of parent-to-child transmission’ services (PPTCT) were remodeled as ‘Integrated Counseling and Testing Centres’ (ICTCs). Today, more than 10 million people have been counseled and tested in more than 4,000 ICTCs spread throughout the country. The NACP III now envisages expansion of testing sites to 5,000 and establishment of another 10,000.
Access to Antiretroviral Treatment (ART)
Highly active antiretroviral treatment (HAART) - a form of treatment involving antiretroviral drugs (ARVs), which significantly delays the progression from HIV to AIDS - has been available in rich countries since 1996. Unfortunately, as in many poor countries, access to this treatment is severely limited in India, with only 7% of those in need receiving them by the end of 2005.  Ironically, India is the major provider of cheap generic copies of ARVs to countries all over the world. While the coverage of treatment remains unacceptably low, improvements are being made. Today, about 80,000 patients are accessing free treatment in 127 centers.
Marfatia YS, Sharma Archana, Modi Megha
Department of Skin and VD, Medical College and SSG Hospital, Vadodara, India
Marfatia Y S
Department of Skin and VD, Medical College and SSG Hospital, Vadodara
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