Stacie M. Greby, DVM, MPH American Embassy School January 21, 2010 HIV in India Stacie M. Greby, DVM, MPH American Embassy School January 21, 2010

Outline Epidemiology HIV HIV in India Definition Scope of work HIV and AIDS Natural history HIV in India Epidemic Response National AIDS Control Programme Phase III (NACP-III)

Epidemiology

Epidemiology Definition Scope of work Study of diseases in man. Population based medicine. Scope of work Disease prevention and control programs Vaccination programs, Outbreak investigation, Emergency response Strategic Information Monitor and evaluation, Surveillance, Operational Research Capacity building and training Infectious diseases, chronic diseases, injury prevention

Epidemiology and HIV Terminology Prevalence and incidence Prevalence Number of cases of a disease in a population Incidence Number of new cases of a disease in a population Rare disease, general and concentrated epidemic Rare disease Prevalence less than 0.5% of the population Generalized HIV epidemic Prevalence is greater than 1% in Antenatal Clinics. Concentrated HIV epidemic Prevalence is less than 1% in Antenatal Clinics but greater than 5% among Most at Risk Populations (MARP) MARP Female Sex Workers (FSW) Men who have Sex with Men (MSM) Injecting Drug Users (IDU)

HIV

HIV What is HIV? What is AIDS? What is the difference? Human Immunosuppressive Virus Virus discovered in mid-1980s What is AIDS? Acquired Immunodeficiency Syndrome First reported in 1980 and designated in 1981 What is the difference? How does it affect disease control?

HIV Natural History Virus Reduces the effectiveness of the immune system Symptoms Opportunistic infections and tumors Latency Progressive Transmission – through bodily fluids Blood Semen Vaginal fluid Preseminal fluid Breast milk What would you do to prevent transmission in a population?

Scenario of A Matured Epidemic

Dynamics of Transmission* MARPs FSW Male Clients MSM IDUs Males Spouses/ Partners Females Stress the temporal order here as first noted by Weniger et al based on the early Thai epidemic. General Population Former MARP Iatrogenic Children *Adapted from Tim Brown 10

Main Drivers of HIV Epidemic, Globally Unpaid Heterosexual Intercourse Between male and female in the general population (African epidemic) Commercial Sex Work Between a female or male sex worker and a client (Asian epidemic) Men who buy sex are the main driving force in Asia and the largest infected population group. An estimated 10 million Asian women sell sex and at least 75 million men buy it regularly. Injecting Drug Use Unprotected anal sex between MSM

HIV in India

HIV Prevalence in India

Modes of HIV Transmission, India Not Specified 4.7% MSM 1.4 % Infected Syringe & Needles 1.3% Unprotected heterosexual contact is the main route accounting for 85.6% of the total HIV transmission

Heterosexual HIV Transmission in India 86% of HIV cases attributed to heterosexual transmission 9% of males in the general population reported having sex with non-regular partner in the last 12 months FSW HIV Prevalence ranges from 5% to 40% 0.5% of adult female population but 7% of HIV infected females Only 38% ever had an HIV test Average 10 clients per week 50% reported at least one Sexually Transmitted Infection symptom 69% of FSWs were ever married 46% did not use condom during last sex with non-paying client Male Clients 5% of sexually active urban males and 3% of sexually active rural males visited a Sex Worker in the last 12 months. 75% are in age group 20-35 years 24 % had sex with more than three FSWs 64% of clients of Female Sex Workers are ever married only 13% use condom with their spouse

MSM Transmission in India 3% of adult males reported ever indulged in MSM activities 10-30% had first sex with male partner before the age of 15 years More than 50% of MSM are married and have female sexual partners 30-50% of MSM reported any one STI symptom in last 12 months 50-60% reported commercial male partners and more than 80% reported non-commercial male partners one month Average 2-12 commercial male partners in a week 15% of MSM are at high risk for acquiring/transmitting HIV

HIV in India Type of epidemic Primary mode of transmission General or concentrated? Why be concerned? Primary mode of transmission Commercial sex work How would you control the epidemic?

HIV in India How would you control the epidemic Goal? Focus? What do you want to accomplish? What is success? Focus? Limited resources and competing priorities MARPs or general population Resources? Own resources or donor resources Three Ones Other benefits Spillover

HIV in India National AIDS Control Organisation (NACO) National AIDS Control Programme Phase III (NACP III) http://www.nacoonline.org/NACO

NACP-III Overall goal Strategy: Specific objective Halt and reverse the epidemic in India over the next 5 years by integrating programs for prevention, care, support and treatment. Strategy: Prevention of new infections in high risk groups and general population through: Saturation of coverage of high risk groups with targeted interventions (TIs) Scaled up interventions in the general population Providing greater care, support and treatment to larger number of People Living with HIV/AIDS (PLHA). Strengthening the infrastructure, systems and human resources in prevention, care, support and treatment programs at the district, state and national level. Strengthening the nationwide Strategic Information Management System. Specific objective Reduce new infection as estimated in the first year of the program by: 60% in high prevalence states so as to obtain the reversal of the epidemic; and 40% in the vulnerable states so as to stabilize the epidemic.

NACP-III Programme Priorities and Thrust Areas Learn from the lessons of the previous two phases Prioritize preventive efforts More than 99% of the population is free from infection Integrate prevention with care, support and treatment. MARPs will receive the highest priority (Sex workers, MSM, IDU) Lower priority groups with high levels of exposure (long distance truckers, prisoners, migrants (including refugees) and street children). Next priority general population services – STI treatment, voluntary counseling and testing and condoms. Ensure all persons who need treatment would have access (prophylaxis, opportunistic infections, and first line ARV drugs). Prevent vertical transmission through universal provision of PPTCT services and assure access to pediatric ART. Address the needs of children infected and affected by HIV through agencies involved in child protection and welfare. Invest in community care centers to provide psycho-social support, outreach services, referrals and palliative care. Work with agencies involved in vulnerability reduction such as women’s groups, youth groups, trade unions etc. to integrate HIV prevention into their activities. Facilitate a multisectoral response including private sector, civil society organizations, PLHA networks and government departments to provide prevention, care, support, treatment and services.