Health care systems in transition III. India, Part II. The current status of HIV-AIDS in India.

The human immunodeficiency virus (HIV) continues to spread around the world, into communities previously little troubled by the epidemic, while also strengthening its grip on areas where acquired immunodeficiency syndrome (AIDS) has become the leading cause of death in adults. In addition, the HIV pandemic has become concentrated in the developing world, mostly in countries least able to afford to care for HIV-infected people. In India, the HIV–AIDS epidemic is now more than 13 years old. Within this short period, it has emerged as one of the most serious public health problems in the country. The first cases of HIV–AIDS in India were reported amongst commercial sex workers in Mumbai and Chennai and injecting drug users (IDUs) in the northeastern states of India. The epidemic has spread rapidly in the areas adjoining these epicentres. By 1997, Maharashtra, Tamil Nadu and Manipur together accounted for over three-quarters of AIDS cases and over two-thirds of HIV infections in India, with Maharashtra reporting almost half the number of cases in the country. Even though the officially reported numbers of cases of HIV infections and AIDS cases are only in the thousands, it is acknowledged that a wide gap exists between the reported and actual cases. The reported cases represent the tip of the iceberg, partly because it is not compulsory to report HIV cases either to the National AIDS Control Organization (NACO) or to state health officials. One conservative estimate of the HIV-infected population in India indicates that 1.5 per cent of the 1 billion Indian population, or 11.5 million individuals in 1997, are already infected with HIV, which makes India the country with the largest number of HIV-infected people in the world. Recent testing of pregnant women in Pondicherry has shown infection rates of around 4 per cent. Amongst truck drivers in the southern states of Madras, HIV prevalence quadrupled from 1.5 per cent in 1995 to 6.2 per cent in 1996. In the northeastern states of Manipur and Nagaland, the major route of transmission of HIV is through needle sharing among IDUs. Here, heroin is smuggled into India from the opium-cultivating regions of Thailand, Laos and Myanmar. This area contains populations who share languages and culture, and who can move freely across international borders. Among the estimated 15 000 IDUs in Manipur, the seroprevalence of HIV increased from zero to 50 per cent within 6 months during 1989–1990. HIV has now also spread to the general population from the IDUs and 1 per cent of antenatal mothers were found to be HIV seropositive in 1991. The nationwide sentinel surveillance data collected in February–March 1998 confirmed that HIV infection is now prevalent in all parts of the country and has spread from urban to rural populations and from individuals involved with high-risk behaviour to the general population. In Mumbai, 2–4 per cent of pregnant women have tested positive for HIV in public hospitals. The women at greatest risk are commercial sex workers and sexual partners of men involved with high-risk behaviour. Indeed, in most prenatal clinics in India, the HIVinfected woman’s major risk factor is having had sex with her husband. Studies indicate that more and more women attending antenatal clinics are testing HIV positive, thereby increasing the risk of perinatal transmission.