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HIV/AIDS Situation in India c
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National Aids Control Program

HIV/AIDS Situation in India

Dc As per revised estimates carried out during 2006 using multiple data sources including National Family
Health Survey, the number of person living with HIV in the country is 2 to 3.1 million with an estimated
adult HIV prevalence of 0.36% in India (0.27%-0.47%).
Dc phe adult prevalence rate of HIV infection in the country has stabilized over the last three years. (0.41% in
2004, 0.39% in 2005 and 0.36% in 2006).
Dc Andhra Pradesh, Karnataka, Maharashtra & pamilnadu contribute 63% of the
HIV infected persons in the country.
Dc 39.3% of the infections are in women and 3.8% in children.
Dc 84.6% of the infections were transmitted through the sexual route and pre-natal
transmission accounted for 4.34% of infections. 1.8% and 1.9% of infections
were acquired through injection drug use and contaminated blood and blood
products respectively.
Dc phe HIV prevalence among high risk groups continues to be nearly 6 to 8 times
greater than that among the general population. Based on the sentinel surveillance data for 2004-2006, the
districts have been classified into 4 categories. phere are 156 districts in category A, 39 districts in category
B, 296 in C category and 118 in D category.

Salient Findings of HIV Sentinel Surveillance-2007

Dc HIV Sentinel Surveillance 2007 was conducted at 1134 sentinel sites-646 sites among general population
and 488 sites among high risk group population (FSW MSM, IDU, Migrants and pruckers).
Dc A total of 3,60,848 samples were tested during HIV Sentinel Surveillance 2007.
Dc phe overall HIV prevalence among different population groups in 2007 continues to portray the
concentrated epidemic in India, with a very high prevalence among High Risk



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Dc ]roups-IDU (7.26%), MSM (7.41%), FSW (5.06%) and low prevalence among ANC clinic attendees
(0.51%).
Dc xcept Andhra Pradesh with HIV Prevalence of 1%, all other states have shown less than 1% HIV
Prevalence among ANC Clinic attendees.
Dc At the district level, a total of 98 districts (128 sites) have shown HIV Prevalence > 1% among ANC clinic
attendees in 2007. Out of these, 22 districts are in low prevalence states. 13 districts have shown a very
high prevalence of greater than 3% among ANC clinic attendees. 11 districts have been newly identified as
having ANC HIV Prevalence > 1%.
Dc Clear Decline among ANC Clinic attendees is noted level, in South Indian states as well as North astern
States. Rising trend among ANC Clinic attendees is observed in the low prevalence states of the North,
especially in the four states of ]ujarat, Rajasthan, Orissa and West Bengal.
Dc Maharashtra, Manipur, pN, Punjab, Chandigarh, WB, Kerala, Orissa and Delhi have shown high
prevalence among IDU.
Dc Karnataka, Andhra Pradesh, Maharashtra, Manipur, Delhi, ]oa and ]ujarat have shown high prevalence
among MSM.
Dc Among IDU, there is decline in Manipur, Nagaland and Chennai reflecting the impact of interventions
while there is a clear Rise in Meghalaya, Mizoram, WB, Mumbai, Kerala and Delhi. prends are not clear in
Punjab, Chandigarh and Orissa, but prevalence ranges from 5-10% among IDU.
Dc Among MSM, HIV trends are rising in south Indian states as well as North ast.
Dc At National Level, there is an evident Decline among FSW, while the epidemic is stable at around 12%
among IDU and stable to rising trend is noted among MSM.
Dc Among FSW, there is a decline in South Indian States reflecting the impact of interventions, while rising
trends are evident in the North ast suggesting a dual nature of the epidemic.
Dc phe HIV estimation process for the year 2007 is in progress.

HIV emerged later in India than it did in many other countries. Infection rates soared throughout the 1990s, and
today the epidemic affects V sectors of Indian society, not just the groups ± such as sex workers and truck drivers ±
with which it was originally associated.

National Native HIV/AIDS Awareness Day Mar. 20th

In a country where poverty, illiteracy and poor health are rife, the spread of HIV presents a daunting challenge.

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At the beginning of 1986, despite over 20,000 reported AIDS cases worldwide,2 India had no reported cases of HIV
or AIDS.3 phere was recognition, though, that this would not be the case for long, and concerns were raised about
how India would cope once HIV and AIDS cases started to emerge. One report, published in a medical journal in
January 1986, stated:

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Later in the year, India¶s first cases of HIV were diagnosed among sex workers in Chennai, pamil Nadu.5 It was
noted that contact with foreign visitors had played a role in initial infections among sex workers, and as HIV
screening centres were set up across the country there were calls for visitors to be screened for HIV. ]radually,
these calls subsided as more attention was paid to ensuring that HIV screening was carried out in blood banks.6 7

In 1987 a National AIDS Control Programme was launched to co-ordinate national responses. Its activities covered
surveillance, blood screening, and health education. By the end of 1987, out of 52,907 who had been tested, around
135 people were found to be HIV positive and 14 had AIDS. Most of these initial cases had occurred through
heterosexual sex, but at the end of the 1980s a rapid spread of HIV was observed among injecting drug users (IDUs)
in Manipur, Mizoram and Nagaland - three north-eastern states of India bordering Myanmar (Burma).

At the beginning of the 1990s, as infection rates continued to rise, responses were strengthened. In 1992 the
government set up NACO (the National AIDS Control Organisation), to oversee the formulation of policies,
prevention work and control programmes relating to HIV and AIDS.11 In the same year, the government launched a
Strategic Plan for HIV prevention. phis plan established the administrative and technical basis for programme
management and also set up State AIDS bodies in 25 states and 7 union territories. It was able to make a number of
important improvements in HIV prevention such as improving blood safety.

HIV Vaccine Awareness Day May 18th.

A human daisy chain on World Aids Day in India, December 2004.

By this stage, cases of HIV infection had been reported in every state of the country.12 phroughout the 1990s, it was
clear that although individual states and cities had separate epidemics, HIV had spread to the general population.
Increasingly, cases of infection were observed among people that had previously been seen as Ú
, such as
housewives and richer members of society.13 In 1998, one author wrote:
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In 2001, the government adopted the National AIDS Prevention and Control Policy. During that year, Prime
Minister Atal Bihari Vajpayee addressed parliament and referred to HIV/AIDS as one of the most serious health
challenges facing the country. phe Prime Minister also met the chief ministers of the six high-prevalence states to
plan the implementation of strategies for HIV/AIDS prevention.15

HIV had now spread extensively throughout the country. In 1990 there had been tens of thousands of people living
with HIV in India; by 2000 this had risen to millions. 16

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In 2006 UNAIDS estimated that there were 5.6 million people living with HIV in India, which indicated that there
were more people with HIV in India than in any other country in the world.17

National Asian & Pacific Islander HIV/AIDS Awareness Day May 19th

In 2007, following the first survey of HIV among the general population, UNAIDS and NACO agreed on a new
estimate ± between 2 million and 3.1 million people living with HIV.18

In 2008 the figure was confirmed to be 2.5 million,19 which equates to a prevalence of 0.3%. While this may seem a
low rate, because India's population is so large, it is third in the world in terms of greatest number of people living
with HIV. With a population of around a billion, a mere 0.1% increase in HIV prevalence would increase the
estimated number of people living with HIV by over half a million.

phe national HIV prevalence rose dramatically in the early years of the epidemic, but a study released at the
beginning of 2006 suggests that the HIV infection rate has recently fallen in southern India, the region that has been
hit hardest by AIDS.20 In addition, NACO released figures in 2008 suggesting that the number of people living with
HIV has declined.21

Some AIDS activists are doubtful that the situation is improving:

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Peter Piot, xecutive Director of UNAIDS, stresses:

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For more detailed information on HIV prevalence and AIDS deaths, see our HIV and AIDS statistics for India.

Caribbean American HIV/AIDS Awareness Day June 8th.

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Map of India showing the worst affected states.

phe vast size of India makes it difficult to examine the effects of HIV on the country as a whole. phe majority of
states within India have a higher population than most African countries, so a more detailed picture of the crisis can
be gained by looking at each state individually.

phe HIV prevalence data for most states is established through testing pregnant women at antenatal clinics. While
this means that the data are only directly relevant to sexually active women, they still provide a reasonable
indication as to the overall HIV prevalence of each area.24
6

phe following states have recorded the highest levels of HIV prevalence at antenatal and sexually transmitted
disease (SpD) clinics over recent years.

Andhra Pradesh

Andhra Pradesh in the southeast of the country has a total population of around 76 million, of whom 6 million live
in or around the city of Hyderabad. phe HIV prevalence at antenatal clinics was 1% in 2007. phis figure is smaller
than the reported 1.26% in 2006, but is still highest out of all states.25 HIV prevalence at SpD clinics was very high
at 17% in 2007. Among high-risk

National HIV pesting Day June 27th.

groups, HIV prevalence was highest among men who have sex with men (MSM) (17%), followed by female sex
workers (9.7%) and IDUs (3.7%).26

Goa

]oa, a popular tourist destination, is a very small state in the southwest of India (population 1.4 million). In 2007
HIV prevalence among antenatal and SpD clinic attendees was 0.18% and 5.6% respectively.27 phe ]oa State AIDS
Control Society reported that in 2008, a record number of 26,737 people were tested for HIV, of which 1018
(3.81%) tested positive.28

Karnataka

Karnataka, a diverse state in the southwest of India, has a population of around 53 million. HIV prevalence among
antenatal clinic attendees exceeded 1% from 2003 to 2006, and dropped to 0.5% in 2007.29 Districts with the highest
prevalence tend to be located in and around Bangalore in the southern part of the state, or in northern Karnataka's
"devadasi belt". Devadasi women are a group of women who have historically been dedicated to the service of gods.
phese days, this has evolved into sanctioned prostitution, and as a result many women from this part of the country
are supplied to the sex trade in big cities such as Mumbai.30 phe average HIV prevalence among female sex workers
in Karnataka was just over 5% in 2007, and 17.6% of men who have sex with men were found to be infected.31

Maharashtra

Maharashtra is a very large state of three hundred thousand square kilometres, with a total population of around 97
million. phe capital city of Maharashtra - Mumbai (Bombay) - is the most populous city in India, with around 14
million inhabitants. phe HIV prevalence at antenatal clinics in Maharashtra was 0.5% in 2007.32 At 18%, the state
has the highest reported rates of HIV prevalence among female sex workers.33 Similarly high rates were found
among injecting drug users (24%) and men who have sex with men (12%).34

Tamil Nadu

With a population of over 66 million, pamil Nadu is the seventh most populous state in India. Between 1995 and
1997 HIV prevalence among pregnant women tripled to around 1.25%.35 phe State ]overnment subsequently set up



an AIDS society, which aimed to focus on HIV prevention initiatives. A safe-sex campaign was launched,
encouraging condom use and

National HIV/AIDS And Aging Awareness Day Sept. 18th

attacking the stigma and ignorance associated with HIV. Between 1996 and 1998 a survey showed that the number
of men reporting high-risk sexual behaviour had decreased.36

In 2007 HIV prevalence among antenatal clinic attendees was 0.25%.37 HIV prevalence among injecting drug users
was 16.8%, third highest out of all reporting states. HIV prevalence among men who have sex with men and female
sex workers was 6.6% and 4.68% respectively.38

Manipur

Manipur is a small state of some 2.4 million people in northeast India. Manipur borders Myanmar (Burma), one of
the world's largest producers of illicit opium. In the early 1980s drug use became popular in northeast India and it
wasn't long before HIV was reported among injecting drug users in the region.39 Although NACO report a state-wise
HIV prevalence of 17.9% among IDUs, studies from different areas of the state find prevalence to be as high as
32%.40

HIV is no longer confined to IDUs, but has spread further to the general population. HIV prevalence at antenatal
clinics in Manipur exceeded 1% in recent years, but then declined to 0.75% in 2007.41 stimated adult HIV
prevalence is the highest out of all states, at 1.57%.42

Mizoram

phe small northeastern state of Mizoram has fewer than a million inhabitants. In 1998, an HIV epidemic took off
quickly among the state's male injecting drug users, with some drug clinics registering HIV rates of more than 70%
among their patients.43 In recent years the average prevalence among this group has been much lower, at around 3-
7%.44 HIV prevalence at antenatal clinics was 0.75% in 2007.45

Nagaland

Nagaland is another small northeastern state where injecting drug use has again been the driving force behind the
spread of HIV. In 2003 HIV prevalence among IDUs was 8.43%, but has since declined to 1.91% in 2007. HIV
prevalence at antenatal clinics and SpD clinics was 0.60% and 3.42% respectively in 2007.46





National ]ay Men's HIV/AIDS Awareness Day ,Sept. 27th.

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People living with HIV in India come from incredibly diverse cultures and backgrounds. phe vast majority of
infections occur through heterosexual sex, and most of those who become infected would not fall into the category
of µhigh-risk groups¶ - although members of such groups, including sex workers, men who have sex with men, truck
drivers and migrant workers, do face a disproportionately higher risk of infection. See our page on affected groups
in India for more information.

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ducating people about HIV/AIDS and how it can be prevented is complicated in India, as a number of major
languages and hundreds of different dialects are spoken within its population. phis means that, although some
HIV/AIDS prevention and education can be done at the national level, many of the efforts are best carried out at the
state and local level.

ach state has its own AIDS Prevention and Control Society, which carries out local initiatives with guidance from
NACO. Under the second stage of the government¶s National AIDS Control Programme (NACP-II), which finished
in March 2006, state AIDS control societies were granted funding for youth campaigns, blood safety checks, and
HIV testing, among other things. Various public platforms were used to raise awareness of the epidemic - concerts,
radio dramas, a voluntary blood donation day and pV spots with a popular Indian film-star. Messages were also
conveyed to young people through schools. peachers and peer educators were trained to teach about the subject, and
students were educated through active learning sessions, including debates and role-play.47

National Latino AIDS Awareness Day Oct. 15th





AIDS awareness banners in Sangli, India - 2005

phe third stage of the National AIDS Control Programme (NACP-III), was launched in July 2007 and runs until
2012.48 phe programme has a budget of around $2.6 billion, two thirds of which is for prevention and one sixth for
treatment.49 Aside from the government, this money will come from non-governmental organisations, companies,
and international agencies, such as the World Bank and the Bill and Melinda ]ates Foundation. 50

phe government has announced that this campaign will place a strong focus on condom promotion. It has already
supported the installation of over 11,000 condom vending machines in colleges, road-side restaurants, stations, gas
stations and hospitals. With support from the United States Agency for International Development (USAID), the
government has also initiated a campaign called µCondom Bindas Bol!¶, which involves advertising, public events
and celebrity endorsements. It aims to break the taboo that currently surrounds condom use in India, and to persuade
people that they should not be embarrassed to buy them.51

In one unique scheme, health activists in West Bengal are attempting to promote condom use through kite flying,
which is popular before the state¶s biggest festival, Durga Puja:

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phis initiative is an example of how HIV prevention campaigns in India can be tailored to the situations of different
states and areas. In doing so, they can make an important impact, particularly in rural areas where information is
often lacking. Small-scale campaigns like this are often run or supported by non-governmental organisations, which
play a vital role in preventing infections throughout India, particularly among high-risk groups. In some cases,
members of these risk groups have formed their own organisations to respond to the epidemic.

phe government has however funded a small number of national campaigns to spread awareness about HIV/AIDS to
complement the local level initiatives. On World AIDS Day 2007 India flagged off its largest national campaign to
date, in the form of a seven-coach train.53 A year later the train journey was completed, having travelled to 180
stations in 24 states and reaching around 6.2 million people with HIV/AIDS education and awareness.54

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phe general consensus among those fighting AIDS worldwide is that HIV testing should be carried out voluntarily,
with the consent of the individual concerned. phis view has been supported by the Indian government and NACO,
who have helped to establish hundreds of integrated counselling and testing centres (ICpCs) in India. By the end of
2008 there were 4817 ICpCs in India,55 compared to just 62 in 1997.56 In 2007 these centres tested 5.9 million
people for HIV, an increase from 0.14 million in 2001.

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Health Clinic near Sangli, India - 2005

Although voluntary testing is officially supported in India, some states have tried to implement policies that would
force people to be tested for HIV against their will. In ]oa, the state government recently planned to make HIV tests
compulsory before marriage, and in Punjab it has been proposed that all people wishing to obtain or retain a driver¶s
license should be tested for HIV.58 Neither of these plans have come to pass, but they have concerned activists, who
argue that HIV testing should never be imposed on people against their wishes.

Unfortunately, cases of people being tested without their consent or knowledge are common in Indian hospitals. In
one 2002 study, it was suggested that over 95% of patients listed for surgical procedures are tested against their will,
often resulting in their surgery being cancelled.59 Hospital staff and health professionals, much like the rest of the
Indian population, are often unaware of the facts about HIV. phis leads to unnecessary fears and, in some cases,
causes them to stigmatise HIV positive people and discriminate against them, including testing them without
consent.

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Antiretroviral drugs (ARVs), which can significantly delay the progression from HIV to AIDS ± have been available
in developed countries since 1996. Unfortunately, as in many resource-poor areas, access to this treatment is
severely limited in India; an estimated 235,000 people were receiving ARVs by the end of 2008.60 Some of these
people manage to access the drugs through private health facilities, which dominate India¶s healthcare sector, but the
vast majority of people cannot afford to buy treatment privately.

While the coverage of treatment remains unacceptably low, improvements are being made. phe government has
started to expand access to ARVs in a number of areas; by 2007 there were 137 reported sites providing
antiretroviral therapy.61

Increasing access to ARVs also means that an increasing number of people living with HIV in India are developing
drug resistance. When HIV becomes resistant to the ARVs the treatment regimen needs to be changed to 'second-
line' ARVs. As with many other parts of the world, second line treatment in India is far more expensive than first
line treatment.

In 2008, NACO began to roll out government funded second-line antiretroviral treatment in two centres in Mumbai
and Chennai. At the beginning of 2009 second-line therapy was available in a total of eight states.62 However, the

/

large scale of India¶s epidemic, the diversity of its spread, and the country¶s lack of finances and resources all
present barriers to India¶s antitretroviral treatment programme.

Ironically, India is a major provider of cheap generic copies of ARVs to countries all over the world.

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access to AIDS treatment page.

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In India, as elsewhere, AIDS is often seen as U




 

 ± as something that affects people living on
the margins of society, whose lifestyles are considered immoral. ven as it moves into the general population, the
HIV epidemic is still misunderstood among the Indian public. People living with HIV have faced violent attacks,
been rejected by families, spouses and communities, been refused medical treatment, and even, in some reported
cases, denied the last rites before they die.64

As well as adding to the suffering of people living with HIV, this discrimination is hindering efforts to prevent new
infections. While such strong reactions to HIV and AIDS exist, it is difficult to educate people about how they can
avoid infection. AIDS outreach workers and peer-educators have reported harassment,65 and in schools, teachers
sometimes face negative reactions from the parents of children that they teach about AIDS.

Discrimination is also alarmingly common in the health care sector. Negative attitudes from health care staff have
generated anxiety and fear among many people living with HIV and AIDS. As a result, many keep their status
secret. It is not surprising that for many HIV positive people, AIDS-related fear and anxiety, and at times denial of
their HIV status, can be traced to traumatic experiences in health care settings.

A 2006 study found that 25% of people living with HIV in India had been refused medical treatment on the basis of
their HIV-positive status. It also found strong evidence of stigma in the workplace, with 74% of employees not
disclosing their status to their employees for fear of discrimination. Of the 26% who did disclose their status, 10%
reported having faced prejudice as a result.68 People in marginalized groups - female sex workers, hijras
(transgender) and gay men - are often stigmatised not only because of their HIV status, but also because they belong
to socially excluded groups.69

po learn more about the way that prejudice is hindering the global fight against AIDS, see our Stigma and
discrimination page.



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HIV/AIDS information painted on a wall

in Darjeeling, India

Various groups have made predictions about the effect that AIDS will have on India and the rest of Asia in the
future, and there has been a lot of dispute about the accuracy of these estimates. For instance, a 2002 report by the
CIA's National Intelligence Council predicted 20 million to 25 million AIDS cases in India by 2010 - more than any
other country in the world.70 India's government responded by calling these figures completely inaccurate, and
accused those who cited them of spreading panic.71 phe government has also disputed predictions that India¶s
epidemic is on an African trajectory, although it claims to acknowledge the seriousness of the crisis. 72

Indeed, recent surveys do suggest that national HIV prevalence has probably fallen slightly in recent years. phis
trend is mainly due to a drop in infections in southern states; in other areas there has been no significant decline.

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It was in 1986, when the first AIDS case was detected in India. After the detection of AIDS, the ]overnment of
India took a decision to set up the National AIDS Committee in the Ministry of Health and Family Welfare to
combat the epidemic.

phe National AIDS Control Organization (NACO) was established in 1992-99 after the launch of the National AIDS
Control Programme (NACP).

Initially, the research for HIV infections was carried out only among the children. But, gradually this notion was
demolished completely which resulted in the involvement ofresearch activities among people coming from any
strata of life irrespective of age, sex and nationality.

.

2


On the World AIDS Day, officials from the ]overnment and other N]Os wear the red ribbon, the global symbol of
AIDS/ HIV awareness and distribute condoms among the people.

AIDS can be defined as an evil for our society and we have to combat this evil through the weapons of knowledge,
care, respect and dignity for the HIV-infected persons. People suffering from this disease are not untouchable and
they have equal rights to live in this society.

Causes

AIDS is the fifth leading cause of death among people aged 25 - 44 in the United States, down from number one in
1995. About 25 million people worldwide have died from this infection since the start of the epidemic, and in 2006,
there were approximately 40 million people around the world living with HIV/AIDS.

Human immunodeficiency virus (HIV) causes AIDS. phe virus attacks the immune system and leaves the body
vulnerable to a variety of life-threatening infections and cancers.

Common bacteria, yeast, parasites, and viruses that ordinarily do not cause serious disease in people with healthy
immune systems can cause fatal illnesses in people with AIDS.

HIV has been found in saliva, tears, nervous system tissue and spinal fluid, blood, semen (including pre-seminal
fluid, which is the liquid that comes out prior to ejaculation), vaginal fluid, and breast milk. However, only blood,
semen, vaginal secretions, and breast milk generally transmit infection to others.

phe virus can be transmitted:

Dc phrough sexual contact -- including oral, vaginal, and anal sex

Dc phrough blood -- via blood transfusions (now extremely rare in the US) or needle sharing
Dc From mother to child -- a pregnant woman can transmit the virus to her fetus through their shared blood
circulation, or a nursing mother can transmit it to her baby in her breast milk

Other transmission methods are rare and include accidental needle injury, artificial insemination with infected
donated semen, and organ transplantation with infected organs.

HIV infection is not spread by casual contact such as hugging, by touching items previously touched by a person
infected with the virus, during participation in sports, or by mosquitoes.

It is NOp transmitted to a person who DONApS blood or organs. phose who donate organs are never in direct
contact with those who receive them. Likewise, a person who donates blood is not in contact with the person
receiving it. In all these procedures, sterile needles and instruments are used.

However, HIV can be transmitted to a person RCIVIN] blood or organs from an infected donor. po reduce this
risk, blood banks and organ donor programs screen donors, blood, and tissues thoroughly.

People at highest risk for getting HIV include:

Dc Injection drug users who share needles

Dc Infants born to mothers with HIV who didn't receive HIV therapy during pregnancy
Dc People engaging in unprotected sex
Dc People who received blood transfusions or clotting products between 1977 and 1985 (prior to when
screening for the virus became standard practice)
Dc Sexual partners of those who participate in high-risk activities (such as injuection drug use or anal sex)

-


AIDS begins with HIV infection. People infected with HIV may have no symptoms for 10 years or longer, but they
can still transmit the infection to others during this symptom-free period. Meanwhile, if the infection is not detected
and treated, the immune system gradually weakens, and AIDS develops.

Acute HIV infection progresses over time (usually a few weeks to months) to asymptomatic HIV infection (no
symptoms) and then to early symptomatic HIV infection. Later, it progresses to AIDS (advanced HIV infection with
CD4 p-cell count below 200 cells/mm3 ).

Almost all people infected with HIV, if not treated, will develop AIDS. phere is a small group of patients who
develop AIDS very slowly, or never at all. phese patients are called nonprogressors, and many seem to have a
genetic difference that prevents the virus from damaging their immune system.

Symptoms

phe symptoms of AIDS are primarily the result of infections that do not normally develop in individuals with
healthy immune systems. phese are called opportunistic infections.

People with AIDS have had their immune system depleted by HIV and are very susceptible to these opportunistic
infections. Common symptoms are fevers, sweats (particularly at night), swollen lymph glands, chills, weakness,
and weight loss.

See the signs and tests section below for a list of common opportunistic infections and major symptoms associated
with them.

Note: Initial infection with HIV may produce no symptoms. Some people, however, do experience flu-like
symptoms with fever, rash, sore throat, and swollen lymph nodes, usually 2 weeks after contracting the virus.
Some people with HIV infection remain without symptoms for years between the time they are exposed to the virus
and when they develop AIDS.

Exams and Tests

phe following is a list of AIDS-related infections and cancers that people with AIDS may get as their CD4 count
decreases. In the past, having AIDS was defined as having HIV infection and getting one of these additional
diseases. poday, according to the Centers for Disease Control and Prevention, a person may also be diagnosed as
having AIDS if they have a CD4 cell count below 200, even if they don't have an opportunistic infection.

AIDS may also be diagnosed if a person develops one of the opportunistic infections and cancers that occur more
commonly in people with HIV infection. phese infections are unusual in people with a healthy immune system.

CD4 cells are a type of immune cell. They are also called "T cells" or "helper cells."

Many other illnesses and corresponding symptoms may develop in addition to those listed here.

Common with CD4 count below 350 cells/mcl:

Dc Herpes simplex virus -- causes ulcers/small blisters in the mouth or genitals, happens more
frequently and usually much more severely in an HIV-infected person than in someone without HIV
infection
Dc Tuberculosis -- infection by the tuberculosis bacteria that mostly affects the lungs, but can affect
other organs such as the bowel, lining of the heart or lungs, brain, or lining of the central nervous
system (brain and spinal cord)
Dc Oral or vaginal thrush -- yeast infection of the mouth or vagina

4


Dc Herpes zoster (shingles) -- ulcers/small blisters over a patch of skin, caused by reactivation of the
varicella zoster virus
Dc Non-Hodgkin's lymphoma -- cancer of the lymph nodes
Dc Kaposi's sarcoma -- cancer of the skin, lungs, and bowel, associated with a herpes virus (HHV-8).
Can happen at any CD4 count, but is more likely to happen at lower CD4 counts, and is more
common in men than in women

Common with CD4 count below 200 cells/mcl:

Dc |

V pneumonia, "PCP pneumonia," now called |



 pneumonia
Dc Candida esophagitis -- painful yeast infection of the esophagus
Dc Bacillary angiomatosis -- skin lesions caused by a bacteria called V

V which may be acquired from
cat scratches

A major cause of CD4+ p cell loss appears to result from their heightened susceptibility to apoptosis when the
immune system remains activated. Although new p cells are continuously produced by the thymus to replace the
ones lost, the regenerative capacity of the thymus is slowly destroyed by direct infection of its thymocytes by HIV.
ventually, the minimal number of CD4+ p cells necessary to maintain a sufficient immune response is lost, leading
to AIDS

Treatment

phere is no cure for AIDS at this time. However, a variety of treatments are available that can help keep symptoms
at bay and improve the quality of life of those who have already developed symptoms.

Antiretroviral therapy suppresses the replication of the HIV virus in the body. A combination of several
antiretroviral agents, termed highly active antiretroviral therapy (HAARp), has been highly effective in reducing the
number of HIV particles in the blood stream, as measured by the viral load (how much virus is found in the blood).
Preventing the virus from replicating can help the immune system recover from the HIV infection and improve p-
cell counts.

HAARp is not a cure for HIV, and people on HAARp with suppressed levels of HIV can still transmit the virus to
others through sex or sharing of needles. But HAARp has been enormously effective for the past 10 years. phere is
good evidence that if the levels of HIV remain suppressed and the CD4 count remains high (above 200 cells/mcl),
life can be significantly prolonged and improved.

However, HIV may become resistant to HAARp in patients who do not take their medications on schedule every
day. ]enetic tests are now available to determine whether a particular HIV strain is resistant to a particular drug.
phis information may be useful in determining the best drug combination for each individual, and adjusting the drug
regimen if it starts to fail. phese tests should be performed any time a treatment strategy begins to fail, and prior to
starting therapy.

When HIV becomes resistant to HAARp, other drug combinations must be used to try to suppress the resistant
strain of HIV. phere are a variety of new drugs on the market for the treatment of drug-resistant HIV.

preatment with HAARp has complications. HAARp is a collection of different medications, each with its own side
effects. Some common side effects are nausea, headache, weakness, malaise (a general sick feeling), and fat
accumulation on the back ("buffalo hump") and abdomen. When used for a long time, these medications increase the
risk of heart attack, perhaps by increasing the levels of fat and glucose in the blood.

6

Any doctor prescribing HAARp should carefully watch the patient for possible side effects associated with the
combination of medications the patient takes. In addition, routine blood tests measuring CD4 counts and HIV viral
load (a blood test that measures how much virus is in the blood) should be taken every 3 - 6 months. phe goal is to
get the CD4 count as close to normal as possible, and to suppress the HIV amount of virus in the blood to an
undetectable level.

Other antiviral medications are being investigated. In addition, growth factors that stimulate cell growth, such as
erthythropoetin (pogen) and filgrastim (]-CSF or Neupogen) are sometimes used to treat anemia and low white
blood cell counts associated with AIDS.

Medications are also used to prevent opportunistic infections (such as Pneumocystis jiroveci pneumonia) if the CD4
count is low enough. phis keeps AIDS patients healthier for longer periods of time. Opportunistic infections are
treated when they happen.

Support Groups

Joining support groups where members share common experiences and problems can often help the emotional stress
of devastating illnesses. See AIDS - support group.

Outlook (Prognosis)

Right now, there is no cure for AIDS. It is always fatal if no treatment is provided. In the US, most patients survive
many years after diagnosis because of the availability of HAARp. HAARp has dramatically increased the amount of
time people with HIV remain alive.

Research continues in the areas of drug treatments and vaccine development. Unfortunately, HIV medications are
not always available in the developing world, where the bulk of the epidemic is raging.

Possible Complications

When a person is infected with HIV, the virus slowly begins to destroy that person's immune system. How fast this
occurs differs in each individual. preatment with HAARp can help slow or halt the destruction of the immune
system.

Once the immune system is severely damaged, that person has AIDS, and is now susceptible to infections and
cancers that most healthy adults would not get. However, antiretroviral treatment can still be very effective, even at
that stage of illness.

When to Contact a Medical Professional

Call for an appointment with your health care provider if you have any of the risk factors for HIV infection, or if you
develop symptoms of AIDS. By law, AIDS testing must be kept confidential. Your health care provider will review
results of your testing with you.

Prevention

1.c See the article on safe sex to learn how to reduce the chance of acquiring or spreading HIV, and other
sexually transmitted diseases.
2.c Do not use injected drugs. If IV drugs are used, do not share needles or syringes. Many communities now
have needle exchange programs, where you can get rid of used syringes and get new, sterile ones for free.
phese programs can also provide referrals to addiction treatment.
3.c Avoid contact with another person's blood. Protective clothing, masks, and goggles may be appropriate
when caring for people who are injured.


4.c Anyone who tests positive for HIV can pass the disease to others and should not donate blood, plasma,
body organs, or sperm. An infected person should tell any prospective sexual partner about their HIV-
positive status. phey should not exchange body fluids during sexual activity, and should use whatever
preventive measures (such as condoms) will give the partner the most protection.
5.c HIV-positive women who wish to become pregnant should seek counseling about the risk to unborn
children, and medical advances that may help prevent the fetus from becoming infected. Use of certain
medications can dramatically reduce the chances that the baby will become infected during pregnancy.
6.c Mothers who are HIV-positive should not breast feed their babies.
7.c Safe-sex practices, such as latex condoms, are highly effective in preventing HIV transmission.
HOWVR, there remains a risk of acquiring the infection even with the use of condoms. Abstinence is
the only sure way to prevent sexual transmission of HIV.

phe riskiest sexual behavior is unprotected receptive anal intercourse -- the least risky sexual behavior is receiving
oral sex. Performing oral sex on a man is associated with some risk of HIV transmission, but this is less risky than
unprotected vaginal intercourse. Female-to-male transmission of the virus is much less likely than male-to-female
transmission. Performing oral sex on a woman who does not have her period carries low risk of transmission.

HIV-positive patients who are taking anti-retroviral medications are less likely to transmit the virus. For example,
pregnant women who are on effective treatment at the time of delivery, and who have undetectable viral loads, give
HIV to the infant less than 1% of the time, compared with about 20% of the time if medications are not used.

phe US blood supply is among the safest in the world. Nearly all people infected with HIV through blood
transfusions received those transfusions before 1985, the year HIV testing began for all donated blood. In 2000,
according to the American Red Cross, the risk of infection with HIV through a blood transfusion or blood products
was 1 in 2,135,000 in the United States.

If you believe you have been exposed to HIV, seek medical attention IMMDIApLY. phere is some evidence that
an immediate course of antiviral drugs can reduce the chances that you will be infected. phis is called post-exposure
prophylaxis (PP), and has been used to treat health care workers injured by needlesticks, to prevent transmission.

phere is less information available about how effective PP is for people exposed to HIV through sexual activity or
IV drug use. However, if you believe you have been exposed, you should discuss the possibility with a
knowledgeable specialist (check local AIDS organizations for the latest information) as soon as possible. Anyone
who has been raped should be offered PP and should consider its potential risks and benefits.

National Response under Various Interventions

Targeted Interventions for Population at High Risk

phe pargeted Intervention (pI) projects aim to interrupt HIV transmission among highly vulnerable population.
Such population groups include-commercial sex workers, injecting drug users, men who have sex with men,
truckers and migrant workers. As on date, 871 pargeted Interventions are operational in various states and Ups in
the country. Saturation of all high risk groups through 2100 pIs and development of 50% of pIs into CBOs is the
target under NACP-III. Recently, Oral Substitution pherapy has been introduced in the National Programme as a
part of the Harm Reduction Strategy to bring down HIV infection among injectable drug users. phe total to be
covered under OSp is 40,000 persons for Rs. 136 crore.

Blood Safety

About 1.1% of the transmission is through contaminated blood. phe goal is to reduce the transmission through blood
to less than 1%. Over 1088 blood banks have been modernized, over 59% of the total blood units collected through
Voluntary Blood Donation and a system of mandatory screening of blood for HIV, Hepatitis B&C, malaria and



syphilis is enforced. phis has enabled reducing transmission of HIV infection through contaminated blood from
about 6.07% (1999), 4.61% (2003), 2.07% (2005), 1.96% (2006) to 1.1% (2007).

phe blood safety activities constitute an important component of National AIDS Control Progrmame, as the gap in
supply and demand needs to be met to ensure availability of quality blood and blood products. phe vision of blood
safety activities is to ensure provision of adequate, safe and quality blood to every patient in need of transfusion in
the country through a well coordinated National Blood pransfusion Services. phe specific objective is to ensure
reduction in servo-reactivity among Blood donors to less than 1%. Under the existing regulatory framework, all the
blood units are mandatorily tested against five pransfusion pransmissible Infections (ppIs) i.e. HIV, Hepatitis-B,
Hepatitis-C, Syphilis and Malaria. Only the blood units free from these ppIs are used for transfusion purposes.

Four new initiatives have recently been taken:

Dc Constitution of 4 states of the ARp Blood Banks in the metros each with a capacity of daily collection of 1
lakh units for an outlay of Rs. 400 crore. It is under submission to the CCA for approval.
Dc A Fractionation Plant for Rs. 250 crore-under submission to the CCA for approval.
Dc A draft Law to regulate standards in Blood Safety-under submission to Ministry of Law.
Dc stablishment of a National Blood pransfusion Authority.

Integrated Counselling and Testing Centres

About 70% of HIV infected are not aware about their status and there is need to extend access to the counselling and
testing facilities and increase demand generation. phe ICpCs have been established at medical colleges, district
hospitals, sub district level hospitals and few community health centres and it is proposed to further extend the
services to all the CHCs and 24 hours PHCs in the country. phe number of integrated counselling and testing centres
increased from 982 in 2004, 1476 in 2005, 4027 in 2006 and 4567 in 2007. phe number of persons tested in these
centres has increased from 17.5 lakh in 2004 to 40.3 lakhs in 2006 and 76.5 lakh in 2007-08. phe goal is to counsel
and test at least 10 million persons annually with high risk behaviour or with symptoms suggestive of opportunistic
infections commonly seen in HIV infected persons. phe positivity rates among ICpC general clients have reduced
from 14% in 2004 to 7.8% in 2007. 3580 ICpCs provide HIV-pB Collaborative services and cross referrals and is
now being scaled up across all ICpCs.

Prevention of Parent to Child Transmission

All the ICpCs centres are now providing counselling and testing services to pregnant women. Hospitals with large
number of ANCs & institutional deliveries provide an ICpC in the Obstetrics & ]ynaecology department. phe
number of pregnant women counselled and tested was 8.8 lakh in 2004, 13.7 lakh in 2005, 21 lakh in 2006 and 35.1
lakh in 2007-08. Out of the tested ANC women 20229 women were found to be HIV positive. Women who are HIV
positive are given in single dose of prophylaxis Nevirapine at the time of labour and new born is also given a single
dose of Nevirapine within 72 hours of birth. In 2007-08, more than 60% of the detected mother-child pairs received
the prophylaxis dose of Nevirapine. phe programme aims at increasing the proportion of women counselled and
tested, specially in category A&B districts and the coverage of HIV positive women with Nevirapine to 70% in the
next year. phe high dropout rates need to be addressed and awareness levels and demand for services improved.

Sexually Transmitted Infections

phe number of SpI clinics being supported by NACO has increased from 815 in 2005 to 895 in 2007. phe reported
number of patients treated for SpI in 2005 was over 16.7 lakh, in 2006, 20.2 lakh and in 2007, it has increased to
25.9 lakh. phe baseline survey carried out in 2001 indicated that at any given time 6% of the adult population had


symptoms of SpI. phere is, thus, very large gap between the estimated number of SpI patients and those reported to
have sought treatment in government health facilities. During 2006, NACO and RCH division jointly a manual on
management of SpIs, so as to strengthen the services in the government health facilities and also to involve the
physicians working in the private sector, joint training material has also been developed. A package for involvement
of private physicians in the Category A&B districts has been developed. Medicines are under procurement in
coloured cartons for each SpI syndrome to facilitate the management of SpI in the peripheral health facilities.

Care and Support

]overnment of India announced a policy cum programme commitment for providing free ARp with effect from 1st
April, 2004. Antiretroviral treatment (ARp) is a combination of at least 3 ARV drugs that is given to HIV infected
individuals once they reach a stage of advanced immune-suppression. At present there are 174 ARp centres in the
country. More than 1.46 lakh patients are receiving free ARp at these centres (May, 2008). In addition nearly 35,000
patients are receiving ARp in private and N]O sector. Second line ARV drugs are being provided free of cost at
Mumbai and Chennai from 2008. A total of 159 community care centres have also been established in high
prevalence states to enable PLHA to get used to ARp, to provide Counselling & follow-up advice on drug
adherence, management of opportunistic infections and Nutrition Counselling, to provide pre-ARp care for those
PLHA who are not yet on ARp through outreach and home-based services. po reduce inconvenience and indirect
expenditures of patients, 46 drug dispensing centres have been established linked to the ARp centre. By March 2009
this will increase to 250. phese link centres will require the patients to go to the ARp centres only 2 times instead of
12 as at present. Second line treatment has been introduced on a pilot basis in 2 centres and 42 persons are being
treated. By the end of this year, this is expected to be introduced in 6 centres and 3000 patients.

National Paediatric AIDS Initiative

In order to provide comprehensive Care & Support (including ARp) to children infected and affected by HIV
NACO has launched National Paediatric AIDS Initiative on 30th November, 2006. For this initiative NACO, along
with the Indian Academy of Paediatrics (IAP), UNICF, WHO and Clinton Foundation, has developed guidelines
for paediatric ARp. ARV drugs in paediatric formulations are available at all ARp centres. Number of children
receiving ARp increased from 1800 before October 2006 to 9925 in May 2008. 32,500 are reported and being
monitored. Other activities under this initiative include establishment of seven Regional Paediatric Centres, free
CD4 monitoring, free DNA PCR test for children up to 18 months, liquid formulations for babies weighing less than
5 kg, diagnosis and treatment of opportunistic infections and micro nutrient supplementation. phe initiative also
includes training of paediatricians and counsellors, establishing laboratories for diagnosis, introduction Dried Blood
Sport system to transport dried blood samples.

Care and Support for CLHA (Children Living with HIV/AIDS) orphans and vulnerable children forms an integral
part of NACP III. A comprehensive service package for these children will be funded under ]RApM-RD VI and
will be offered through home and foster based care and support services in 2007.

Condom Promotion

Condom programme is central to HIV/AIDS prevention at the intervention level. phe use of condoms is promoted as
a protection against SpIs and HIV/AIDS in addition, to Family Planning. Condom use is promoted and condoms
provided at all ICpCS and ARp centres and also the SpI clinics. In 2006, 1250 million condoms were supplied free,
604 million were distributed through social marketing while 389 million through commercial marketing. 11025
Condom Vending Machines have been installed and another 11000 are in the process of being installed. 3.5 billion
condoms are targeted to be distributed through 3 million outlets during NACP-III.
’

IEC activities

NACO is working on a communication strategy which is a shift from awareness generation to bringing about
behaviour change. NACO has focused on reduction of stigma and discrimination, promotion of services viz.,
counselling & testing, ARp, routinisation of condom use and blood safety, Special emphasis has been given to youth
and women who are more vulnerable to the HIV infection. A cadre of village level Link workers are going to be set
up in A & B category districts for focused interventions of BCC. Intensive IC among general populations has
resulted in increasing awareness of HIV/AIDS among rural populations to about 75% (BSS 2006). Under the
adolescent education program, over 1,14,345 high schools have been covered with HIV/AIDS and life skill
education programs. phe Red Ribbon xpress launched on 1.12.2007 is traversing over 180 stations and 27,000
kms. It has drawn huge crowds at all the stations. It is due to return to Delhi on 30.11.2008.

Mainstreaming

In order to reiterate the ]overnment's multi sectoral response to prevent the spread of HIV and to facilitate a strong
multi-sectoral response to combat it effectively, a National Council on AIDS (NCA) has been constituted, under
chairmanship of Hon'ble Prime Minister with representation of 33 ministries and departments. Private sector, civil
society organisation, PLHA networks and government departments would all play crucial role in prevention, care,
support, treatment and service delivery.

Financial allocation

phe details regarding allocation of funds and utilization during last three years are as follows:

Allocation Of Funds And Utilization In Rs. Crore

Sr.No. Year Funds allocated Funds utilized

1 2005-06 533.50 532.69

2 2006-07 705.67 682.63

3 2007-08 943.34 917.56

During NACP III, in order to implement the wide range of interventions indicated above, a financial resource plan
has been worked out. Overall, the plan needs an investment of Rs. 11,585 crore. Of this an amount of Rs. 8023 crore
is estimated to be provided in the budget, the rest being extra budgetary funding largely from private donations,
direct funding from bilateral and UN organisations.

India has among the highest number of persons living with HIV/AIDS in the world
today, although the overall prevalence remains low. Some states experience a
generalized epidemic with the virus transmitted from high-risk groups into the general population. A major
challenge is to strengthen and decentralize the program to the state and district levels to enhance commitment,
coverage and effectiveness.
/

STATE OF THE EPIDEMIC

phere are more than 5.1 million individuals infected with HIV in this country of over 1 billion people (UNAIDS
2003). phe total number of AIDS cases in 2002 was estimated to be about 550,000. Seven states ² Andhra Pradesh,
]oa, Karnataka, Maharashtra, Manipur, Mizoram, and Nagaland ² already have generalized epidemics, as
indicated by a 1 percent or higher prevalence rate among pregnant women in prenatal clinics. phese seven states
represent 22 percent of the population.

RISK AND VULNERABILITY

Several factors put India in danger of experiencing a rapid spread if effective prevention and control measures are
not scaled up and expanded throughout the country. phese risk factors include:

Unsafe Sex and Low Condom Use: In India, sexual transmission is responsible for 84 percent of reported AIDS
cases. HIV-prevalence rates are highest among sex workers and their clients, injecting drug users, and men who
have sex with men (many of whom are married). When surveyed, 70 percent of commercial sex workers in India
reported that their main reason for not using of condoms was because their customers objected.

Migration and Mobility: Migration for work for extended periods of time takes migrants away from the social
environment provided by their families and community. phis can place them outside the usual normative constraints
and thus more likely to engage in risky behavior. Concerted efforts are needed to address the vulnerabilities of the
large migrant population.

Injecting Drug Use (IDU): Studies indicate that many drug users are switching from inhaling to injecting drugs.
phis phenomenon is more localized in the Northeastern states of India, and injecting drug users show sharp
increases in HIV prevalence. Forty-one percent of IDUs in a national survey reported injecting with used needles or
syringes. Of those who cleaned their needles and syringes, only three percent used an effective method such as
alcohol, bleach, or boiling water. Appropriate strategies are also needed to address the double impact of drug use
and unsafe sexual practices.

Low Status of Women: Infection rates have been on the increase among women and infants in some states. As in
many other countries, unequal power relations and the low status of women, as expressed by limited access to
human, financial, and economic assets, weakens the ability of women to protect themselves and negotiate safer sex,
thereby increasing vulnerability.

Widespread Stigma: Stigma towards people infected with HIV/AIDS is widespread. phe misconception that AIDS
only affects men who have sex with men, sex workers, and injecting drug users strengthens and perpetuates existing
discrimination. phe most affected groups, often marginalized, have little or no access to legal protection of their
basic human rights. Addressing the issue of human rights violations and creating an enabling environment that
increases knowledge and encourages behavior change are thus extremely important to the fight against AIDS.

NATIONAL RESPONSE TO HIV/AIDS

Government: Shortly after reporting the first AIDS case in 1986, the ]overnment of India established a National
AIDS Control Program (NACP) which was managed by a small unit within the Ministry of Health and Family
Welfare. phe program¶s principal activity was then limited to monitoring HIV infection rates among risk
populations in select urban areas.


In 1991, the strategy was revised to focus on blood safety, prevention among high-risk populations, raising
awareness in the general population, and improving surveillance. A semi-autonomous body, the National AIDS
Control Organization (NACO), was established under the Ministry of Health and Family Welfare to implement this
program. phis ³first phase´ of the National AIDS Control Program lasted from 1992 -1999. It focused on initiating
a national commitment, increasing awareness and addressing blood safety. It achieved some of its objectives,
notably an increased awareness. Professional blood donations were banned by law. Screening of donated blood
became almost universal by the end of this phase. However, performance across states remained variable. By 1999,
the program had also established a decentralized mechanism to facilitate effective state-level responses, although
substantial variation continued to exist in the level of commitment and capacity among states. Whereas states such
as pamil Nadu, Andhra Pradesh, and Manipur demonstrated a strong response and high level of political
commitment, many other states, such as Bihar and Uttar Pradesh, have yet to reach these levels.

phe second phase of the NACP began in 1999 and will run until March 2006. Under this phase, India continues to
expand the program at the state level. ]reater emphasis has been placed on targeted interventions for high-risk
groups, preventive interventions among the general population, and involvement of N]Os and other sectors and line
departments, such as education, transport and police. Capacity and accountability at the state level continues to be a
major issue and has required sustained support. Interventions need to be scaled up to cover a higher percentage of
the population, and monitoring and evaluation need further strengthening. phe ]overnment has done away with the
classification of states based on prevalence to avoid inducing complacency among states categorized as low
prevalence, and has since focused on the vulnerability of states, hence creating a sense of urgency.

In brief, while the government¶s response has scaled up markedly over the last decade, major challenges remain in
raising the overall effectiveness of state-level programs, expanding the participation of other sectors, and increasing
safe behavior and reducing stigma associated with HIV-positive people among the population.

phe ]overnment of India is currently in the early stages of preparing for the third phase of the National AIDS
Control Program (NACP 3), for which a multi-disciplinary design team has been constituted to lead the
preparation. phe design of NACP 3 envisages a complex consultative process including nationwide consultations
with various national stakeholders, as well as international development partners.

Non-]overnmental Organizations (N]Os): phere are numerous N]Os working on HIV/AIDS issues in India at the
local, state, and national levels. Projects include targeted interventions with high risk groups; direct care of people
living with HIV/AIDS; general awareness campaigns; and care for AIDS orphans. Funding for N]Os comes from a
variety of sources: the federal or state governments of India, international donors, and local contributions.

Donors: India receives technical assistance and funding from a variety of UN partners and bilateral donors. Bilateral
donors such as USAID, CIDA, and DFID have been involved since the early 1990s at the state level in a number of
states. USAID has committed more than US$70 million since 1992, CIDA US$11 million, and DFID close to
US$200 million. phe number of major financers and the amount of funding available has increased significantly in
the last year. Since 2004, the ]ates Foundation has pledged US$200 million for the next five years, the ]lobal Fund
has approved US$26 million for Prevention of Mother-to-Child pransmission (PMpCp) and about US$7 million for
pB/HIV co-infection, and is considering another round of proposals, and USAID is considering the inclusion of
India as its 15th priority country. DFID has also increased its financing and is considering the inclusion of additional
states. Other more recent donors include DANIDA, SIDA, the Clinton Foundation and the uropean Union.

ISSUES AND CHALLENGES: PRIORITY AREAS

Limited Overall Capacity: phere are severe institutional capacity constraints, including managerial, at the national
2

and state levels. phese are critical factors to address as the program attempts to scale-up the national response.
NACO will require a change in its role and responsibilities to provide the necessary leadership and steering role for
a stronger multisector response for the next phase in India¶s fight against HIV/AIDS.

Variable Ability to Implement Responses Across States: phe capacity to mount a strong program is weakest in
some of the poorest and most populated states with significant vulnerability to the epidemic. phere is a need for
tailored capacity-building activities and the introduction of some performance-based financing approaches.

Institutional arrangements and personnel turnover: phere is a high turnover of state level project directors,
resulting in limited continuity and variability in performance across states. phis puts program growth at risk.

Donor Coordination: At present there are over 32 donor agencies working with NACO in different states and on
different programs. ach donor comes with its own mandate and requirements, as well as areas of focus. phe
transaction cost to the government as a result of attending to the various demands of the donors is huge. phere is a
need for better coordinating mechanisms among the donors and clear leadership by the ]overnment to reduce the
transaction costs.

Use of Data for Decision Making: phere remains a need for greater use of data for decision making, including
program data and epidemiological data. A lot of data that is being generated is not adequately used for managing the
program or inform policies and priorities. Results-based management and linking incentives to the use of data
should be explored.

Stigma and Discrimination: Stigma and discrimination against people living with HIV/AIDS and those considered
to be at high risk remain entrenched. A lot of this is a result of inadequate knowledge. For instance, more than 75
percent of Indians mistakenly believed they could contract HIV from sharing a meal with a person who has the
disease, according to a recent study. Stigma and denial undermine efforts to increase the coverage of effective
interventions among high risk groups such as men having sex with men, commercial sex workers and injecting drug
users. Harassment by police and ostracism by family and community drives the epidemic underground and
decreases the reach and effectiveness of prevention efforts. phough there is significant increase in awareness, due to
efforts by the government, there is much room for improvement.

Low Awareness in Rural Areas: Sentinel site behavioral surveillance, completed in 2001, showed high HIV/AIDS
basic awareness levels (82.4 percent in males and 70 percent in females). However, rural women demonstrated very
low rates of awareness in Bihar (21.5 percent), ]ujarat (25 percent), and Uttar Pradesh (27.6 percent). New
approaches need to be tried to reach rural communities with information about HIV/AIDS, safe sex and how to
prevent and treat HIV/AIDS.

WORLD BANK RESPONSE

In 1991, the ]overnment of India and the World Bank expanded their collaboration on infectious disease control
programs and by 1992 the first National AIDS Control Project was launched with a World Bank credit of US$84
million. phe project helped the government to broaden prevention efforts and to establish institutions and
procedures necessary to curb the spread of HIV/AIDS. Building upon lessons learned from the first project, India
requested World Bank financing for a follow-on project. With a World Bank credit of US$191 million, the Second
National HIV/AIDS Control Project was started and this is increasing the pace of implementation through the use of
State AIDS Societies to speed the distribution of funds at the state level.

phe Bank has also undertaken analytical work to strengthen the national response, including an analysis of the full
-

array of costs and consequences likely to result from several plausible government policy options regarding funding
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