Overview

In 2016, India had 80 000 (62 000 - 100 000) new HIV infections and 62 000 (43 000 - 91 000) AIDS-related deaths. There were 2 100 000 (1 700 000 - 2 600 000) people living with HIV in 2016, among whom 49% (40% - 61%) were accessing antiretroviral therapy.

The key populations most affected by HIV in India are:

  • Sex workers, with an HIV prevalence of 2.2%.
  • Gay men and other men who have sex with men, with an HIV prevalence of 4.3%.
  • People who inject drugs, with an HIV prevalence of 9.9%.
  • Transgender people, with an HIV prevalence of 7.2%.

Since 2010, new HIV infections have decreased by 46% and AIDS-related deaths have decreased by 22%. 

To advance towards the Fast-Track Targets and eliminate mother-to-child transmission of HIV and syphilis by 2020—as articulated in the 2017 National Health Policy—the delivery of more cost-effective and integrated HIV services is required. This scale-up is included in the recently finalized National Strategic Plan 2017–2024.


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Results
Achievements

Overview

The Joint United Nations Team on AIDS (Joint Team) reinforced its technical and financial support for the AIDS response at national, state and city levels in 2016. This support was informed by analysis of available evidence, which pointed out not only the increasing heterogeneity and dynamism of India’s many sub-epidemics, but also highlighted population specific vulnerabilities and risk behaviour.  

HIV testing and treatment

Towards making the AIDS response more comprehensive and responsive, the Joint Team collaborated with the National AIDS Control Organization (NACO) on the National AIDS Control Programme (NACP IV) Mid-term Appraisal (MTA) and initiatives to reinforce the HIV continuum of prevention to treatment and care. The Joint Team on AIDS supported the entire MTA process including the planning, coordination, development of methodology and tools, desk review and analysis of evidence and field visits. It played a key role in the analysis of data and compilation of reports. One of the recommendations from the MTA was the roll-out of community based testing and update of testing and counselling guidelines. By December 2016, India’s HIV testing and counselling (HTC) guidelines were updated—inclusive of strategies such and community based testing—and disseminated. E-modules for training of trainers are being developed so that by 2017 these can be implemented.

Following the announcement made by Government of India on World AIDS Day 2015 to raise the treatment threshold to ≤CD450, guidelines on ART initiation have been updated in June 2016. ART coverage in India has steadily increased since treatment has been introduced in 2004. As of December 2016, one million people living with HIV (PLHIV) were getting ART.

As an increasing number of PLHIV become eligible for treatment, it will be essential to expand the quality of treatment and care services, encourage early HIV testing and ensure ART adherence. The Joint Team supported efforts to establish and monitor prevention to treatment cascades for the national level and in high priority states. Advocacy was conducted at different levels on the need to fast track and closely monitors progress toward 90-90-90 targets. More granular analysis of data from different sources is undertaken to facilitate this process and promote earlier testing and enrolment in treatment.

Ensuring the regular supply of essential commodities is another important priority. In this regard, the Joint Team on AIDS supported an assessment of the Procurement and Supply Management (PSM) system and continued to provide technical support in this area to prevent stock-out of medicines and to promote efficient and sustainable PSM practices. 

Elimination of mother-to-child transmission (eMTCT)

Efforts were strengthened to prevent vertical HIV transmission. The Joint Team leveraged its partnership across two divisions of the Ministry of Health—NACO and the Reproductive and Child Health Division (RCH) - to improve the coverage and quality of eMTCT services. Progress has been observed in several states, particularly in southern India. During the fiscal year 2015-16 for instance, over 90% of all women who were tested received prevention of mother-to-child transmission (PMTCT) services. However, there is scope to reinforce efforts in certain northern and central states, where PMTCT interventions need to be further prioritised. Technical support is being provided at national and state level to strengthen maintenance of patients’ line lists and track the cohort of HIV positive pregnant women and their children at the field level. A standard cascade of key indicators is monitored through periodic review meetings held at different levels and visits to facilities for field monitoring and mentoring. The development of protocols illustrating the methodology and tools for the sub-national validation of eMTCT was also supported in 2016.

For maternal health, the Safe Motherhood Initiative launched by India’s Prime Minister in 2016 will be a key activity to further improve the quality of antenatal care. This will help in identifying and tracking high risk pregnancies including those due to HIV and Syphilis. The Joint Team actively collaborated with the Government and Professional Associations to frame the operational guidelines support the launch of the initiative and roll it out across states. 

HIV prevention among young people and key populations

To reinforce HIV prevention among youth and adolescents in the general population, the Joint Team advocated with the Ministry for Human Resource Development and secured integration of the ‘Adolescent Education Programme’ (AEP) into the new Draft National Education Policy.  The AEP is also being reviewed in specific states and findings will inform future policy and programmes. 

A main route for HIV transmission in India is unprotected sex among key populations and their clients/partners/spouses. The Joint Team support has helped finance combination prevention targeted at different key populations including female sex workers (FSW), men who have sex with men (MSM) and people who inject drugs (PWID). The prevention programme, coordinated by NACO and implemented by non-governmental organizations (NGOs) and community-based organizations (CBOs) across the country has been reviewed in the MTA with help of the Joint Team with the aim of redesigning service delivery models and interventions to achieve greater impact. 

Transgender people account for the second highest HIV prevalence out of all key population groups (7.5%). To reinforce transgender specific HIV prevention interventions, the Joint Team is supporting NACO in developing human resource and organizational capacities in 17 states with a focus on CBOs implementing prevention projects. The Joint Team also advocated and provided technical assistance for the formulation of state level Transgender Welfare Boards in five states including Chhattisgarh, Kerala, Manipur, Rajasthan and West Bengal.

HIV prevention among PWID is also prioritized as they remain the group who is most vulnerable to HIV. The Joint Team has continued to advocate for a coherent public health approach to drug use in India using the MTA and other platforms. Regarding injecting drug use specifically, more will need to be done to avert new infections among PWID by further expanding access to quality prevention and harm reduction services. Both opioid substitution therapy (OST) and needle and syringe exchange programmes have to be scaled up in high epidemic areas, especially in the North-East where injecting drug use is concentrated. The Joint Team has provided technical support to community networks/representatives to do so.

Gender inequality and gender-based violence (GBV)

Efforts will be needed to strengthen women’s access to HIV services and empower women and girls to lessen their risks of HIV infection. To promote HIV services for women, a meeting was held with gender experts and research organizations to critically look at available data and information on gendered responses, and identify issues and gaps in the National AIDS Control Programme. The outputs from this will be used for an advocacy agenda and to inform future planning.

Human rights, stigma and discrimination

Addressing stigma and discrimination against PLHIV and key populations has remained a central component of the Joint Team’s efforts. Action by national and state governments included introduction and provision of social protection for PLHIV, their families and other vulnerable populations. This is coupled with efforts for mainstreaming HIV in various ministries and government departments. 

The Joint Team is working with partners to scale up the PLHIV Stigma Index tool usage within the current grants and programmes—based on experience with use of the tool in seven states. In the reporting period it also supported community led movements and collectives of lawyers to introduce supportive legislations for PLHIV and those affected by HIV. These efforts have resulted in recognition of transgender rights through passage of the HIV Bill and Transgender Bill, respectively, in India’s Parliament.

Secretariat functions

In 2016, the Joint Team was engaged in high level dialogue with government representatives at national and state/city level on 2020 Fast-Track targets and 2030 Sustainable Development Goals (SDGs). Government counterparts have in turn expressed commitment to these targets and global goals at various national and international platforms. At the city level, collaboration is ongoing with Mumbai authorities, as part of the Fast-Track City Initiative, with a detailed situational analysis of the epidemic and response undertaken as a first step to informing city-specific planning and local resource mobilization in 2017.

After the MTA, four Working Groups (WGs) have been established to look at (i) course correction in the NACP IV prevention programme, (ii) future response design, (iii) strengthen governance, and (iv) improve key population size estimates. A High Level Committee (HLC) has also been constituted to make recommendations on the future of India’s AIDS programme. Recommendations from the WGs and HLC have been submitted to NACO for consideration in the 2017 planning process.

One of the challenges that the Joint Team identified in the 2015 Joint Programme Monitoring System (JPMS) report, and sought to overcome, was making the AIDS programme more responsive based on current epidemiologic and response contexts and needs, especially at local level. There has been progress in this regard through the work of the WGs and HLC as well as through state and district level work undertaken by members of the Joint Team on AIDS. 

For example, the Joint Programme provided technical support in 2017 to the Government and private sector for generate data on the HIV epidemic. A sample set from Integrated Counselling and Testing Centres data has been analysed and used as basis to assess HIV positivity rates among workers and inform prioritisation of workplace programmes. A study on experiences of discrimination among LGBTQ in India in multiple states has also been conducted and findings are being finalised.

Strategic information systems’ strengthening

Another MTA recommendation was a more thorough review of strengths and weaknesses of India’s strategic information systems. As a first step towards this aim, the Joint Programme with NACO and partners convened an "Expert Consultation Meeting on HIV Surveillance and Estimations” with global and regional experts participating. Key issues and recommendations have been summarized in a report and already started to be implemented for strengthening India’s strategic information systems and practices with a gradual move toward greater use of routine programme monitoring data for surveillance and for M&E of the epidemic. New data from the Integrated Biological and Behavioural Surveillance (IBBS) survey among FSW, MSM and PWID was disseminated, and their use promoted especially at the district and state level. Making a more granular use of data from different sources to identify the geographical areas in the country and key populations which are most affected by the epidemic will remain a priority in 2017.

Challenges

While there has been progress, strategic gaps remain in the response to the AIDS epidemic, impeding India’s efforts towards meeting Fast-Track targets for 2020 and 2030, including in:

  • effective and sustainable delivery of the continuum of HIV prevention to treatment and care for key populations;
  • addressing vulnerability of partners/spouses and women and young people;

Introducing innovation in how to reach out to increasingly ‘hidden’ key populations and greater community involvement in the promotion of early HIV testing, immediate enrolment in treatment and care, and adherence are critical priorities that need to be pursued with vigour to reach 90-90-90 targets by 2020 and end AIDS by 2030.  

Community-based testing was formally adopted towards the end of 2016; however it still needs to be rolled-out. ‘Test and treat’ strategies were successfully included in the Global Fund country proposal through Joint Team advocacy. It has started to be piloted in certain states, but still needs to be effectively scaled-up across the country. Technical support will need to be sustained in this area.

In order to rapidly scale-up high impact interventions towards Fast-Track targets (e.g. ‘treat-all’), investments will need to be ‘front-loaded.’ The challenge is that domestic allocation to the AIDS programme has not increased over the years. New sources of financing for the coming years, particularly post-2017, will need to be explored. Potential aspects of effective programme integration will also need to be identified as this will allow to create synergies and to ‘do more with less’.

A conducive legal environment is central to ensure the rights to health and other services for PLHIV and key populations, including non-discrimination, inclusion and social protection. While there has been momentum in advancing passage of the HIV Bill in Parliament during 2016 —as part of community led movements—and advancing transgenders rights through the Transgender Bill, they are yet to be passed by the Parliament. Support to community organizations and lawyers will need to be sustained.

A key challenge in 2014 and 2015 was the issue of medicines stock-outs and discontinuity in services on account of change in the fund flow mechanisms and delays in the release of funds from the state treasury. The issue of continuity of drug supply and HIV related services has been resolved in the short-term thanks to sustained advocacy with the Government; however, a long term solution will have to be worked out, particularly to facilitate gradual integration of HIV into health and development services.

The challenge of procurement shortfalls and concern with commodity security for drugs, diagnostics, condoms, etc. was a key concern in 2014 and 2015. With community monitoring the situation at the ground-level and advocacy with Government, the situation has significantly improved in 2016. Steps are being taken to reinforce human resource capacities on procurement and supply chain management including through formal trainings. However instances of drug stock-outs are at times reported in the media and need to be monitored so that appropriate response measures can be taken.

Key future actions

Key future actions by the Joint Team will include:

  • strengthening strategic evidence towards Fast-Track 2020 targets and 2030 SDGs through technical support for national key populations size estimates, surveillance, HIV estimates, and strengthening information management across the HIV prevention to care cascade. Conducting location-wise and population-specific situational analysis to inform local planning in selected priority states, districts and cities;
  • sustaining technical support to follow-up activities from the NACP IV MTA including the development ofa National Strategic Plan (NSP) or NACP-V in 2017 inclusive of redesign of prevention interventions with focus on key populations as well as clients/partners/spouses, and critical elements of ‘integration’. Target setting for 2020/21 in line with Fast-Track commitments;
  • sustaining technical support to the programme at national, state, district and city level on high impact interventions needed to fast-track AIDS responses among various populations. This includes roll-out of community-based testing, adoption of ‘test and treat’ policy for all population groups, and other high-impact interventions; 
  • with other development partners, developing a resource mobilization strategy to sustain the AIDS response and long-term sustainability plans for specific components of the AIDS programme - including for treatment and care, prevention, etc. – within the wider health agenda;
  • technical assistance to Government and civil society organizations for development and submission of the Global Fund New Funding Model proposal (2018-2020);
  • continuing support to civil society and community system strengthening initiatives to facilitate the task of PLHIV and key populations in their advocacy engagement, service delivery role, higher policy and legislative dialogue, internal cohesion and coordination, and facilitating their interaction with the Government;
  • sustaining support to community led advocacy for development of legislation on the rights of PLHIV and key populations including measures to address stigma and discrimination (HIV Bill, TG Bill, etc.);
  • reinforcing a multisectoral response to HIV to ensure HIV-related SDG targets can be achieved by India by 2030.
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Contact

countries_india_contact

Name: 
Bilali CAMARA
Role: 
UNAIDS Country Director