Sustained progress, but no room for complacency: Results of 2015 HIV estimations in India.

BACKGROUND & OBJECTIVES: Evidence-based planning has been the cornerstone of India's response to HIV/AIDS. Here we describe the process, method and tools used for generating the 2015 HIV estimates and provide a summary of the main results. METHODS: Spectrum software supported by the UNAIDS was used to produce HIV estimates for India as a whole and its States/Union Territories. This tool takes into consideration the size and HIV prevalence of defined population groups and programme data to estimate HIV prevalence, incidence and mortality over time as well as treatment needs. RESULTS: India's national adult prevalence of HIV was 0.26 per cent in 2015. Of the 2.1 million people living with HIV/AIDS, the largest numbers were in Andhra Pradesh, Maharashtra and Karnataka. New HIV infections were an estimated 86,000 in 2015, reflecting a decline by around 32 per cent from 2007. The declining trend in incidence was mirrored in most States, though an increasing trend was detected in Assam, Chandigarh, Chhattisgarh, Gujarat, Sikkim, Tripura and Uttar Pradesh. AIDS-related deaths were estimated to be 67,600 in 2015, reflecting a 54 per cent decline from 2007. There were variations in the rate and trend of decline across India for this indicator also. INTERPRETATION & CONCLUSIONS: While key indicators measured through Spectrum modelling confirm success of the National AIDS Control Programme, there is no room for complacency as rising incidence trends in some geographical areas and population pockets remain the cause of concern. Progress achieved so far in responding to HIV/AIDS needs to be sustained to end the HIV epidemic.

Prevalence and determinants of heterosexual anal-intercourse among female sex workers in India: Findings from nationwide cross-sectional biological and behavioural survey.

BACKGROUND: The vulnerability of female sex workers (FSWs) to HIV infection increases if unprotected heterosexual anal intercourse (HAI) is practiced. OBJECTIVES: To estimate the prevalence of HAI among FSWs, and associated factors, and prevalence of consistent condom use (CCU) during HAI and associated factors. METHODS: Analysis of cross-sectional data from nationwide biological and behavioural survey, conducted at 73 randomly selected domains with sample size of 27,000 in India. RESULTS: A total of 25,932 FSWs were included in the analysis, after excluding 1075 (3.9%) FSWs for which the data were incomplete. The prevalence of HAI was 29.9% (95% CI, 29.3, 30.4); The CCU during HAI in the last one month was 58.9%. Younger age at the start of sex work, use of mobile phone/internet for soliciting client, home as a place of sex work, consumption of alcohol/drug, and physical violence against FSWs were associated with higher odds of HAI. Frequent contact with outreach workers, awareness of sexually transmitted infection, and older age at the start of sex work was associated with CCU. CONCLUSION: Prevalence of HAI was high among FSW in India. The national program could target those factors that reduce the odds of HAI and/or promote CCU.

Survival of Children Living with Human Immunodeficiency Virus on Antiretroviral Therapy in Andhra Pradesh, India.

OBJECTIVE: To assess the survival probability and associated factors among children living with human immunodeficiency virus (CLHIV) receiving antiretroviral therapy (ART) in India. METHODS: The data on 5874 children (55% boys) from one of the high HIV burden states of India from the cohort were analyzed. Data were extracted from the computerized management information system of the National AIDS Control Organization (NACO). Children were eligible for inclusion if they had started ART during 2007-2013, and had at least one potential follow-up. Kaplan Meier survival and Cox proportional hazards models were used to measure survival probability. RESULTS: The baseline median (IQR) CD4 count at the start of antiretroviral therapy was 244 (153, 398). Overall, the mortality was 30 per 1000 child years; 39 in the <5 year age group and 25 in 5-9 year age group. Mortality was highest among infants (86 per 1000 child years). Those with CD4 count ≤ 200 were six times more likely to die (adjusted HR: 6.3, 95% CI 3.5, 11.4) as compared to those with a CD4 count of ≥350/mm3. CONCLUSION: Mortality rates among CLHIV is significantly higher among children less than five years when the CD4 count at the start of ART is above 200. Additionally, lower CD4 count, HIV clinical staging IV, and lack of functional status seems to be associated with high mortality in children who are on ART.

Modelling and estimation of HIV prevalence and number of people living with HIV in India, 2010-2011.

This paper provides HIV estimation methodology used in India and key HIV estimates for 2010-2011. We used a modified version of the Spectrum tool that included an Estimation and Projection Package as part of its AIDS Impact Module. Inputs related to population size, age-specific pattern of fertility, gender-ratio at birth, age and gender-specific pattern of mortality, and volume and age-gender distribution of net migration were derived from census records, the Sample Registration System and large-scale demographic health surveys. Epidemiological and programmatic data were derived from HIV sentinel surveillance, large-scale epidemiological surveys and the programme management information system. Estimated adult HIV prevalence retained a declining trend in India, following its peak in 2002 at a level of 0.41% (within bounds 0.35-0.47%). By 2010 and 2011, it levelled at estimates of 0.28% (0.24-0.34%) and 0.27% (0.22-0.33%), respectively. The estimated number of people living with HIV (PLHIV) reduced by 8% between 2007 and 2011. While children accounted for approximately 6.3% of total HIV infections in 2007, this proportion increased to about 7% in 2011. With changing priorities and epidemic patterns, the programme has to customise its strategies to effectively address the emerging vulnerabilities and adapt them to suit the requirements of different geographical regions.

HIV epidemic among men who have sex with men in India: national scenario of an unfinished agenda.

BACKGROUND: Although India has demonstrated success in the overall reduction of human immunodeficiency virus (HIV) incidence by 57% in the past 10 years, its control among men who have sex with men (MSM) remains a critical challenge. This paper describes the current status, geographic variability, and factors associated with HIV among MSM from the national perspective. METHODS: DATA ON THE LEVELS AND TRENDS OF HIV SEROPOSITIVITY AND ASSOCIATED RISK BEHAVIORS AMONG MSM WERE ANALYZED AND PRESENTED FROM THE FOLLOWING DATA SOURCES: 1) annual HIV Sentinel Surveillance (HSS) conducted during 2003-10, 2) two rounds of the high-risk group size estimation conducted in 2005 and 2009, 3) two rounds of the Behavioral Surveillance Survey conducted in 2006 and 2009, and 4) the Integrated Bio-behavioral Assessment Round 2. Data were analyzed according to selected sociodemographic characteristics and sexual identities of MSM to understand the factors associated with high HIV prevalence. RESULTS: HSS data indicate that at the national level, HIV prevalence among MSM overall is declining (from 12.3% in 2003 to 4.43% in 2010). However, marginal increasing trends were observed in Chandigarh (from 1.4% in 2004 to 2.8% in 2008) and Haryana (from 0% in 2006 to 3.2% in 2008). HSS data indicate high (>5%) levels and increasing trends in HIV prevalence among MSM in eight states of India during 2003-10. Analysis of 2010 HSS data indicates that HIV prevalence was >10% in seven states. The factors associated with high HIV prevalence among MSM were being a kothi (the receptive partner in oral and anal sex, and typically with effeminate mannerisms) or a double-decker (both penetrative and receptive partner) rather than being a panthi (the penetrative partner in oral or anal sex) (8% vs 4.3%; P<0.05), being older than 25 years in age than their younger counterparts (9% vs 4.5%; P<0.05), illiterate rather than literate MSM (9.5% vs 6.9%; P<0.05), and employed versus unemployed MSM (9.1% vs 7.8%; P<0.05). CONCLUSION: While HIV prevalence among MSM at the national level is declining, it continues to remain high in some states and cities. Programs need to build on the successes in reducing HIV among female sex workers in order to control the high HIV prevalence among MSM in India.

Predictors of bisexual behaviour among MSM attending intervention sites may help in prevention interventions for this bridge to the heterosexual epidemic in India: data from HIV sentinel surveillance.

BACKGROUND: Indian cultural tradition demanding marriage, many MSM howsoever they self-identify are likely to be married or have sex with women. To consolidate India's HIV prevention gains, it is important to understand and address the interaction between the MSM and heterosexual epidemics in India and create specific interventions for bisexual MSM. The challenge is to identify and intervene this hard to reach population. Data from HIV Sentinel Surveillance 2011 among MSM in four Indian states were analyzed to assess predictors and prevalence of bisexual behaviour in MSM. METHODS: Between March-May 2011, 4682 men (15-49 years) who had anal/oral sex with a male partner in the past month, attending intervention sites and consenting for an un-linked anonymous survey answered an 11- item questionnaire and provided blood for HIV test by finger stick at 19 designated surveillance sites. RESULTS: Of 4682 MSM tested overall, 5% were illiterate, 51% reported only receptive anal intercourse, 21% only penetrative and 28% both. 36% MSM had ever received money for sex. Overall 6.8% were HIV infected. 44% MSM were bisexual in the last six months. On multivariate analysis, 'being bisexual' was found to be independently associated with 'older age': 26-30 years [AOR = 3.1, 95% CI(2.7, 3.7)], >30 years [AOR = 6.5, 95% CI(5.5, 7.7)]; 'reporting penetrative behaviour alone' with other men [AOR = 5.8, 95% CI(4.8, 7.0), p<0.01] and 'reporting both penetrative and receptive behaviour' [AOR = 2.7, 95% CI(2.3, 3.1) p<0.01]. Those who both paid and received money for sex [AOR = 0.49, 95% CI (0.38, 0.62)] were significantly less likely to be bisexual. CONCLUSIONS: A substantial proportion of men receiving services from Targeted Intervention programs are bisexual and the easy opportunity for intervention in this setting should be capitalised upon. Focusing on older MSM, as well as MSM who show penetrative behaviour with other men, could help in reaching this population.

Estimate of HIV prevalence and number of people living with HIV in India 2008-2009.

OBJECTIVES: To update the estimation of the adult HIV prevalence and number of people living with HIV (PLHIV) in India for the year 2008-2009 with the combination of improved data and methods. DESIGN: Based on HIV sentinel surveillance (HSS) data and a set of epidemiological assumptions, estimates of HIV prevalence and burden in India have been derived. SETTING: HSS sites spread over all the States of India. PARTICIPANTS: Secondary data from HSS sites which include attendees of antenatal clinics and sites under targeted interventions of high-risk groups, namely, female sex workers (FSW), intravenous drug users (IDU) and men having sex with men (MSM). PRIMARY AND SECONDARY OUTCOME MEASURES: Estimates of adult HIV prevalence and PLHIV in India and its states. RESULTS: The adult HIV prevalence in India has declined to an estimated 0.31% (0.25-0.39%) in 2009 against 0.36% (0.29-0.45%) in 2006. Among the high prevalence states, the HIV prevalence has declined in Tamil Nadu to 0.33% in 2009 and other states show either a plateau or a slightly declining trend over the time period 2006-2009. There are states in the low prevalence states where the adult HIV prevalence has risen over the last 4 years. The estimated number of PLHIV in India is 2.4 million (1.93-3.04 million) in 2009. Of which, 39% are women, children under 15 years of age account for 4.4% of all infections, while people aged 15-49 years account for 82.4% of all infections. CONCLUSIONS: The estimated adult prevalence has declined in few states, a plateau or a slightly declining trend over the time. In future, efforts may be made to examine the implications of the emerging trend of the HIV prevalence on the recent infections in the study population.