Roundtable Presentation S Tripathy National AIDS Research Institute 73 G Block, MIDC Bhosari, Pune , India

Epidemiology of HIV/ AIDS in India National AIDS Research Institute, Pune, India

Indian HIV/ AIDS epidemic [Important milestones] 1986First report of HIV infections in sex workers in Chennai, first report of AIDS in Mumbai 1989HIV infection reported among intravenous drug users in Manipur State 1991Indian National AIDS Control Programme was launched India PMTCT feasibility studies initiated by NACO 2001Indian pharmaceutical companies marketed ARV drugs with considerable price reduction

Phases of spread of HIV epidemic in India Phase IAt risk population Female sex workers Intravenous drug users Phase IIBridge population Male STD patients Other drug users Phase IIILow/ No risk population Spouses of male STD pts Spouses of drug users Phase IVChildren of HIV infected women Children of HIV infecteddrug users Commonest mode of HIV spread in India is by sexual route Mother to child transmission is on the rise HIV spread among intravenous drug users mostly in north-eastern states Blood transfusion associated spread is on the decline

Factors related to HIV infection [STD clinic attendees in Pune] * Practice of sex work * No. of sex partners * Receptive anal sex * Females in sex work (FSW) * Men having sex with FSW recently * Lack of formal education * Persons living away from family * Previous / present STDs * Absence of circumcision

HIV/AIDS IN MANIPUR HIV was first detected in Manipur in 1989 among intravenous drug users, HIV prevalence >70% in drug users 75.2% knew that needle sharing could lead to acquisition of AIDS, however, needle sharing was practiced by 96.8% Drug users: predominantly male (94.8%), between 15 and 35 years (95.3%) Median duration of drug use: 5 years, No. of times heroin used: 1 – 14 per day SKB ICMR

AIDS Epidemiology Modes of transmission Sexual84.24% Perinatal26.1% Blood2.99% IDUs2.83% Others7.32%

Status of HIV epidemic in India

Distribution in States Maharashtra10797 Gujarat2141 Karnataka1617 Tamil Nadu18276 Andhra Pradesh2565 Manipur1238 Nagaland298

High prevalent States States where HIV prevalence in antenatal women is 1% or more. Moderate prevalent States States where the HIV prevalence in antenatal women is less than 1% and prevalence in STD and other high risk groups is 5% or more. Low prevalent States States where the HIV prevalence in antenatal women is less than 1% and HIV prevalence among STD and other high-risk group is less than 5%.

High Prevalent states HIV Prevalence STD%ANC% Andhra Pradesh Karnataka Maharashtra Manipur Nagaland Tamil Nadu

Moderate Prevalent States HIV Prevalence STD%ANC% Goa Kerala Mizoram

HIV Prevalence Trend in India Prevalence New Infections m m0.2 m m0.16 m m0.11 m m Inference : New infections are declining

Sentinel Surveillance for HIV Infection in pregnant women in Pune

Sentinel surveillance for HIV Infection in tuberculosis patients in Pune HIV seroprealence % Tuberculosis is the most likely presentation of AIDS in India

Molecular epidemiology HIV-1 C is the commonest prevalent subtype in India

Clinical condition PatientsMedian CD4 pSensSpecPPVNPV Oral candidiasis Herpes zoster Pulm. TB Lymphadeno- pathy Weight loss Rash Diarrhoea Fever * Oral candidiasis and weight loss were associated with and were highly predictive of low CD4 counts * Absence of clinical conditions were good predictors of high CD4 counts Clinical conditions and CD4 counts

Clinical Profile of AIDS in South India Pulmonary tuberculosis (49.1%; median duration of survival, 45 months) Pneumocystis carinii pneumonia(6.1%; median duration of survival, 24 months) Cryptococcal meningitis (4.7%; median duration of survival, 22 months) CNS toxoplasmosis (3%; median duration of survival, 28 months) Clinical Infectious Diseases 2003; 36:79 – 85

Median CD4 Counts in AIDS Cases in South India Pulmonary tuberculosis 111 cells/mL Extrapulmonary tuberculosis 122 cells/mL P. carinii pneumonia 87 cells/mL Cryptosporidiosis 133 cells/mL Cryptococcal meningitis 91 cells/mL CNS toxoplasmosis35 cells/mL Cytomegalovirus retinitis 51 cells/mL Clinical Infectious Diseases 2003; 36:79 – 85

Autopsy finding in AIDS in Mumbai 85 adult brains studied with at least 21 sections from each using routine and special stains CNS lesions observed in 67 cases (79%) Opportunistic infections were present in 33 cases (39%) Toxoplasmosis (11 cases, 13%) Tuberculosis (10 cases, 12%), Cryptococcosis (seven cases, 8%) Cytomegalovirus infection (six cases, 7%) AIDS Feb 12;12(3):309-13

Generic ART Medication in India Lamivudine+Zidovudine Efavirenz 600mg Nevirapine 200mg Didanosine-EC 250mg Didanosine-EC 400mg Stavudine 30mg Stavudine 40mg Lamivudine 150mg Zidovudine 300mg Indinavir400 mg

Healthcare Resources National AIDS Cotrol Organization Hospitals (Government and Private) Researchers NGOs CBOs Free ART programme from the National AIDS Control Programme