United Nations Population Fund - India HIV/AIDS It is ironic that a microscopic virus jeopardises the well-being of millions of people. Indeed, HIV/AIDS has emerged as possibly one of the greatest contemporary threats to global development and security. Nearly 2.4 million people are living with HIV/AIDS (PLHA) (Source: http://www.nacoonline.org). Although the global HIV incidence rate (annual number of new HIV infections as a proportion of previously uninfected persons), which peaked in the late 1990s, has levelled off, AIDS is among the leading causes of death globally. Since it was first recognised in 1981, AIDS has caused over 25 million deaths across the world. Recent surveys reveal that sustained, intensive programmes in diverse settings are reducing HIV incidence through behaviour changes, such as increased condom usage, delayed sexual initiation and fewer sexual partners. The HIV estimates 2008-09 highlight an overall reduction in adult HIV prevalence and HIV incidence (new infections) in India. Adult HIV prevalence at national level has declined from 0.41% in 2000 to 0.31% in 2009, Taking note of all these manifestations of the HIV pandemic, the Millennium Development Goals (MDGs) committed all countries to reverse the spread of HIV/AIDS by 2015. Need to Address High-Risk Groups The HIV epidemic in India is concentrated among high-risk groups, with HIV prevalence continuing to be as high as six to eight times within these groups as compared to the rest of the population. Approximately 0.31% of India’s adult population is living with HIV. Revised national estimates reflect the availability of improved data rather than a substantial decrease in actual HIV prevalence. This means that the proportion of people living with HIV in India is lower than previously estimated, but the epidemic continues to affect large numbers of people. The transmission route is still predominantly sexual (87.1%); other routes, in order of proportion, include parent to child (5.4%), infected needles and syringes (1.6%), men who have sex with men (1.5%), unsafe blood and blood products (1%) and unspecified/other routes (3.3%). Sex work continues to act as the most important source of HIV infections in India due to the large size of clients that get infected from sex workers. After the sexual mode, parent to child has emerged as an important mode of transmission in India. Higher HIV prevalence among intravenous drug users (IDUs) is an important feature of the northeastern states. However, in 2006, new sites of high HIV prevalence among IDUs have been identified in the states of Kerala, Maharashtra, Punjab, Tamil Nadu and West Bengal, suggesting diversified drivers of the epidemic. The distribution of HIV districts in the country is heterogeneous, given that several isolated pockets of high prevalence have been identified in several regions. Based on data from HIV sentinel surveillance systems, 195 districts are categorised as A and B for priority attention in the National AIDS Control Programme. Among highburden states, the epidemic shows a stable trend in states like Karnataka and Andhra Pradesh, while it is on the decline in other high-burden states. Rising HIV prevalence is observed among different population groups in the low-burden north Indian states. Extremely vulnerable groups: Women, youth, migrants The general reasons for people’s vulnerability to HIV infection are illiteracy, cultural taboos and lack of information on transmission and prevention. It has been noted that more men are infected than women. Indeed, when AIDS emerged in the 1980s, it mostly affected men. However, today, women account for nearly half of all people living with HIV worldwide. In fact, the number of HIV-positive women and girls has risen in every region of the world. Physiological factors aggravate women’s vulnerability. In India, the prevalence of early marriage, illiteracy and ignorance about risk factors, and gender inequalities increase women’s vulnerability. Moreover, limited roles in decision-making and negligible spaces for negotiation within domestic relationships limit women’s access to HIV prevention methods and other related sexual/reproductive health (RH) services. National Aids Control Organization (NACO) statistics report only 0.29 per cent of all AIDS cases among women. This feminizations of HIV/AIDS brings into stark focus the inequity inherent in people's behaviour, which limits women’s options to safeguard themselves. Several women are extremely vulnerable to HIV even though they do not practise high-risk behaviour. In some cases, marriage itself is a risk. Significant proportions of new infections are reported from monogamous women in stable marital relationships. Prevalence is also high in the 15–49 age group (83%of all infections), indicating that AIDS still threatens a critical section of society, those in the prime of their working lives. Early sexual initiation and increase in premarital sex combined with lack of information, skills and access to safe sexual practices, exacerbate vulnerability. Increased drug use is also an important factor in the spread of HIV amongst young people. Migrant and mobile populations are not only highly vulnerable to HIV infection due to long periods of absence from homes and families, but also carry infections from highrisk groups like commercial sex workers to the general population. They are an important bridge population group in the epidemic. Government policies In June 2001, along with other member states, India adopted the Declaration of Commitment on HIV/AIDS at the United Nations General Assembly. The National AIDS Prevention and Control Policy (2002) has been the overall framework within which national response to the HIV/AIDS threat has been crafted. The implementation of this policy is guided by the National Council on AIDS, chaired by the Prime Minister. With the growing complexity of the epidemic, policy frameworks and approaches have been realigned. The focus has shifted from raising awareness to facilitating behavioural changes, and from a national response to a decentralized response. There is also increasing engagement of NGOs and networks of people living with HIV. The National AIDS Control Programme 2007–12 (NACP III) is the third phase of India’s HIV Control Programme. It aims to halt and reverse the spread of HIV epidemic in the country. Its four-pronged approach focuses on: 1. Prevention of new infections, 2. Provision of greater care, support and treatment to the already infected, 3. Strengthening of infrastructure, systems and human resources, and 4. Development of strategic information management systems. Mid-term Review of NACP-III: A comprehensive evaluation of strategies, plans, resources and activities undertaken in the first half of NACP-III was conducted in 2009. Prevalence among Antenatal Clinic attendees, Sexually Transmitted Infections patients, Female Sex Workers and Men having Sex with Men is declining. Vast majority of new infections and existing burden of disease were concentrated in 5-15 percent of districts. Impressive gains have been made in ART services, upscaling of ICTCs and identifying PLHAs. There was significant scale-up of Targeted Interventions; and condom distribution had increased. Urgent need to scale up interventions The HIV/AIDS epidemic is a serious and deeply entrenched global health crisis, which demands a robust, evidence-informed and strategically sustained response. Since a cure is not in sight yet, the only hope of reversing the impacts of AIDS is prevention. The scale and scope of HIV-prevention measures that have demonstrated results need to be intensified. Preventing infections, therefore, is top priority. Given that targeted interventions are showing results, there is need to saturate coverage of high-risk behaviour groups such as sex workers, men having sex with men (MSMs) and IDUs. Programs also need to reach out to bridge population (truckers, migrants and vulnerable youth). For the general population, the focus needs to be on scaling up interventions such as behaviour change communication, access to counselling and testing services, prevention of parentto-child transmission, comprehensive condom programming with a focus on dual protection, greater convergence with RH interventions, and prioritizing the prevention needs of adolescents and youth. There is need to prevent other Sexually Transmitted Infections (STIs) as well. BSS (2006) and Sentinel Surveillance reports from NACO have reported that the incidence of HIV/AIDS is higher among those with pre-existing STIs. Another important requirement is the provision of Care, Support and Treatment (including management of Opportunistic Infections) and Anti-retroviral Therapy (ART). This holistic approach is vital for suppressing viral multiplication. This helps in restoring pathogen fighting systems, slows or halts disease progression and improves quality of life. Availability of ART also helps mitigate the stigma associated with the disease, and consequent socioeconomic discrimination. It must also be highlighted that HIV prevention gets a big boost by successful HIV treatment. By alleviating the social stigma linked with the disease, it makes voluntary testing and counselling more acceptable to high-risk groups. It is believed that a dualsolution strategy, combining prevention and treatment, will have the greatest impact in reducing both the number of new infections as well as AIDS-related deaths. Without treatment opportunities, however, prevention efforts can stall. Likewise, prevention is needed to help keep new infections at bay, and thus to make treatment sustainable. The ultimate goal is universal access to prevention, treatment, care and support. What UNFPA India does UNFPA works with range of stakeholders such as Ministry of Health and Family Welfare, Ministry of Human Resource and Development, Ministry of Youth Affairs and Sports, NACO, selected state AIDS control societies and civil society organizations to strengthen prevention interventions of NACP III in the context of the “Three Ones approach”: one national programme action framework, one national coordinating authority and one agreed country-level monitoring and evaluation system for resultsbased management. In keeping with the division of labour within UN organisations, UNFPA’s action priorities are prevention of infections among sex workers, carrying out HIV/AIDS awareness amongst adolescents, and enabling comprehensive interventions. In the area of condom programming, UNFPA would also assist the government in enabling convergence of Reproductive Health and HIV interventions.