Findings from the 2017 HIV estimation round & trend analysis of key indicators 2010-2017: Evidence for prioritising HIV/AIDS programme in India.

Background & objectives: The National AIDS Control Organisation (NACO) and the ICMR-National Institute of Medical Statistics, the nodal agency for conducting HIV estimations in India, have been generating HIV estimates regularly since 2003. The objective of this study was to describe India's biennial HIV estimation 2017 process, data inputs, tool, methodology and epidemiological assumptions used to generate the HIV estimates and trends of key indicators for 2010-2017 at national and State/Union Territory levels. Methods: Demographic Projection (DemProj) and AIDS Impact Modules (AIM) of Spectrum 5.63 software recommended by the United Nations Programme on HIV and AIDS Global Reference Group on HIV Estimates, Modelling and Projections, were used for generating HIV estimations on key indicators. HIV sentinel surveillance, epidemiological and programme data were entered into Estimation Projection Package (EPP), and curve fitting was done using EPP classic model. Finally, calibration was done using the State HIV prevalence of two rounds of National Family Health Survey (NFHS) -3 and -4 and Integrated Biological and Behavioural Surveillance (IBBS), 2014-2015. Results: The national adult prevalence of HIV was estimated to be 0.22 per cent in 2017. Mizoram, Manipur and Nagaland had the highest prevalence over one per cent. An estimated 2.1 million people were living with HIV in 2017, with Maharashtra estimated to have the highest number. Of the 88 thousand annual new HIV infections estimated nationally in 2017, Telangana accounted for the largest share. HIV incidence was found to be higher among key population groups, especially people who inject drugs. The annual AIDS-related deaths were estimated to be 69 thousand nationally. For all indicators, geographic variation in levels and trends between States existed. Interpretation & conclusions: With a slow decline in annual new HIV infections by only 27 per cent from 2010 to 2017 against the national target of 75 per cent by 2020, the national target to end AIDS by 2030 may be missed; although at the sub-national level some States have made better progress to reduce new HIV infection. It calls for reinforcement of HIV prevention, diagnosis and treatment efforts by geographical regions and population groups.

HIV/AIDS-Related risk behaviors, HIV prevalence, and determinants for HIV prevalence among hijra/transgender people in India: Findings from the 2014-2015 integrated biological and behavioural surveillance.

BACKGROUND: Hijra or transgender (H/TG) people are significantly affected by HIV in India. HIV prevalence among H/TG is the second highest after people who inject drugs. Effective interventions require understanding about various risk behaviors and associated factors for high prevalence. OBJECTIVES: This study analyzes the known risk behaviors and vulnerabilities of HIV-positive and HIV-negative H/TG people to identify the determinants of HIV seropositivity in this high-risk group. METHODS: Using secondary data from India's 2014 to 2015 Integrated Biological and Behavioural Surveillance survey, this analysis was conducted among 3325 H/TG people across seven states. Probability-based sampling methods were used to recruit H/TG people. Informed consent was obtained for the collection of behavioral information and blood samples for HIV testing. Multivariable binary logistic regression analysis was undertaken to identify the determinants of HIV seropositivity. RESULTS: HIV prevalence for this group of respondents was 9.5%. Multivariable analysis of survey data revealed higher odds of HIV infection if H/TG had regular male partners (adjusted odds ratio [AOR]: 1.81, confidence interval [CI]: 1.07-3.06), were living in the states of Maharashtra (AOR: 6.08, CI: 3.02-12.22) and Odisha (AOR: 2.91, CI: 1.05-8.06), and were members of self-help groups (AOR: 2.08, CI: 1.04-4.14). None of the demographic or behavioral correlates of risk were found to be associated with HIV infection. CONCLUSION: The findings suggest that community and structural factors, which are inadequately covered in surveys such as IBBS, play a more important role than individual behavioral factors.

Estimating the Population Size of Males Who Inject Drugs in Myanmar: Methods for Obtaining Township and National Estimates.

Estimating the sizes of key populations at risk for HIV is crucial for HIV prevention and treatment. We provide findings of population size estimates (PSE) of males who inject drugs (MWID) in Myanmar, provide an intuitive method for countries to extrapolate subnational estimates into national estimates and provide guidance on how to maximize the utility of current PSE techniques. We used unique object and service multipliers, and successive sampling PSE in conjunction with a respondent driven sampling survey of MWID in ten Myanmar townships in 2014. Township estimates were assessed at a stakeholder meeting for biases and coded into ranges of high, medium and low MWID prevalence areas. Using the sampled townships as benchmarks for a range of MWID proportion estimates, national level MWID size estimates were derived by multiplying the adult male population for all townships with their corresponding proportion estimates. Final PSE ranged from high (4.12%), medium (1.02%) and low (0.11%), with the final agreed national point estimate of 83,000 MWID. Using estimates from survey data, this can translate into actual numbers of MWID living with HIV and practicing risky injecting and sexual behaviors. Although PSE are vital for monitoring HIV epidemics, no guidance exists for interpreting results of different PSE techniques or for extrapolating these results into national estimates. Assessing bias and gaining consensus on township level estimates and deriving ranges of MWID PSE throughout the country using stakeholder input is intuitive and accessible to countries.

Unsafe injecting practices, sexual risk behaviours and determinants of HIV among men who inject drugs: Results from Integrated Biological and Behavioural Surveillance in India.

In India, while an overall reduction in HIV is achieved among most key populations, the continued higher prevalence among people who inject drugs (PWIDs) is an area of concern. This paper analyses unsafe injecting and sexual risk behaviours in male PWIDs according to HIV status and also examines the determinants of HIV infection in this high-risk group. Data from India's Integrated Biological and Behavioural Surveillance, conducted across 29 Indian states and Union Territories among 19,902 male PWIDs, were used. Informed consent was obtained and men aged 15 years or more, who used psychotropic substances or drugs in the past three months for non-medical reasons were recruited for the survey. Results from the multivariable analysis suggest that drug use debut at age 25 years or above (adjusted odds ratio [AOR]: 1.41, confidence interval [CI]: 1.05-1.88), engagement in drug use for a longer duration (AOR: 1.81, CI: 1.32-2.48), injecting three times or more per day (AOR: 1.53, CI: 1.1-2.12), sharing of needle/syringes (AOR: 1.34, CI: 1.02-1.76), self-reported sexually transmitted infections (AOR: 1.55, CI: 1.12-2.14) and higher self-risk perception for exposure to HIV (AOR: 2.08, CI: 1.58-2.75) increase the likelihood of HIV infection. Sustained higher prevalence, unsafe injecting and risky sexual practices are major challenges which may prevent India from reaching the 'end of AIDS' by 2030. This underscores the need for adoption of a tailored, evidence-driven HIV prevention approach that adequately addresses local needs to limit the spread of HIV within this population, and thereby prevents the onward transmission of HIV to the general population.

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.