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ndia is one of the largest and most populated countries in the world, with over one billion inhabitants.

. Of this number, it's estimated that around 2.4 million


people are currently living with HV.1
HV emerged later in ndia than it did in many other countries. nfection rates soared throughout the 1990s, and today the epidemic affects all sectors of
ndian society, not just the groups such as sex workers and truck drivers with which it was originally associated.
n a country where poverty, illiteracy and poor health are rife, the spread of HV presents a daunting challenge.
The History of HIV/AIDS in India
t the beginning of 1986, despite over 20,000 reported DS cases worldwide,2 ndia had no reported cases of HV or DS.3 There was recognition, though,
that this would not be the case for long, and concerns were raised about how ndia would cope once HV and DS cases started to emerge. One report,
published in a medical journal in January 1986, stated:
"Unlike developed countries, India lacks the scientific laboratories, research facilities, equipment, and medical personnel to deal with an AIDS epidemic. In
addition, factors such as cultural taboos against discussion of sexual practices, poor coordination between local health authorities and their communities,
widespread poverty and malnutrition, and a lack of capacity to test and store blood would severely hinder the ability of the Government to control AIDS if the
disease did become widespread."4
ater in the year, ndia's first cases of HV were diagnosed among sex workers in Chennai, Tamil Nadu.5 t was noted that contact with foreign visitors had
played a role in initial infections among sex workers, and as HV screening centres were set up across the country there were calls for visitors to be screened
for HV. Gradually, these calls subsided as more attention was paid to ensuring that HV screening was carried out in blood banks.6 7
n 1987 a National DS Control Programme was launched to co-ordinate national responses. ts activities covered surveillance, blood screening, and health
education.8 By the end of 1987, out of 52,907 who had been tested, around 135 people were found to be HV positive and 14 had DS.9 Most of these initial
cases had occurred through heterosexual sex, but at the end of the 1980s a rapid spread of HV was observed among injecting drug users (DUs) in
Manipur, Mizoram and Nagaland - three north-eastern states of ndia bordering Myanmar (Burma).10
t the beginning of the 1990s, as infection rates continued to rise, responses were strengthened. n 1992 the government set up NCO (the National DS
Control Organisation), to oversee the formulation of policies, prevention work and control programmes relating to HV and DS.11 n the same year, the
government launched a Strategic Plan, the National DS Control Programme (NCP) for HV prevention. This plan established the administrative and
technical basis for programme management and also set up State DS Control Societies (SCS) in 25 states and 7 union territories. t was able to make a
number of important improvements in HV prevention such as improving blood safety.
human daisy chain on World ids Day in ndia, December 2004.
By this stage, cases of HV infection had been reported in every state of the country.12 Throughout the 1990s, it was clear that although individual states and
cities had separate epidemics, HV had spread to the general population. ncreasingly, cases of infection were observed among people that had previously
been seen as'low-risk', such as housewives and richer members of society.13 n 1998, one author wrote:
"HIV infection is now common in India; exactly what the prevalence is, is not really known, but it can be stated without any fear of being wrong that infection
is widespread. it is spreading rapidly into those segments that society in India does not recognise as being at risk. AIDS is coming out of the closet."14
n 1999, the second phase of the National DS Control Programme (NCP ) came into effect with the stated aim of reducing the spread of HV through
promoting behaviour change. During this time, the prevention of mother-to-child transmission (PMTCT) programme and the provision of free antiretroviral
treatment were implemented for the first time.15 n 2001, the government adopted the National DS Prevention and Control Policy and former Prime
Minister tal Bihari Vajpayee referred to HV/DS as one of the most serious health challenges facing the country when he addressed parliament. Vajpayee
also met the chief ministers of the six high-prevalence states to plan the implementation of strategies for HV/DS prevention.16
The third phase (NCP ) began in 2006, with the highest priority placed on reaching 80 percent of high-risk groups including sex workers, men who have
sex with men, and injecting drug users with targeted interventions.17 Targeted interventions are generally carried out by civil society or community
organisations in partnership with the State DS Control Societies. They include outreach programmes focused on behaviour change through peer
education, distribution of condoms and other risk reduction materials, treatment of sexually transmitted diseases, linkages to health services, as well as
advocacy and training of local groups. The NCP also seeks to decentralise the HV effort to the most local level, i.e. districts, and engage more non-
governmental organisations in providing welfare services to those living with HV/DS.18
:rrent estimates
n 2006 UNDS estimated that there were 5.6 million people living with HV in ndia, which indicated that there were more people with HV in ndia than in
any other country in the world.19 n 2007, following the first survey of HV among the general population, UNDS and NCO agreed on a new estimate
between 2 million and 3.1 million people living with HV.20 n 2008 the figure was estimated to be 2.31 million.21 n 2009 it was estimated that 2.4 million
people were living with HV in ndia, which equates to a prevalence of 0.3%.22 While this may seem low, because ndia's population is so large, it is third in
the world in terms of greatest number of people living with HV. With a population of around a billion, a mere 0.1% increase in HV prevalence would increase
the estimated number of people living with HV by over half a million.
The HIV/AIDS sit:ation in different states
Map of ndia showing the worst affected states.
The vast size of ndia makes it difficult to examine the effects of HV on the country as a whole. The majority of states within ndia have a higher population
than most frican countries, so a more detailed picture of the crisis can be gained by looking at each state individually.
The HV prevalence data for most states is established through testing pregnant women at antenatal clinics. While this means that the data are only directly
relevant to sexually active women, they still provide a reasonable indication as to the overall HV prevalence of each area.23
The following states have recorded the highest levels of HV prevalence at antenatal and sexually transmitted disease (STD) clinics over recent years.
ndhra Pradesh
ndhra Pradesh in the southeast of the country has a total population of around 76 million, of whom 6 million live in or around the city of Hyderabad. The HV
prevalence at antenatal clinics was 1% in 2007. This figure is smaller than the reported 1.26% in 2006, but remains the highest out of all states.24 HV
prevalence at STD clinics was very high at 17% in 2007. mong high-risk groups, HV prevalence was highest among men who have sex with men (MSM)
(17%), followed by female sex workers (9.7%) and DUs (3.7%).25
Goa
Goa, a popular tourist destination, is a very small state in the southwest of ndia (population 1.4 million). n 2007 HV prevalence among antenatal and STD
clinic attendees was 0.18% and 5.6% respectively.26 The Goa State DS Control Society reported that in 2008, a record number of 26,737 people were
tested for HV, of which 1018 (3.81%) tested positive.27
Karnataka
Karnataka, a diverse state in the southwest of ndia, has a population of around 53 million. HV prevalence among antenatal clinic attendees exceeded 1%
from 2003 to 2006, and dropped to 0.5% in 2007.28 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". Devadasi women are a group of women who have historically been dedicated to the service of gods.
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.29 The average HV prevalence among female sex workers in Karnataka was just over 5% in 2007, and 17.6% of men who have sex with
men were found to be infected.30
Maharashtra
Maharashtra is a very large state of three hundred thousand square kilometres, with a total population of around 97 million. The capital city of Maharashtra -
Mumbai (Bombay) - is the most populous city in ndia, with around 14 million inhabitants. The HV prevalence at antenatal clinics in Maharashtra was 0.5% in
2007.31 t 18%, the state has the highest reported rates of HV prevalence among female sex workers.32 Similarly high rates were found among injecting
drug users (24%) and men who have sex with men (12%).33
Tamil Nadu
With a population of over 66 million, Tamil Nadu is the seventh most populous state in ndia. Between 1995 and 1997 HV prevalence among pregnant
women tripled to around 1.25%.34 The State Government subsequently set up an DS society, which aimed to focus on HV prevention initiatives. safe-
sex campaign was launched, encouraging condom use and attacking the stigma and ignorance associated with HV. Between 1996 and 1998 a survey
showed that the number of men reporting high-risk sexual behaviour had decreased.35
n 2007 HV prevalence among antenatal clinic attendees was 0.25%.36 HV prevalence among injecting drug users was 16.8%, third highest out of all
reporting states. HV prevalence among men who have sex with men and female sex workers was 6.6% and 4.68% respectively.37
Manipur
Manipur is a small state of some 2.4 million people in northeast ndia. Manipur borders Myanmar (Burma), one of the world's largest producers of illicit
opium. n the early 1980s drug use became popular in northeast ndia and it wasn't long before HV was reported among injecting drug users in the
region.38 lthough NCO report a state-wise HV prevalence of 17.9% among DUs, studies from different areas of the state find prevalence to be as high as
32%.39
HV is no longer confined to DUs, but has spread further to the general population. HV prevalence at antenatal clinics in Manipur exceeded 1% in recent
years, but then declined to 0.75% in 2007.40 Estimated adult HV prevalence is the highest out of all states, at 1.57%.41
Mizoram
The small northeastern state of Mizoram has fewer than a million inhabitants. n 1998, an HV epidemic took off quickly among the state's male injecting drug
users, with some drug clinics registering HV rates of more than 70% among their patients.42 n recent years the average prevalence among this group has
been much lower, at around 3-7%.43 HV prevalence at antenatal clinics was 0.75% in 2007.44
Nagaland
Nagaland is another small northeastern state where injecting drug use has again been the driving force behind the spread of HV. n 2003 HV prevalence
among DUs was 8.43%, but has since declined to 1.91% in 2007. HV prevalence at antenatal clinics and STD clinics was 0.60% and 3.42% respectively in
2007.45
The Punjab
The Punjab, a state in northern mainland ndia, has shown an increase in prevalence among injecting drug users (13.8% in 2007) in recent years.46 One of
the richest cities in the Punjab, udhiana, has an HV prevalence of 21% among DUs while the HV prevalence among DUs in the capital of the state,
mritsar, has reached 30%.47 Denis Broun, head of UNDS in ndia has stated, "the problem of DUs has been underestimated in mainland ndia, as most
of the problem was thought to be in the northeast."48
ho is affected by HIV and AIDS in India?
People living with HV in ndia come from incredibly diverse cultures and backgrounds. The vast majority of infections occur through heterosexual sex (80%),
and is concentrated among high risk groups including sex workers, men who have sex with men, and injecting drug users as well as truck drivers and
migrant workers. See our page on affected groups in ndia for more information.
HIV prevention
Educating people about HV/DS and how it can be prevented is complicated in ndia, as a number of major languages and hundreds of different dialects
are spoken within its population. This means that, although some HV/DS prevention and education can be done at the national level, many of the efforts
are best carried out at the state and local level.
Each state has its own DS Prevention and Control Society, which carries out local initiatives with guidance from NCO. Under the second stage of the
government's National DS Control Programme (NCP-), which finished in March 2006, state DS control societies were granted funding for youth
campaigns, blood safety checks, and HV testing, among other things. Various public platforms were used to raise awareness of the epidemic - concerts,
radio dramas, a voluntary blood donation day and TV spots with a popular ndian film-star. Messages were also conveyed to young people through schools.
Teachers and peer educators were trained to teach about the subject, and students were educated through active learning sessions, including debates and
role-play.49
DS awareness banners in Sangli, ndia - 2005
The third stage of the National DS Control Programme (NCP-), was launched in 2006 and runs until 2011.50 The programme has a budget of around
$2.6 billion, two thirds of which is for prevention and one sixth for treatment.51 side from the government, this money will come from non-governmental
organisations, companies, and international agencies, such as the World Bank and the Bill and Melinda Gates Foundation.52
s part of its focus on prevention, the government has supported the installation of over 11,000 condom vending machines in colleges, road-side
restaurants, stations, gas stations and hospitals. With support from the United States gency for nternational Development (USD), the government has
also initiated a campaign called 'Condom Bindas Bol!' (Condom-Just say it!), which involves advertising, public events and celebrity endorsements. t aims to
break the taboo that currently surrounds condom use in ndia, and to persuade people that they should not be embarrassed to buy them.53
n one unique scheme, health activists in West Bengal promoted condom use through kite flying, which is popular before the state's biggest festival, Durga
Puja:
%he colourful kites carry the message that using a condom is a simple and instinctive act. they can fly high in the sky and land at distant places where we
cannot reach.4
This initiative is an example of how HV prevention campaigns in ndia can be tailored to the situations of different states and areas. n doing so, they can
make an important impact, particularly in rural areas where information is often lacking. Small-scale campaigns like this are often run or supported by non-
governmental organisations, which play a vital role in preventing infections throughout ndia, particularly among high-risk groups. n some cases, members of
these risk groups have formed their own organisations to respond to the epidemic.
The government has however funded a small number of national campaigns to spread awareness about HV/DS to complement the local level initiatives.
On World DS Day 2007 ndia flagged off its largest national campaign to date, in the form of a seven-coach train called the 'Red Ribbon Express.'55 year
later the train journey was completed, having travelled to 180 stations in 24 states and reaching around 6.2 million people with HV/DS education and
awareness.56 Following the success of the campaign, the 'Red Ribbon Express' took off again in December 2009, and now includes counseling and training
services, HV testing, treatment of sexually transmitted diseases (STDS) as well as HV/DS education and awareness.57
ccording to a mid-year report on the progress of the second round of the Red Ribbon Express, NCO estimates that 3.8 million people were reached in the
first six months of the campaign.58 ccording to NCO the 'response has been overwhelming', with queues of people waiting to access the services a
common sight, and follow up surveys indicating that knowledge of transmission routes of HV and prevention methods have increased significantly in the
areas visited by the train.
PMTCT
n 2004 only 5% of pregnant women living with HV received antiretrovirals (RVs) to prevent mother-to-child transmission (PMTCT) in ndia. By 2009 it was
estimated that 17 to 48% of pregnant women living with HV and 27% of HV exposed infants received RVs for PMTCT.59 s a result of such low coverage,
thousands of children are still infected every year through mother-to-child transmission in ndia.60 61 Of those HV positive pregnant women who receive
RVs for PMTCT in the country, almost all only receive single dose nevirapine, an RV prophalaxis for PMTCT which is no longer recommended by WHO.62
Testing
The general consensus among those fighting DS worldwide is that HV testing should be carried out voluntarily, with the consent of the individual
concerned. This view has been supported by the ndian government and NCO, who have helped to establish hundreds of integrated counselling and testing
centres (CTCs) in ndia. By the end of 2009 there were 5135 CTCs in ndia,63 compared to just 62 in 1997.64 By 2009 these centres tested had tested 13.4
million people for HV, an increase from 4 million in 2006.65
Health Clinic near Sangli, ndia - 2005
lthough voluntary testing is officially supported in ndia, some states have tried to implement policies that would force people to be tested for HV against
their will. n Goa and ndhra Pradesh the state governments proposed a bill in 2006 to make HV tests compulsory before marriage, and in Punjab it has
been proposed that all people wishing to obtain or retain a driver's license should be tested for HV.66 Neither of these plans have come to pass, but they
have concerned activists, who argue that HV testing should never be imposed on people against their wishes.
Unfortunately, cases of people being tested without their consent or knowledge are common in ndian hospitals. n one 2002 study, it was suggested that
over 95% of patients listed for surgical procedures are tested against their will, often resulting in their surgery being cancelled.67 Hospital staff and health
professionals, much like the rest of the ndian population, are often unaware of the facts about HV. This leads to unnecessary fears and, in some cases,
causes them to stigmatise HV positive people and discriminate against them, including testing them without consent.
ndia has certainly made progress in expanding HV testing to its large population. However, considering only 50% of those currently infected with HV are
aware of their status there is still significant work to be done in this area.68
Treatment for peopIe Iiving with HIV
ntiretroviral drugs (RVs), which can significantly delay the progression from HV to DS have been available in developed countries since 1996.
Unfortunately, as in many resource-poor areas, access to this treatment is limited in ndia; an estimated 285,000 people were receiving free RVs in
2009.69 This, totalled with the number receiving RVs through the private sector, amounted to 320,000 people receiving RVs in 2009. ccording to NCO,
this represents just over half of the adults estimated to be in need of antiretroviral treatment in ndia. However, according to WHO's latest treatment
guidelines (2010), which recommend starting treatment earlier, revised estimates may indicate that only around 1 in 4 people in need of HV treatment are
currently receiving it.70
While the coverage of treatment remains unacceptably low, improvements are being made. The government has started to expand access to RVs in a
number of areas; by November 2009 there were 266 reported sites providing antiretroviral therapy.71
ncreasing access to RVs also means that an increasing number of people living with HV in ndia are developing drug resistance. When HV becomes
resistant to the RVs the treatment regimen needs to be changed to 'second-line' RVs. s with many other parts of the world, second-line treatment in
ndia is far more expensive than first-line treatment.
n 2008, NCO began to roll out government funded second-line antiretroviral treatment in two centres in Mumbai and Chennai. However coverage remains
limited; of the 3,000 who needed to be on second line treatment, about 970 were receiving it as of January 2010.72 73 One reason for this is expense; second
line RV drugs, unlike first line RVs, are not produced on a large scale in ndia due to patent issues that control drug pricing. Therefore, they can be 10
times more expensive than first line RVs.
ronically, ndia is a major provider of cheap generic copies of RVs to countries all over the world. However, the large scale of ndia's epidemic, the diversity
of its spread, and the country's lack of finances and resources continue to present barriers to ndia's antitretroviral treatment programme. The ndian
government has also been criticised for not providing palliative care for HV patients.74
To read about the challenges faced in increasing access to antiretroviral drugs around the world, see our Universal access to DS treatment page.
Stigma and discrimination in India
n ndia, as elsewhere, DS is often seen as "someone else's problem" as something that affects people living on the margins of society, whose lifestyles
are considered immoral. Even as it moves into the general population, the HV epidemic is still misunderstood among the ndian public. People living with
HV have faced violent attacks, been rejected by families, spouses and communities, been refused medical treatment, and even, in some reported cases,
denied the last rites before they die.75
schoolteacher fired after testing HV-positive is embraced by daughter
s well as adding to the suffering of people living with HV, this discrimination is hindering efforts to prevent new infections. While such strong reactions to
HV and DS exist, it is difficult to educate people about how they can avoid infection. DS outreach workers and peer-educators have reported
harassment,76 and in schools, teachers sometimes face negative reactions from the parents of children that they teach about DS:
"When I discussed with my mother about having an AIDS education program, she said, 'you learn and come home and talk about it in the neighbourhood,
they will kick you'. She feels that we should not talk about it."Female student, Chennai77
Discrimination is also alarmingly common in the health care sector. Negative attitudes from health care staff have generated anxiety and fear among many
people living with HV and DS. s a result, many keep their status secret. t is not surprising that for many HV positive people, DS-related fear and
anxiety, and at times denial of their HV status, can be traced to traumatic experiences in health care settings.
%here is an almost hysterical kind of fear ... at all levels, starting from the humblest, the sweeper or the ward boy, up to the heads of departments, which
make them pathologically scared of having to deal with an HIV positive patient. Wherever they have an HIV patient, the responses are shameful.78
2006 study found that 25% of people living with HV in ndia had been refused medical treatment on the basis of their HV-positive status. t also found
strong evidence of stigma in the workplace, with 74% of employees not disclosing their status to their employees for fear of discrimination. Of the 26% who
did disclose their status, 10% reported having faced prejudice as a result.79 People in marginalized groups - female sex workers, hijras (transgender)
and gay men - are often stigmatised not only because of their HV status, but also because they belong to socially excluded groups.80
Stigma is made worse by a lack of knowledge about DS. lthough a high percentage of people have heard about HV and DS in urban areas (94% of
men and 83% of women) this is much lower in rural areas where only 77% of men and 50% of women have heard of HV and DS.81 However, the real
challenge lies with ignorance about how HV is transmitted - for example the majority of men and women in rural areas believe that DS can be transmitted
by mosquito bites.82 n 2009, NCO carried a population based survey in Nagaland, where it was shown that 72.8% of people surveyed believed HV could
be transmitted by sharing food with someone.83
To learn more about the way that prejudice is hindering the global fight against DS, see our Stigma and discrimination page.
:nding for the HIV epidemic in India
HV spending increased steadily in ndia from 2003 to 2007 but has since fallen.84 85 n 2006-2007 $171 million was spent to contain and prevent the growth
of HV, which represented an increase of 28% from the previous year.86 Currently, ndia spends about 5% of its health budget on HV and DS.87 However,
the World Bank has warned that ndia will have to scale up prevention efforts in order to avoid spending more of its health budget in the future. ccording to
the World Bank's report, by 2020 ndia will have to spend 7% of its health budget on DS if the rising tide of the DS epidemic in New Delhi, Mumbai, the
north and the north east is not halted.88 This would put further strain on a struggling health sector which, on top of HV and DS, faces a growing multitude
of health challenges including malaria, diabetes, heart disease and cancer. Yet, in 2008-2009 spending on HV/DS fell by 15% to $146 million.89
The f:t:re of HIV and AIDS in India
HV/DS information painted on a wall in Darjeeling, ndia
Various groups have made predictions about the effect that DS will have on ndia and the rest of sia in the future, and there has been a lot of dispute
about the accuracy of these estimates. For instance, a 2002 report by the C's National ntelligence Council predicted 20 million to 25 million DS cases in
ndia by 2010 - more than any other country in the world.90 ndia's government responded by calling these figures completely inaccurate, and accused those
who cited them of spreading panic.91 The government has also disputed predictions that ndia's epidemic is on an frican trajectory, although it claims to
acknowledge the seriousness of the crisis.92
ndeed, recent surveys do suggest that national HV prevalence has probably fallen slightly in recent years. This trend is mainly due to a drop in infections in
southern states; in other areas there has been no significant decline.
"In the north-east, the dual HIV epidemic driven by unsafe sex and injecting drug use is highly concerning. Moreover, there are many areas in the northern
states where HIV is increasing, particularly among injecting drug users." Sujatha Rao, Director General of NACO93
Even if the country's epidemic does not match the severity of those in southern frica, it is clear that HV and DS will have a devastating effect on the lives
of millions of ndians for many years to come. t is essential that effective action is taken to minimise this impact.
"%he challenges India faces to overcome this epidemic are enormous. Yet India possesses in ample quantities all the resources needed to achieve universal
access to HIV prevention and treatment. defeating AIDS will require a significant intensification of our efforts, in India, just as in the rest of the world" Peter
Piot, former Executive Director of UNAIDS.94