Time to redefine the HIV epidemic, in India?

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Time to redefine the HIV epidemic, in India?

Dear Colleagues,

Based on the recommendations of the Asian AIDS Commission Report, is it time to

redefine the classification of HIV prevalence in India?

On behalf of the UNAIDS Regional Support Team for Asia and the

Pacific, AIDS ASIA eFORUM is hosting an e_Consultation on Asian AIDS

Commission Report: " Redefining AIDS in Asia – Crafting an effective

response " .

After a brief lull, we are picking up the e_discussion on the Report

of the Commission on AIDS in Asia. In the next few days we will be

posting summaries and key points of the responses to the questions

raised in the original call for discussion

Re: AIDS_ASIA/message/1292

The Asian AIDS Commission Report: " Redefining AIDS in Asia – Crafting

an effective response " argues that the " standard classification

of `low-level', `concentrated' or `generalised' based on the HIV

prevalence in pregnant women does not capture the actual nature and

dynamics of Asia's epidemics. "

The Commission, headed by Dr. Rangarajan, the previous economic

advisor to the Prime Minister of India, instead proposes four

epidemic scenarios for Asia: latent, expanding, mature, and declining

(pages 53-54, table 2.1; pages 65-70) and links a proposed package of

prevention interventions with the most impact for each scenario.

In this posting, we focuses the implications of the AIDS Commissions

report to Indian Civil Society. How the Indian HIV civil society can

one take this finding forward and how might one advocate for how

government should invest their resources?

Efforts to defining the HIV epidemic and the calculation of the HIV

prevalence in itself in India has gone through various stages. During

earlier period of HIV response in India , the states were classified

into 3 groups. High HIV prevalence, Moderate prevalence and Low

prevalence states

Group I High HIV prevalence states which include Maharashtra , Tamil

Nadu, Karnataka, Andhra Pradesh and Manipur where HIV prevalence

rates were 1 % or more in antenatal women.

Group II Moderate prevalence states include Gujarat, Goa, Kerala,

West Bengal and Nagaland where HIV prevalence rates were 5% or more

among high HIV risk behaviour groups but below 1% in antenatal women.

Group III Low prevalence states include the remaining states where

HIV prevalence rates in any of the high risk behaviour groups were

still less than 5% and as also HIV

During the 3rd phase of National AIDS Control Programme (NACP 3)

the National AIDS Control Organization (NACO) has classified states

as high prevalent, medium prevalent, highly vulnerable and vulnerable

states. According to NACO, the index of vulnerability is based on

extent of migration, size of population, and poor health

infrastructure.

Among highly vulnerable states are: Bihar, Rajasthan, MP, UP,

Uttaranchal, Chhatisgarh, Jharkhand, Orissa, and Assam .

National AIDS Control Programme – III envisages district level

planning and implementation of all the programmatic initiatives. For

the purpose of planning and implementation of NACP-III, all the

districts in the country are classified into four categories based on

HIV prevalence in the districts among different population groups for

three consecutive years.

The definitions of the four categories are as follows:

Category A: More than 1% ANC prevalence in district in any of the

sites in the last 3 years.

Category B: Less than 1% ANC prevalence in all the sites during last

3 years with more than 5% prevalence in any HRG site

(STD/FSW/MSM/IDU).

Category C: Less than 1% ANC prevalence in all sites during last 3

years with less than 5% in all HRG sites, with known hot spots

(Migrants, truckers, large aggregation of factory workers, tourist

etc).

Category D: Less than 1% ANC prevalence in all sites during last 3

years with less than 5% in all HRG sites with no known hot spots OR

no or poor HIV data.

(ANC: Ante-natal Clinic; HRG: High Risk Group; STD: Sexually

Transmitted Disease; FSW: Female Sex Worker; MSM: Men who have Sex

with Men; IDU: Injecting Drug User.)

At the launch of NACP-III, districts were categorized based on the

HIV Sentinel Surveillance data from the years 2003, 2004 & 2005 and

there were 140 Category A districts and 47 Category B districts.

With the availability of the data from HIV Sentinel Surveillance

2006, the district categorisation is revised taking the data from the

last three years i.e. 2004-2006 into consideration. It may be

mentioned that during 2006, a large number of sentinel sites were

added, especially in the north Indian states. According to the

revised district categorisation, there are 156 Category A districts

and 39 Category B districts (Total of 195 districts) that require

priority attention.

Out of these 156 Category A districts, 122 districts fall in the six

high prevalence states of Andhra Pradhesh, Karnataka, Tamil Nadu,

Maharashtra, Manipur and Nagaland while 34 districts fall in the low

burden states of North India .

Among the Category B districts, besides five districts in Tamil Nadu,

rest of the 34 districts fall in low burden states. These districts

have a great potential for the spread of HIV Epidemic and if

sufficient attention is not given, they may progress to Category A.

The fact that 68 high prevalence districts were found in the low

burden states suggests the heterogenous mode of spread of HIV

epidemic in India and brings to focus the newly emerging pockets of

HIV infection in the country.

In comparison to the earlier district categorization, 33 new

districts have entered Category A while 17 districts which were in

Category A previously have moved out.

21 out of 33 districts that have entered Category A are in the low

burden states.

Similarly, 9 new districts have entered Category B while 17 districts

which were in Category B previously have moved out.

According to NACO, this paradigm has since shifted based upon

existing migration patterns, gender inequality, cultural beliefs and

practices, poverty, access to health and education, levels of

knowledge about HIV, and health infrastructure.

Further, HIV has spread from high risk to low risk populations, is spreading

rapidly amongst women, is already higher in some rural areas than urban ones,

and is now present in all states of the Union.

Thus, states previously classified as low prevalence, have been

reclassified as `highly vulnerable' or `vulnerable' to guard against

complacency and reflect the increasing threat of the epidemic.

In this context, how the Indian civil society would react to the

proposal of the AIDS Commission- the report was released in India

by the Prime Minister- to classify the epidemic scenarios for Asia :

latent, expanding, mature, and declining and to link the proposed

package of prevention interventions with the most impact for each

scenario?.

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message or by visiting the following url

AIDS_ASIA/

A free electronic version of the full report is available form the

following url or from the moderator of the discussion

http://data.unaids.org/pub/Report/2008/20080326_report_commission_aids_en.pdf

Please send your mailing address if you would like to receive a printed copy of

this report.

AIDS ASIA e FORUM

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