B.1 hiv-in-india


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B.1 hiv-in-india

  1. 1. Context: HIV/AIDS in India Essential Advocacy Project
  2. 2. Overview: HIV/AIDS in India <ul><li>Focus: What we know and what more we need to know for ‘evidence based’ decision-making to be a reality. </li></ul><ul><li>Much of presentation drawn from Containing HIV/AIDS in India: the unfinished agenda , Chadrasekaran et al, Lancet , August 2006 (in participants’ resources). </li></ul><ul><li>NACO estimated that adult HIV prevalence in India in 2005 was 0.88% = 5.2 million people living with HIV (aged between 15 - 49). </li></ul><ul><li>This masks significant regional and sub regional variations in a country with a population of 1 billion across 31 states and 593 districts. </li></ul>
  3. 3. Overview: HIV/AIDS in India <ul><li>India’s epidemic is very diverse - no single pattern of what is driving HIV infections. </li></ul><ul><li>Substantial epidemics in several pockets in India, not just in high prevalence states but within specific districts within high prevalence states and outside these states. </li></ul><ul><li>Presentation focuses on six high prevalence states in which Avahan works: </li></ul><ul><ul><li>South: Maharashtra, Tamil Nadu, Andhra Pradesh, Karnataka. </li></ul></ul><ul><ul><li>North East : Nagaland and Manipur. </li></ul></ul>
  4. 4. Data sources and limitations <ul><li>Main source of HIV prevalence data: sentinel surveillance from antenatal clinics (ANC) and STI clinics; some limited surveillance among high risk groups (HRG include FSW, MSM, IDU, also referred to as key populations - KPs). </li></ul><ul><li>Surveillance system has rapidly expanded from 180 sites in 1993 to 393 ANC sites and 179 STI sites in 2005. </li></ul><ul><li>As at 2005, HIV prevalence data collected from 132 targeted intervention with KPs (facility based). </li></ul><ul><li>Challenge: surveillance data currently not providing real insights into trends over time. We’ll see this dilemma as we use available data in this course. </li></ul>
  5. 5. Why? Data limitations <ul><li>Rapid site expansion leading to sites with different characteristics from year to year. </li></ul><ul><li>Variable patterns of attendance at ANC = data not representative of general population. </li></ul><ul><li>Surveillance through ANC good as a late marker of trends once HIV in general population. </li></ul><ul><li>BUT must understand trends in these different epidemics BEFORE then to inform programming planning and measuring effectiveness of programming among KPs. </li></ul><ul><li>To do so, need to map and estimate size of KPs, measure HIV prevalence and assess risk behavior over time. </li></ul>
  6. 6. Current situation: Data on KPs <ul><li>Few systematic processes for mapping and estimating size of different KPs, measuring HIV prevalence and assessing risk behavior over time among FSW, IDU, MSM, so such data currently sparse. </li></ul><ul><li>State and facility based data can help. BUT BIG task to gather different sources of data, and analyse it in order to have a picture of what is happening in different epidemics in HIV prevalence states and elsewhere in India. </li></ul><ul><li>Data will improve: New data expected including Integrated Bio- Behavioural Assessment (IBBA) by FHI for Avahan; National BSS 2006; National Family Health Survey (2005). </li></ul>
  7. 7. What we know: Southern states <ul><li>Total population of 292 million across the 4 states, 3.5 million people living with HIV, approximately 67% of India’s epidemic. </li></ul><ul><li>Based on current data, transmission largely heterosexual. </li></ul><ul><li>Fairly comprehensive mapping and size estimations of some KPs and some behavioural, prevalence and facility based studies. </li></ul><ul><li>HIV prevalence range: </li></ul><ul><ul><ul><li>Regionally >1% median ANC </li></ul></ul></ul><ul><ul><ul><li>STI: 3.6 - 32.4% </li></ul></ul></ul><ul><ul><ul><li>FSW: 1.2 - 50.2% </li></ul></ul></ul><ul><ul><ul><li>MSM: 4.4 - 14.8% </li></ul></ul></ul><ul><ul><ul><li>TG: 43.9 - 68% </li></ul></ul></ul><ul><ul><ul><li>IDU: 0 - 33.2% </li></ul></ul></ul>
  8. 8. What we know: Southern states <ul><li>ANC HIV surveillance in some districts for 7 years; in all for last 2 years. </li></ul><ul><li>25 - 40% of districts have STI sentinel surveillance among STI patients. </li></ul><ul><li>5 - 25% districts have facility based sentinel surveillance for KPs. </li></ul><ul><li>History of prevention programming: </li></ul><ul><ul><li>7 -12 years of FSW and high risk male prevention programming </li></ul></ul><ul><ul><li>IDU and MSM prevention programming more recent and more limited. </li></ul></ul>
  9. 9. Southern states: Female sex workers <ul><li>Transmission risk vary considerably depending on the typology of sex work: where; number of transactions per day; norms around condoms use. Example : In southern states, only 5 - 10% of sex work takes place in brothels, compared with 55% street based and 20 - 30% home based (Avahan). </li></ul><ul><li>HIV prevalence among sex workers varies widely. Where reported condom use is high often lower HIV prevalence. Example : Relatively low rate of 9.5% HIV prevalence among FSW in Tamil Nadu correlate with high rates of self-reported condom use. </li></ul><ul><li>STI prevalence rates are variable but generally high. </li></ul>
  10. 10. Southern states: Sex between men <ul><li>Complex tapestry of self classification (kothis; panthis; transgender) and associated sexual behaviour impacts on HIV risk. </li></ul><ul><li>Sex between men seems common in both urban and rural areas. Example: Study in 5 rural districts found 10% of single men and 3% married men reported anal sex with another man in the previous year. </li></ul><ul><li>Limited reports suggest high rates of STIs in MSM. </li></ul><ul><li>Many MSM also have sex with women. Example: In AP, 51% of MSM reported sex with regular female partner in previous 3 months. Condom use with last male partner 44%, with last female partner 16%. </li></ul>
  11. 11. Southern states: IDU <ul><li>People who inject drugs are found in most major cities. </li></ul><ul><li>HIV prevalence ranging from 2 - 44%. </li></ul><ul><li>Few IDU programmes in southern states. Example: 80% of NACO supported prevention interventions for IDUs are in NE. </li></ul><ul><li>Little known about IDU overlap with other high risk groups outside north eastern states. </li></ul>
  12. 12. Coverage of HRG: Southern states <ul><li>Number of targeted interventions for KPs: Under NACP 2 (NACO supported only): </li></ul><ul><ul><ul><li>FSW: 98; MSM: 15; IDU: 4 </li></ul></ul></ul><ul><ul><ul><li>Compared with other: 252 including for migrant workers, prisoners, street children </li></ul></ul></ul><ul><li>Coverage of targeted interventions for KPs (NACP 2 and where available Avahan): </li></ul><ul><ul><ul><li>FSW: 73% </li></ul></ul></ul><ul><ul><ul><li>MSM: 37% (range 8 - 63%) </li></ul></ul></ul><ul><ul><ul><li>IDU: not clear, likely very low. </li></ul></ul></ul>
  13. 13. Testing & treatment: Southern states <ul><li>VCTC sites in 2005 = 510 </li></ul><ul><li>524,249 VCTC clients </li></ul><ul><li>Estimated HIV infection 2004 = 3.5 million </li></ul><ul><li>ARV government clinics in 2005 = 29 </li></ul><ul><li>91,589 (2.48%) on ARVs (from government clinics) </li></ul>
  14. 14. What we know: North East states <ul><li>Includes Mizoram, as well as Nagaland and Manipur = population 5.5 million, estimated 63,521 people living with HIV. </li></ul><ul><li>Transmission primarily through injecting drug use. </li></ul><ul><li>Reasonable mapping and size estimations of IDUs and sex workers. </li></ul><ul><li>HIV prevalence range: </li></ul><ul><ul><ul><li>Regionally >1% median ANC (except Mizoram) </li></ul></ul></ul><ul><ul><ul><li>STI: 3.5 - 15.6% </li></ul></ul></ul><ul><ul><ul><li>FSW: 4 - 29.7% </li></ul></ul></ul><ul><ul><ul><li>MSM: 15.6% </li></ul></ul></ul><ul><ul><ul><li>IDU: 0.4 - 33.6% </li></ul></ul></ul>
  15. 15. What we know: North East states <ul><li>ANC HIV surveillance in some districts for 7 years; in all for the last 2 years. </li></ul><ul><li>25 - 40% of districts have STI sentinel surveillance among STI patients. </li></ul><ul><li>Surveillance for high risk groups limited to one site per group per state and some facility and population based studies. </li></ul><ul><li>History of prevention programming: </li></ul><ul><ul><li>Over 8 years - IDU </li></ul></ul><ul><ul><li>Sex workers and MSM more recent and limited. </li></ul></ul>
  16. 16. North East: IDU <ul><li>Recent size estimates data show injecting drug users could constitute 1.9 - 2.7% of adult population in Manipur and Nagaland. </li></ul><ul><li>NACO 2006 report estimates 24.1% HIV prevalence among IDUs in Manipur and 4.51% in Nagaland. </li></ul><ul><li>Sample of IDU in NE: 75% were HIV positive, most were under the age of 19 years, two thirds were sexually active and 3% reported using condoms. </li></ul>
  17. 17. North East: Female sex workers <ul><li>NACO 2006 report estimates 11.4% HIV prevalence in Manipur and 10.8% in Nagaland among FSWs in 2005. </li></ul><ul><li>Mapping in NE show substantial numbers of sex workers in urban/ valley areas where IDU are also in high numbers. </li></ul><ul><li>Data from one VCTC suggests increasing HIV prevalence among FSW. </li></ul><ul><li>Given previous slide: Importance of understanding intersection between injecting drug users and sexual networks, including sex work. </li></ul>
  18. 18. North East: Sex between men <ul><li>Sex between men seems common in both urban and rural areas, self classification (kothis; panthis; transgender) and associated sexual behaviour poorly understood in NE. </li></ul><ul><li>NACO 2006 report estimates 15.6% HIV prevalence in Manipur; no data available for Nagaland in 2005. </li></ul><ul><li>No specific analysis of MSM HIV risk in NE in Lancet article, suggest more data is needed. </li></ul>
  19. 19. Coverage of HRG: North East states <ul><li>Number of targeted interventions for KPs: Under NACP 2: </li></ul><ul><ul><ul><li>IDU: 64; FSW: 13; MSM: 1 </li></ul></ul></ul><ul><ul><ul><li>Others: 17 </li></ul></ul></ul><ul><li>Coverage of targeted interventions for KPs (NACP 2 and where available Avahan): </li></ul><ul><ul><ul><li>IDU: 71 - 76% (excluding Mizoram) </li></ul></ul></ul><ul><ul><ul><li>FSW: Not clear </li></ul></ul></ul><ul><ul><ul><li>MSM: Not clear, likely low </li></ul></ul></ul>
  20. 20. Testing & Treatment: North East states <ul><li>VCTC sites in 2005 = 19 </li></ul><ul><li>9,786 VCTC clients </li></ul><ul><li>Estimated HIV infection 2004 = 63,521 </li></ul><ul><li>ARV government clinics in 2005 = 3 </li></ul><ul><li>1,577 (2.48%) on ARVs from government clinics. </li></ul>
  21. 21. National response and resources <ul><li>NACP I - 1992, launched with World Bank funds </li></ul><ul><li>Spent disproportionately by a few states: Tamil Nadu; West Bengal and Maharashtra </li></ul><ul><li>Over next few years, more state and national level programmes and new donors </li></ul><ul><li>NACP II launched 1999. Tamil Nadu and West Bengal showed early successes, less clear for other states. </li></ul><ul><li>NACP III - launched in early 2007, to cover 2007 - 2011. First time national plan developed with civil society input. Expect plan will provide for scale up in TIs for KPs. </li></ul>
  22. 22. National response and resources <ul><li>Estimated total spent on HIV in India in 2004 was US$ 79 million (including Avahan funds) = $0.15 per capita adult population. </li></ul><ul><li>Compare: </li></ul><ul><ul><li>$1.74 per capita in Thailand </li></ul></ul><ul><ul><li>$0.28 per capita in China </li></ul></ul><ul><li>Low government expenditure on health in India in general = $7 per capita. </li></ul>
  23. 23. National response: targeting HRG <ul><li>As at August 2005 = 956 targeted interventions covering FSW, IDU, MSM, migrant workers, slum children, prisoners, truckers and a range of others. </li></ul><ul><li>Only 296 (31%) of the total TIs focussed on FSW, IDU and MSM. </li></ul><ul><li>Assessment of these programmes in 2002 - 03 identified some shortcomings including: </li></ul><ul><ul><li>Lack of co-ordinated state level strategy </li></ul></ul><ul><ul><li>Limited focus on coverage </li></ul></ul><ul><ul><li>Substantial focus on non priority groups. </li></ul></ul>
  24. 24. National response: targeting HRG <ul><li>Lack of good quality data has impeded targeted prevention programmes that address those most affected, as we’ve seen. </li></ul><ul><li>Assessment also found: </li></ul><ul><ul><li>Primary focus on BCC; condom distribution </li></ul></ul><ul><ul><li>Limited options for quality STI treatment </li></ul></ul><ul><ul><li>Need for much greater attention on addressing structural factors that impede effective programming </li></ul></ul><ul><li>Points to the need for advocacy to create an ‘enabling environment’. </li></ul>
  25. 25. Advocacy: enabling environment <ul><li>An enabling environment is an environment where public policy, laws, and practices: </li></ul><ul><ul><li>protect and promote the rights of PLWHA, SWs, MSM, and IDUs </li></ul></ul><ul><ul><li>support effective programmes </li></ul></ul><ul><ul><li>reduce vulnerability to HIV/AIDS, and </li></ul></ul><ul><ul><li>address its consequences. </li></ul></ul>
  26. 26. Human rights not an optional extra <ul><li>We know that preventing spread of HIV is not just about individual behavior change. </li></ul><ul><li>We need to understand and address the structural barriers that people at risk and living with the virus face. </li></ul><ul><li>Stigma and discrimination: </li></ul><ul><ul><li>reduces access to information about HIV prevention and care </li></ul></ul><ul><ul><li>undermines people’s ability to make informed decisions about their behavior and health </li></ul></ul><ul><ul><li>prevents people from implementing safer behaviors. </li></ul></ul><ul><li>Health and human rights are mutually reinforcing: where rights are protected, vulnerability to HIV infection is reduced and impacts of HIV/AIDS alleviated. </li></ul>
  27. 27. Urgency: Evidence based approach <ul><li>Too many resources and too much effort has been expended without enough impact, because it has not been guided by evidence and a rights based approach. </li></ul><ul><li>Appropriate targeted interventions are essential to preventing HIV transmission and addressing the consequences of HIV/AIDS. </li></ul><ul><li>Responses MUST be guided by evidence about what we know works and what needs to be done to address the structural barriers that people at risk of HIV infection and living with the virus face. </li></ul>
  28. 28. Evidence based advocacy <ul><li>We must know where better data is needed; what different types of data are available; what the data show; and how to use it to make the case for the right programmes to meet the needs of those most at risk and ensure policies and practices that create an enabling environment in order to halt the spread of HIV and reduce impact on those living with and affected by HIV. </li></ul><ul><li>This course is designed to do just that: To assist you to become familiar with different types of data, where to find it, and how to use it to strengthen your advocacy efforts. </li></ul>