INRODUCTION India is one of the largest and most populated countries in the world, with over one billion

inhabitants. Of this number, it's estimated that around 2.4 million people are currently living with HIV.1 HIV emerged later in India than it did in many other countries. Infection rates soared throughout the 1990s, and today the epidemic affects all sectors of Indian society, not just the groups such as sex workers and truck drivers with which it was originally associated. In a country where poverty, illiteracy and poor health are rife, the spread of HIV presents a daunting challenge. HISTORY OF HIV/AIDS IN INDIA At the beginning of 1986, despite over 20,000 reported AIDS cases worldwide,2 India had no reported cases of HIV or AIDS.3 There 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: Unlike developed countries, India lacks the scientific laboratories, research facilities, equipment, and medical personnel to deal with an AIDS epidemic. In addition, factors such as cultural taboos against discussion of sexual practices, poor coordination between local health authorities and their communities, widespread poverty and malnutrition, and a lack of capacity to test and store blood would severely hinder the ability of the Government to control AIDS if the disease did become widespread.4 Later in the year, Indias first cases of HIV were diagnosed among sex workers in Chennai, Tamil 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. Gradually, 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.8 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.9 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).10 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, the National AIDS Control Programme (NACP) for HIV prevention. This plan established the administrative and technical basis for programme management and also set up State AIDS Control Societies (SACS) 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.

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 Throughout 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 aslow-risk, such as housewives and richer members of society.13 In 1998, one author wrote: HIV infection is now common in India; exactly what the prevalence is, is not really known, but it can be stated without any fear of being wrong that infection is widespread it is spreading rapidly into those segments that society in India does not recognise as being at risk. AIDS is coming out of the closet.14 In 1999, the second phase of the National AIDS Control Programme (NACP II) came into effect with the stated aim of reducing the spread of HIV through promoting behaviour change. During this time, the prevention of mother-to-child transmission (PMTCT) programme and the provision of free antiretroviral treatment were implemented for the first time.15 In 2001, the government adopted the National AIDS Prevention and Control Policy and former Prime Minister Atal Bihari Vajpayee referred to HIV/AIDS as one of the most serious health challenges facing the country when he addressed parliament. Vajpayee also met the chief ministers of the six high-prevalence states to plan the implementation of strategies for HIV/AIDS prevention.16 The third phase (NACP III) began in 2006, with the highest priority placed on reaching 80 percent of high-risk groups including sex workers, men who have sex with men, and injecting drug users with targeted interventions.17 Targeted interventions are generally carried out by civil society or community organisations in partnership with the State AIDS Control Societies. They include outreach programmes focused on behaviour change through peer education, distribution of condoms and other risk reduction materials, treatment of sexually transmitted diseases, linkages to health services, as well as advocacy and training of local groups. The NACP III also seeks to decentralise the HIV effort to the most local level, i.e. districts, and engage more non-governmental organisations in providing welfare services to those living with HIV/AIDS.18

Current estimates 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.19 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.20 In 2008 the figure was estimated to be 2.31 million.21 In 2009 it was estimated that 2.4 million people were living with HIV in India, which equates to a prevalence of 0.3%.22 While this may seem low, 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.

The HIV/AIDS situation in different states

Map of India showing the worst affected states.

The vast size of India makes it difficult to examine the effects of HIV on the country as a whole. The 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. The 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.23 The following states have recorded the highest levels of HIV prevalence at antenatal and sexually transmitted disease (STD) 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. The HIV prevalence at antenatal clinics was 1% in 2007. This figure is smaller than the reported 1.26% in 2006, but remains the highest out of all states.24 HIV prevalence at STD clinics was very high at 17% in 2007. Among high-risk 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%).25 Goa Goa, 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 STD clinic attendees was 0.18% and 5.6% respectively.26 The Goa 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.27 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 2007.28 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. These 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.29 The 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.30 However, there have been success stories in Karnataka. A prevention programme for female sex workers in three selected districts between 2004 and 2009 was associated with a drop in HIV prevalence from 25 percent to 13 percent amongst the population.31 Maharashtra Maharashtra is a very large state of three hundred thousand square kilometres, with a total population of around 97 million. The capital city of Maharashtra - Mumbai (Bombay) - is the most populous city in India, with around 14 million inhabitants. The 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, Tamil Nadu is the seventh most populous state in India. Between 1995 and 1997 HIV prevalence among pregnant women tripled to around 1.25%.35 The State Government subsequently set up an AIDS society, which aimed to focus on HIV prevention initiatives. A safe-sex campaign was launched, encouraging condom use and 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 Estimated adult HIV prevalence is the highest out of all states, at 1.57%.42 Mizoram The 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 STD clinics was 0.60% and 3.42% respectively in 2007.46 The Punjab

The Punjab, a state in northern mainland India, has shown an increase in prevalence among injecting drug users (13.8% in 2007) in recent years.47 One of the richest cities in the Punjab, Ludhiana, has an HIV prevalence of 21% among IDUs while the HIV prevalence among IDUs in the capital of the state, Amritsar, has reached 30%.48 Denis Broun, head of UNAIDS in India has stated, "the problem of IDUs has been underestimated in mainland India, as most of the problem was thought to be in the northeast."49

Who is affected by HIV and AIDS in India? People living with HIV in India come from incredibly diverse cultures and backgrounds. The vast majority of infections occur through heterosexual sex (80%), and is concentrated among high risk groups including sex workers, men who have sex with men, and injecting drug users as well as truck drivers and migrant workers. See our page on affected groups in India for more information.

HIV prevention Educating 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. This 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. Each state has its own AIDS Prevention and Control Society, which carries out local initiatives with guidance from NACO. Under the second stage of the governments 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 TV spots with a popular Indian film-star. Messages were also conveyed to young people through schools. Teachers and peer educators were trained to teach about the subject, and students were educated through active learning sessions, including debates and role-play.50

AIDS awareness banners in Sangli, India 2005

The third stage of the National AIDS Control Programme (NACP-III), was launched in 2006 and runs until 2011.51 The programme has a budget of around $2.6 billion, two thirds of which is for prevention and one sixth for treatment.52 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 Gates Foundation.53 As part of its focus on prevention, the government has 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 Condom Bindas Bol! (Condom-Just say it!), 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.54 In one unique scheme, health activists in West Bengal promoted condom use through kite flying, which is popular before the states biggest festival, Durga Puja: "The colourful kites carry the message that using a condom is a simple and instinctive act they can fly high in the sky and land at distant places where we cannot reach."55 This 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. The 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 called the 'Red Ribbon Express.'56 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.57 Following the success of the campaign, the 'Red Ribbon Express' took off for a second time in December 2009 and a third time in February 2012. The train now includes counselling and training services, HIV testing, treatment of sexually transmitted diseases (STDS) as well as HIV/AIDS education and awareness.58 Phase three of the Red Ribbon Express has a focus on reaching migrant populations who are particularly at risk of HIV. Its strategy involves using its strength as an HIV service that migrates to focus on reaching places with a high out-migration.59 According to a mid-year report on the progress of the second round of the Red Ribbon Express, NACO estimates that 3.8 million people were reached in the first six months of the campaign.60 According to NACO the 'response has been overwhelming', with queues of people waiting to access the services a common sight, and follow up surveys indicating that knowledge of transmission routes of HIV and prevention methods have increased significantly in the areas visited by the train. PMTCT In 2004 only 5 percent of pregnant women living with HIV received antiretrovirals (ARVs) to prevent mother-to-child transmission (PMTCT) in India. At least 60 percent of pregnant

women living with HIV still go without antiretroviral treatment,61 and it was estimated in 2009 that only 27 percent of HIV exposed infants received ARVs for PMTCT.62 As a result of such low coverage, thousands of children are still infected every year through mother-tochild transmission in India.63 64 Of those HIV positive pregnant women who receive ARVs for PMTCT in the country, almost all only receive single dose nevirapine, an ARV prophalaxis for PMTCT which is no longer recommended by WHO.65

Testing The general consensus among those fighting AIDS worldwide is that HIV testing should be carried out voluntarily, with the consent of the individual concerned. This view has been supported by the Indian government and NACO, who have helped to establish hundreds of integrated counselling and testing centres (ICTCs) in India. By the end of 2009 there were 5135 ICTCs in India,66 compared to just 62 in 1997.67 By 2009 these centres tested had tested 13.4 million people for HIV, an increase from 4 million in 2006.68

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 Goa and Andhra Pradesh the state governments proposed a bill in 2006 to make HIV tests compulsory before marriage, and in Punjab it has been proposed that all people wishing to obtain or retain a drivers license should be tested for HIV.69 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.70 Hospital staff and health professionals, much like the rest of the Indian population, are often unaware of the facts about HIV. This leads to unnecessary fears and, in some cases, causes them to stigmatise HIV positive people and discriminate against them, including testing them without consent. India has certainly made progress in expanding HIV testing to its large population. However, considering only 50% of those currently infected with HIV are aware of their status there is still significant work to be done in this area.71

Treatment for people living with HIV 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 limited in India; an estimated 285,000 people were receiving free ARVs in 2009.72 This, totalled with the number receiving ARVs through the private sector, amounted to 320,000 people receiving ARVs in 2009. According to NACO, this represents just over half of the adults estimated to be in need of antiretroviral treatment in India. However, according to WHO's latest treatment guidelines (2010), which recommend starting treatment earlier, revised estimates may indicate that only around 1 in 4 people in need of HIV treatment are currently receiving it.73 While the coverage of treatment remains unacceptably low, improvements are being made. The government has started to expand access to ARVs in a number of areas; by November 2009 there were 266 reported sites providing antiretroviral therapy.74 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. However coverage remains limited; of the 3,000 who needed to be on second line treatment, about 970 were receiving it as of January 2010.75 76 One reason for this is expense; second line ARV drugs, unlike first line ARVs, are not produced on a large scale in India due to patent issues that control drug pricing. Therefore, they can be 10 times more expensive than first line ARVs. Ironically, India is a major provider of cheap generic copies of ARVs to countries all over the world. However, the large scale of Indias epidemic, the diversity of its spread, and the countrys lack of finances and resources continue to present barriers to Indias antitretroviral treatment programme. The Indian government has also been criticised for not providing palliative care for HIV patients.77 To read about the challenges faced in increasing access to antiretroviral drugs around the world, see our Universal access to AIDS treatment page.

Stigma and discrimination in India In India, as elsewhere, AIDS is often seen as someone elses problem as something that affects people living on the margins of society, whose lifestyles are considered immoral. Even 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.78

A schoolteacher fired after testing HIVpositive is embraced by daughter 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,79 and in schools, teachers sometimes face negative reactions from the parents of children that they teach about AIDS: When I discussed with my mother about having an AIDS education program, she said, you learn and come home and talk about it in the neighbourhood, they will kick you. She feels that we should not talk about it.Female student, Chennai80 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. "There is an almost hysterical kind of fear ... at all levels, starting from the humblest, the sweeper or the ward boy, up to the heads of departments, which make them pathologically scared of having to deal with an HIV positive patient. Wherever they have an HIV patient, the responses are shameful."81 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.82 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.83 Stigma is made worse by a lack of knowledge about AIDS. Although a high percentage of people have heard about HIV and AIDS in urban areas (94% of men and 83% of women) this is much lower in rural areas where only 77% of men and 50% of women have heard of HIV and AIDS.84 However, the real challenge lies with ignorance about how HIV is transmitted for example the majority of men and women in rural areas believe that AIDS can be transmitted by mosquito bites.85 In 2009, NACO carried a population based survey in Nagaland, where it was shown that 72.8% of people surveyed believed HIV could be transmitted by sharing food with someone.86 To learn more about the way that prejudice is hindering the global fight against AIDS, see our Stigma and discrimination page.

Funding for the HIV epidemic in India HIV spending increased steadily in India from 2003 to 2007 but has since fallen.87 88 In 2006-2007 $171 million was spent to contain and prevent the growth of HIV, which represented an increase of 28% from the previous year.89 Currently, India spends about 5% of its health budget on HIV and AIDS.90 However, the World Bank has warned that India will have to scale up prevention efforts in order to avoid spending more of its health budget in the future. According to the World Banks report, by 2020 India will have to spend 7% of its health budget on AIDS if the rising tide of the AIDS epidemic in New Delhi, Mumbai, the north and the north east is not halted.91 This would put further strain on a struggling health sector which, on top of HIV and AIDS, faces a growing multitude of health challenges including malaria, diabetes, heart disease and cancer. Yet, in 2008-2009 spending on HIV/AIDS fell by 15% to $146 million.92

The future of HIV and AIDS in India

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.93 India's government responded by calling these figures completely inaccurate, and accused those who cited them of spreading panic.94 The government has also disputed predictions that Indias epidemic is on an African trajectory, although it claims to acknowledge the seriousness of the crisis.95 According to UNAIDS, there has been improvement over time. Between 1996 and 2010 the rate of new HIV infections fell by 56 percent.96 . This trend is mainly due to a drop in infections in southern states; in other areas there has been no significant decline.

In the north-east, the dual HIV epidemic driven by unsafe sex and injecting drug use is highly concerning. Moreover, there are many areas in the northern states where HIV is increasing, particularly among injecting drug users. Sujatha Rao, Director General of NACO97 Even if the country's epidemic does not match the severity of those in southern Africa, it is clear that HIV and AIDS will have a devastating effect on the lives of millions of Indians for many years to come. It is essential that effective action is taken to minimise this impact. The challenges India faces to overcome this epidemic are enormous. Yet India possesses in ample quantities all the resources needed to achieve universal access to HIV prevention and treatment defeating AIDS will require a significant intensification of our efforts, in India, just as in the rest of the world Peter Piot, former Executive Director of UNAIDS.98

As per the HIV Estimations 2010, India is estimated to have 23.9 lakh people infected with HIV in 2009 at an estimated adult HIV prevalence of 0.31%. Adult HIV prevalence among men is 0.36%, while among women, it is 0.25%.

India and Statewise HIV Statistics 2010

State Estimated Adult HIV Prevalence Male (%) Andaman & NicobarIslands 0.29 Andhra Pradesh 1.07 Arunachal Pradesh 0.2 Assam 0.1 Bihar 0.26 Chandigarh 0.46 Chhattisgarh 0.34 Dadra Nagar Haveli0.17 Daman & Diu 0.18 Delhi 0.35 Goa 0.58 Gujarat 0.44 Haryana 0.17 Himachal Pradesh 0.23 Jammu & Kashmir 0.09 Jharkhand 0.16 Female (%)

0.15 0.73 0.12 0.06 0.17 0.29 0.22 0.12 0.13 0.23 0.4 0.3 0.07 0.16 0.06 0.1

Karnataka Kerala Madhya Pradesh Maharashtra Manipur Meghalaya Mizoram Nagaland Orissa Puducherry Punjab Rajasthan Sikkim Tamil Nadu Tripura Uttar Pradesh Uttarakhand West Bengal INDIA

0.75 0.23 0.23 0.64 1.89 0.1 0.97 0.94 0.35 0.33 0.37 0.22 0.07 0.39 0.18 0.11 0.12 0.34 0.36

0.51 0.15 0.16 0.45 0.9 0.07 0.64 0.61 0.23 0.22 0.26 0.15 0.05 0.27 0.12 0.07 0.08 0.23 0.25

Source: http://pib.nic.in/newsite/PrintRelease.aspx?relid=67292

he following states have recorded the highest levels of HIV prevalence at antenatal and sexually transmitted disease (STD) 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, The HIV prevalence at antenatal clinics was 1% in 2007. This figure is smaller than the reported 1.26% in 2006, but is still highest out of all stales. HIV prevalence at ST D Defines was very high at 17% in 2007. Among high-risk groups, HIV prevalence was highest among men who have sex with men (MSM) (17%), followed by female sex workers (97%) and IDUs (3.7%).

Goa
Goa, 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 STD clinic attendees was 0.18% and 5.6% respectively The Goa State AIDS Control Society reported that in 2008, a record number of 26,737 people were tested for HIV of which 1,018 (3.81%) tested positive.

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. Districts with the highest prevalence tend to be located in and around Bangalore in the southern part of the state or in northern Karnatakas devadasi belt. Devadasi women are a group of women who have historically been dedicated to the service of gods. These 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. The average HIV prevalence among female sex workers in Karnataka was just over in 2007. and 17.6& of men who have sex with men were found to be infected.

Maharashtra
Maharashtra is a very large state of three hundred thousand square kilometers, with a total population of around 97 million. The capital city of Maharashtra Mum ha (Bombay) is the most populous city in India, with around M million Inhabitants. The HIV prevalence at antenatal clinics in Maharashtra was 0.5% in 2007. At 18%, the state has the highest reported rates of HIV prevalence among female sex workers. Similarly high rates were found among injecting drug users {24%) and men who have sex with men (12%) (Nagelkerke, 2002).

Tamil Nadu

With a population of over 66 million, Tamil Nadu is tire seventh most populous state in India. Between 1995 and 1997 HIV prevalence among pregnant women tripled to around 1.25%. The State Government subsequently set up an AIDS society, which aimed to focus on HIV prevention initiatives. A safe sex campaign was launched, encouraging condom use and attacking the stigma and ignorance associated with HIV. Between 1996 and 1998 a survey showed that the number of men reporting high-risk sexual behavior had deceased In 2007 HIV prevalence among antenatal clinic attendees was 0 25%, HIV prevalence among injecting drug users was 16.8W 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.

Manipur
Manipur is a small state of some 2-4 million people in northeast India. Manipur borders Myanmar (Burma), one of the worlds largest producers of illicit opium In the early 1980s drug use became popular in northeast India and it wasnt king before HTV was reported among injecting drug users in the legion, although NACO report a slate-wise HIV prevalence of 17.9% among IDUs, studies from different areas of the state find prevalence to be as high as 32%. 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 0.7S% in 20D7, estimated adult HIV prevalence is the highest out of all states at 1.57%.

Mizoram
The Small north eastern State Of Mizoram has fewer than a million inhabitants. In 1598, an HIV epidemic took off quickly among the states male injecting drug users, with some drug clinics registering HIV rates of more than 70% among their patients. In recent years the average prevalence among this group has been much lower, at around 3.7%, HIV prevalence at antenatal clinics was 0 75% in 2007.

Nagaland

Nagaland is another small north eastern state where injecting drug use has again been the driving force behind the spread of HIV, In 003 HIV prevalence among IDUs was 8.43%, but has since declined to 1.91%. in 2007, HIV prevalence at antenatal clinics and STD clinics was 0.60% and 3,42% respectively in 2007.

Punjab
Punjab, a state in northern mainland India, has shown an increase in prevalence among injecting drug users (13.8% in 2007) in recent years. One of the richest cities in the Punjab, Ludhiana, has an HIV prevalence of 21% among IDUs. Denis Broun, head of UNAIDS in India has staled the problem of IDUs has been underestimated In mainland India, as most of the problem was thought to be in the northeast. India being the fourth largest country with people affected with AIDS, it has established medical centers and awareness campaigns throughout the nation in order to get rid of AIDS, the fatal disease.

gujarat
HIV/AIDS Statewise statistics India 2010
As per the HIV Estimations 2010, India is estimated to have 23.9 lakh people infected with HIV in 2009 at an estimated adult HIV prevalence of 0.31%. Adult HIV prevalence among men is 0.36%, while among women, it is 0.25%. India and Statewise HIV Statistics 2010 State Estimated Adult HIV Prevalence Male (%) Female (%) Andaman & NicobarIslands 0.29 0.15 Andhra [...]

References

Nagelkerke, N. J (2002). Modeling HIV/AIDS epidemics in Botswana and India: impact of interventions to prevent transmission, SAGE, London

National Family Health Survey 2005-2006, HIV statistics

The National Family Health Survey, conducted between 2005 and 2006, measured HIV prevalence among the general adult population of India, as presented in the table below.6 The survey found HIV prevalence among men to be considerably higher than that among women.

H Age group 15-19 20-24 25-29 30-34 35-39 40-44 45-49 Total age 15-49 Male 0.01 0.19 0.43 0.64 0.53 0.41 0.48 0.36

The National Family Health Survey, which tested more than 100,000 people for HIV, also found prevalence to be higher in urban areas (0.35%) than in rural areas (0.25%).

IDS
Acquired Immuno-Deficiency Syndrome or AIDS is a life threatening disease, which is a major cause of concern for the government. As of now, AIDS does not have a known scientific cure, so it is important that people be educated about prevention strategies.

Preventive Steps
Here are a few steps that can help check the spread of HIV AIDS:

Safe sex: It will just take a single episode of unprotected sex with an infected partner for HIV to be passed. Therefore safer sex, which would imply use of condoms, is the best way to protect oneself from AIDS. Using clean needles will prevent the risk of infection through injecting drug use. The HIV positive mothers can minimize the risk of passing on the infection to the baby by going for a caesarean birth, not breast feeding the child and using anti-retroviral therapy. It is important that every one should spread AIDS awareness and the methods that need to be followed to check its spread.

NATIONAL AIDS CONTROL PROGRAMME

Introduction

Human Immunodeficiency Virus (HIV) is a lanti virus that belongs to the retroviruses group may cause HIV infection/AIDS. Acquired Immunodeficiency Syndrome (AIDS) has emerged as one of the most serious public health problem in the country after reporting of the first case in 1986. The initial cases of HIV/AIDS were reported among commercial sex workers in Mumbai and Chennai and injecting drug users in the north-eastern State of Manipur. The disease spread rapidly in the areas adjoining these epicentres and by 1996 Maharashtra, Tamil Nadu and Manipur together accounted for 77 percent of the total AIDS cases. Out of these, Tamil Nadu reporting almost half the number of cases in the country. However, the overall prevalence in the country is very low, as compared to many other countries in the Asia-Pacific region.

Burden of Disease World

According to UNAIDS/WHO estimates, 11 men, women and children were infected per minute during 1998. More than 95% of all HIV-infected people now live in developing world.

India

The trends of HIV infection in India are alarming. Following characteristics of the AIDS epidemic have been observed:

In the recent years it has spread from urban to rural areas and from individuals practicing risk behaviour to the general population. More and more women attending antenatal clinics are being found testing HIVpositive thereby increasing the risk of perinatal transmission. One in every 4 cases of HIV positive reported is a woman. About 84% of the infections occur through the sexual route (both heterosexual and homosexual). Other roots of transmission are blood transmission, injectable drug use and perinatal transmission. Another 4% through injecting drug use. About 80% of the reported cases are occurring in sexually active and economically productive age group of 15-44 years. HIV positive in antenatal clinic varied from 0% in Assam to 1.71% in Maharashtra. The average prevalence work out as a low 0.7% but with more than 500 million adult in the country. NACO calculates that 4.8 million people are infected.

Attributable factors of the HIV spread are:

1. Labour migration and mobility in search of employment from economically backward to more advanced regions; 2. Low literacy levels leading to low awareness among the potential high risk groups; 3. Gender disparity; 4. High prevalence of Sexually Transmitted Infections and Reproductive Tract Infections both among men and women; 5. The social stigma attached to sexually transmitted infections also hold good for HIV/AIDS, even in a much more serious manner. This coupled with lack of awareness results in reporting of full-blown AIDS cases in cities like Mumbai and Chennai; 6. There have been cases of refusal of AIDS patients in hospitals and nursing homes both in Government and private sectors. This has compounded the misery of the AIDS patients; 7. Isolation of AIDS cases in the wards creates a scare among the general patients; 8. At some occasions, discrimination at workplace leads to loss of employment; 9. The treatment options are still in the trial stage and too expensive; 10. Still no effective vaccine is available; 11. Multi-drug protease inhibitor therapy, popularly known as 'cocktail therapy', helps only in prolonging the life of the patient. There are fears of patients developing drug resistance and side effects if the therapy is not administered under proper medical supervision; 12. There were instances of quacks taking advantage of the situation and promising cure through so-called herbal treatment providing only false assurances;

13. Existence of a large number of unlicensed small and medium blood banks in the private sector has also compounded the problem; 14. The twin problem of drug addiction and HIV transmission raise a serious ethical and moral issues in the Needle exchange programmes and condom distribution as legally no person should take drug or should go to prostitutes; 15. Although transmission of HIV through use of needles, razors and other cutting instruments in the thousands of beauty parlors, hair-cutting saloons is insignificant, lack of hygiene practices in majority of these establishments also poses a health risk to the unsuspecting general population who visit these places every day; 16. There is also a twin challenge of HIV/TB infection. Nearly 60% of the AIDS cases are reported to be opportunistic TB infection cases. Treatment of TB among the HIVinfected persons is a new challenge to the National TB Control Programme. Some of the anti tubercular drugs recommended for TB treatment pose complications in cases of HIV-infected persons, e.g. thiacetazone can cause skin eruptions. There is no risk of HIV from any TB patient unless he or she practices high risk behaviour or gets infected from transfusion of HIV-infected blood; 17. Inadequate understanding of the serious implications of the disease among the legislators, political and social leaders, bureaucracy, media, leaders of trade and industry and even among medical and paramedical personnel engaged in provision of health care; 18. Difficulty in identifying, reaching, and covering risk groups for interventions; 19. Poor involvement of NGOs due to Borrower's and recipients' non-familiarity with guidelines and project processing requirements; 20. Vacant posts frequent transfers, holding of dual charges, and changes in staffing patterns is again major hurdle in implementation of preventive programme strategies; 21. Lack of uniformity in the processes of disbursement of funds in various states; and 22. Large segment of civil society did not acknowledge HIV as a priority in the early 1990s and were critical of the Central Government and the World Bank for drawing attention towards HIV/AIDS.

National AIDS Control Programme Phase - I (1992-99)

During this phase, the National AIDS Control Project was developed for prevention and control of AIDS in the country.

Project Objectives

The ultimate objective of the project was to slow the spread of HIV to reduce future morbidity, mortality, and the impact of AIDS by initiating a major effort in the prevention of HIV transmission. The specific objectives were:

(a) Involve all States and Union Territories in developing HIV/AIDS preventive activities with a special focus on the major epicenters of the epidemic; (b) Attain a satisfactory level of public awareness on HIV transmission and prevention;

(c) Develop health promotion interventions among risk behaviour groups; (d) Screen all blood units collected for blood transfusions; (e) Decrease the practice of professional blood donations; (f) Develop skills in clinical management, health education and counseling, and psychosocial support to HIV seropositive persons, AIDS patients and their associates; (g) Strengthen and control of Sexually Transmitted Diseases (STD); and (h) Monitor the development of the HIV/AIDS epidemic in the country.

Achievement of Phase I

1. Awareness levels that were almost insignificant have increased to about 70-80% in urban areas even though the level of awareness in rural areas remains low at about 30%; 2. Modernisation and strengthening of blood banks; 3. Introduction of licensing system of blood banks and gradual phasing out of professional blood donors; and 4. Availability of good quality condoms through social marketing has made a significant increase in its use.

National AIDS Prevention and Control Policy (NAPCP) 2002

The NAPCP 2002 has been announced with the aim of bringing AIDS transmission at zero level by 2007. 1. Prevention of further spread of the disease by making the people at large and specially the high-risk groups aware of its implications and provide them with necessary tools for protecting themselves from getting infected. Control of Sexually Transmitted Diseases among sexually active and economically productive groups together with promotion of condom use a measure of prevention from HIV infection will be the most important component of the prevention strategy; 2. To provide an enabling socioeconomic environment so that individuals and families affected with HIV / AIDS can manage the problem; and 3. Improve services for the care of People Living With AIDS (PLWA) in times of sickness both in hospitals and at homes through community health care. For this purpose the policy addresses the following components of the national AIDS control programme for bringing in a paradigm shift in the response to HIV / AIDS at all levels both within and outside the Government:

A. Programme Management

National State Empowered State B.

AIDS Level AIDS Advocacy & Control Social

Committee Strengthening Committee Societies Mobilisation

Participation of Non-Governmental Organisational/Community Based Organisations Counseling C. HIV Research D. People E. F. G. Policy for Blood Safety
National AIDS Control Programme Phase II (1999-2004)

Surveillance,

Monitoring

&

Research Testing Development Intervention

& Target Living Sexually Transmitted Condom With Disease AIDS Control

(PLWAs) Programme Programme

The Phase II of the National AIDS Control Programme has become effective in 1999. It is a 100% Centrally sponsored scheme implemented in 32 States/UTs and 3 Municipal Corporations namely Ahmedabad, Chennai and Mumbai through AIDS Control Societies.

Aims of Phase II

1. To shift the focus from raising awareness to changing behaviour through interventions, particularly for groups at high risk of contracting and spreading HIV; 2. To support decentralisation of service delivery to the State and Municipalities and a new facilitating role for National AIDS Control Organisation. Program delivery would be flexible, evidence-based, participatory and to rely on local programme implementation plans; 3. To protect human rights by encouraging voluntary counseling and testing and discouraging mandatory testing; 4. To support structured and evidence-based annual reviews and ongoing operational research; and 5. To encourage management reforms, such as better managed State level AIDS Control Societies and improved drug and equipment procurement practices. These reforms are proposed with a view to bring about a sense of 'ownership' of the programme among the States, Municipal Corporations, NGOs and other implementing agencies.

Key Objectives

A. To reduce the spread of HIV infection in India; and B. Strengthen India's capacity to respond to HIV/AIDS on a long-term basis.
Project Strategies

A. Delivery of cost-effective Interventions against HIV/AIDS. 1. Priority targeted intervention for groups at high risk 2. Preventive Intervention for the general community a). IEC and awareness campaigns. b). Providing voluntary testing and counseling. c). Reduce transmission by blood transfusion and occupational exposure. 3. Low cost AIDS care.

B. Strengthen Capacity 1. Institutional strengthening a). Building implementation capacity at the States and Municipal levels b). Strengthening leadership capacity of NACO c). Expand and improve nationwide STI/HIV/AIDS sentinel surveillance d). Training e). Build capacity for monitoring and evaluation programme activities. f). Increase India's capacity for research on HIV/AIDS 2. Intersectoral Collaboration Procurement Arrangements Indigenous System of Medicine (ISM) Monitoring and Evaluation of the Programme Financial Management System

NACO
National AIDS Control Organisations work and programme evolve and revolve around its twin objective of bringing about HIV prevention and providing treatment to people living with HIV. In this mission, NACO establishes an interface with the health service organisations through meetings, seminars and training programmes in sensitising and training healthcare providers, and augmenting services for prevention and treatment ofHIV/AIDS. Through the State AIDS Prevention and Control Societies (SACS) and various NGOs, NACO guides prevention programme at state, district and village level that reaches out to health workers, high risk groups, bridge population andgeneral people, particularly women. To improve the visibility and acceptance of its prevention messages NACO seeks active participation of public idols and political leaders. Over the years, it has developed innovative means to spread awareness and bring about behaviour change among various high risk groups. NACO also works with various school education boards in reaching out HIV education and life skills to highly vulnerable adolescent population of the country. It is also working with various government organisations in spreading the message of prevention and addressing the vulnerability of the personnel.