|Year : 2018 | Volume
| Issue : 2 | Page : 138-142
HIV prevalence trend from HIV sentinel surveillance over a decade in India: An overview
Bhavna Sangal, Pradeep Kumar, Neeraj Dhingra
Strategic Information Management Unit, National AIDS Control Organisation, Ministry of Health and Family Welfare, New Delhi, India
|Date of Web Publication||14-Jun-2018|
Innsbrucker Street 36, 10825, Berlin
Source of Support: None, Conflict of Interest: None
| Abstract|| |
We aim to describe trends in antenatal HIV prevalence in India, at a national and regional level from consistent sentinel surveillance sites (2003–2015) among Antenatal Clinic (ANC) attendees. Data were analyzed from a total of 1,885,207 ANC attendees recruited at ANC sites. The consistent sites were grouped by years of initiation (Group 1: 2003–2005 and Group 2: 2006–2008) and according to six regions. Chi-square test for linear trend was applied to test the statistical significance of the trend. Nationally, at Group 1 sites, HIV prevalence was 0.93% in 2003, which declined to 0.36% in 2015 (P < 0.001). Similarly, at Group 2 sites, prevalence ranged from 0.25% to 0.23% during 2006–2015 (P > 0.05). The findings suggest that HIV is conclusively declining at old sites, nationally as well as in most of the other regions but increasing in the northern region. At newer sites, the conclusive declining trend is evident only in the southern region. National AIDS response must consider these variations to allow locally appropriate responses to the epidemic.
Keywords: HIV, India, sentinel, surveillance, survey
|How to cite this article:|
Sangal B, Kumar P, Dhingra N. HIV prevalence trend from HIV sentinel surveillance over a decade in India: An overview. Indian J Public Health 2018;62:138-42
|How to cite this URL:|
Sangal B, Kumar P, Dhingra N. HIV prevalence trend from HIV sentinel surveillance over a decade in India: An overview. Indian J Public Health [serial online] 2018 [cited 2020 Jun 2];62:138-42. Available from: http://www.ijph.in/text.asp?2018/62/2/138/234497
India has one of the world's largest, robust, and fully functional HIV Surveillance Systems., HIV Surveillance in India was initiated in 1985, even before detection of the first case of HIV in the country, by the Indian Council of Medical Research to search for HIV infection in the country. The surveillance networks were gradually expanded, and as India started to formulate its response toward the HIV epidemic, HIV sentinel surveillance (HSS) was implemented in 1995 at 52 sentinel sites. HSS was formalized in the form of annual system in 1998 at 180 sentinel sites; since then, surveillance network has gradually expanded by almost eightfold,, with 89% of 640 districts having at least one sentinel site in 2015 round of HSS., As the surveillance sites were expanded, a strong institutional framework for training, monitoring, and supervision was established in the form of nodal and regional institutes; stringent laboratory system was put in place for specimen testing.
Over the years, HIV prevalence data generated through HSS have not only been used to track the magnitude and direction of the epidemic at the national and subnational level and in different population groups, but have also been used extensively for burden estimations, resource allocation as well as impact assessment of HIV/AIDS response., The focused interventions provided rich dividends as India compared globally toward halting and reversing the HIV/AIDS epidemic.
Pregnant women attending Antenatal Clinic (ANC) is one of the population groups covered under HSS in India since the beginning of annual HSS. HSS at ANC sites was done at 776 sites during the 14th round of HSS in India, in 2015. Tracking HIV prevalence among pregnant women has been considered a good proxy for tracking HIV/AIDS epidemic in general population., In this study, we report HIV prevalence levels at a national and subnational level from ANC HSS sites over 12 years to present time trend and regional differences in India. The methodology of ANC HSS has been described in detail elsewhere.,,
In the current analysis, we have defined consistent sites as those sites which have been included in at least four rounds of surveillance during 2003–2015. Surveillance sites were first expanded in high prevalence pockets which were mostly in urban areas (till 2005) and then gradually expanded to cover almost all of the country including the initiation of sites in rural areas (till 2008). Accordingly, consistent sites since 2003–2005 were grouped into one category (Group 1); sites which were consistent since 2006–2008 have been grouped into another category (Group 2). To analyze trends over time at the regional level, we grouped the consistent sites into six geographical regions, that is, North (Delhi, Haryana, Jammu and Kashmir, Punjab, Himachal Pradesh, Rajasthan, Chandigarh, and Uttarakhand); Central (Chhattisgarh, Madhya Pradesh, and Uttar Pradesh); East (Jharkhand, Andaman and Nicobar Islands, Bihar, Odisha, and West Bengal); North East (Arunachal Pradesh, Assam, Manipur, Mizoram, Meghalaya, Nagaland, Sikkim, and Tripura); West (Goa, Gujarat, Daman and Diu, Dadra and Nagar Haveli, and Maharashtra), and South (Andhra Pradesh, Karnataka, Kerala, Tamil Nadu, Puducherry, and Telangana). Overall, a total of 1,336,386 ANC clinic attendees were recruited at 383 sites consistent since 2003–2005 (old sites) in various rounds of surveillance till 2015. At sites consistent since 2006–2008 (new sites), another 548,821 ANC clinic attendees were recruited in different rounds of HSS till 2015. Thus, the analysis is based on a pooled sample size of 1,885,207 recruited under nine rounds of surveillance.
Seroprevalence, the key outcome measure for each year from the consistent sites, was calculated as P = x/n, where x is the total number of ANC attendees recruited in HSS and tested HIV reactive at consistent sites and n is the total number of ANC attendees recruited in HSS and tested for HIV at consistent sites. We calculated the 95% confidence interval (CI) for seroprevalence using the standard formula based on the binomial and normal theory method. Chi-square test for linear trends using Centers for Disease Control and Prevention (CDC) Epi Info version 3.5.1 (Atlanta, Georgia, US) was applied to test the statistical significance of HIV prevalence trend over the years.
| HIV Prevalence Trend at the National Level|| |
A total sample size of pregnant women recruited under HSS in Group 1 consistent sites ranged from 139.7 thousand to 151.6 thousand in various rounds of surveillance during 2003–2015 [Table 1]. The prevalence of HIV was 0.93% (95% CI: 0.88%–0.98%) in 2003, which declined significantly from 0.65% (CI: 0.61%–0.69%) in 2007 to 0.36% in 2015 (P < 0.001). At Group 2 sites, total recruitment of pregnant women ranged from 69.9 thousand to 99.3 thousand in various rounds of surveillance during 2006–2015. The prevalence at these sites ranged from 0.25% (CI: 0.21%–0.29%) to 0.23% (CI: 0.20%–0.26%) during 2006–2015 (P = 0.19).
|Table 1: HIV prevalence trend at the national level among antenatal clinic attendees (original)|
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| HIV Prevalence Trend at the Regional Level|| |
Group 1 sites
A significant rising trend of HIV prevalence was seen in northern India, from 0.16% (CI: 0.09%–0.23%) in 2003 to 0.33% (CI: 0.23%–0.44%) in 2015 among ANC clinic attendees with a considerable increase visible from 2007 onward. In the central part of India also, trends were observed to be statistically significantly, declining from 0.43% (CI: 0.32%–0.55%) in 2003 to 0.16% (CI: 0.09%–0.22%) in 2015. A similar declining trend of HIV prevalence was observed in Northeast India, from 1.19% (CI: 1–1.39) in 2003 to 0.73% (CI: 0.59–0.88) in 2015. In the Eastern part of the country, HIV prevalence was observed to be rising from 0.25% (CI: 0.15%–0.34%) in 2003 to 0.33% (CI: 0.22%–0.44%) in 2015, but the trend was not statistically significant. A declining trend of HIV prevalence was observed in Southern India, from 1.20% (CI: 1.11–1.29) in 2003 to 0.34% (CI: 0.30–0.38) in 2015 (P < 0.001). Similar trends were seen in the Western (from 1.03% in 2003 to 0.35% in 2015) states with decline from 1.03% (CI: 0.92–1.14) in 2003 to 0.35% (CI: 0.28–0.41) in 2015 (P < 0.001). The trend was found to be statistically significant in both the regions [Figure 1].
|Figure 1: Statistical Significance (using P value) of the region-wise trends based on 561 consistent sites among 35 States/UTs based on Antenatal Clinic HIV sentinel surveillance Data from 2003 to 2015 (original).|
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Group 2 sites
In the northern and the central regions, HIV prevalence trend was observed to be stable from 2006 to 2015; however, the trend was not significant. On the other hand, in the Eastern and the Western regions, the trend was observed to be declining; however, it was also not statically significant. In the Southern (from 0.83% [CI: 0.54–1.13] in 2007 to 0.29% [CI: 0.15–0.43] in 2015, P < 0.001) and the Eastern (from 0.30 [CI: 0.22–0.38] in 2006 to 0.21 [CI: 0.16–0.27] in 2015, P < 0.008) regions the observed decline in prevalence was statistically significant.
| Achievements and the Way Forward|| |
The present analysis is the first to compare the prevalence of HIV across different regions and at the aggregate level using data from nine rounds of surveillance among ANC clinic attendees. The declining trend, at sites consistent since 2003–2005, has not only been observed at the national level but also in all of the regions except for the East. The decline is quite prominent in the Southern, Western, and Northeastern states that included states such as Andhra Pradesh, Karnataka, Tamil Nadu, Maharashtra, Manipur, and Nagaland; states which were labeled as having a generalized epidemic at the beginning of the 21st century., In the southern states, the decline has been predominant even at relatively newer consistent sites, situated largely at sub-district hospitals and in rural areas, indicating toward an overall reduction in the epidemic in the region. It is a significant achievement, especially when viewed in the context that world was fearing that Indian HIV/AIDS epidemic is on African trajectory and country response to the HIV/AIDS epidemic is not enough to turn around the epidemic. The decline noticed in the region is consistent with the estimated trends in prevalence and incidence in the region derived from the globally recommended HIV burden estimation methods. While the success in the high prevalence pockets has been well demonstrated, the same is not as evident in the low-prevalence pockets; bringing the prevalence substantially down from these levels will be much more challenging. However, as India gears for ending AIDS epidemic as a public health threat by 2030 as a part of sustainable development goal, the imminent need to scale up the current momentum of interventions in low prevalence states cannot be underestimated. Further, the heterogeneity in the national and regional epidemic scenario necessitates the implementation of tailored interventions to address the determinants of HIV informed by analysis of local risks operating at various levels.
We thank Dr Srinivas Venkatesh, Deputy Director General, National AIDS Control Organisation, Dr. Om Prakash, Scientist F, National JALMA Institute of Leprosy and other microbial infections, Agra, Uttar Pradesh, India, Dr Yujwal Raj Former National Programme Officer, NACO, and Shreena Ramnathan for the intellectual inputs given by them during preparation of the draft.
Financial support and sponsorship
Conflicts of interest
The authors alone are responsible for the views expressed in this article and they do not necessarily represent the decisions, policy or views of the National AIDS Control Organisation.
| References|| |
García Calleja JM, Jacobson J, Garg R, Thuy N, Stengaard A, Alonso M, et al.
Has the quality of serosurveillance in low- and middle-income countries improved since the last HIV estimates round in 2007? Status and trends through 2009. Sex Transm Infect 2010;86 Suppl 2:ii35-42.
Lal S. Surveillance of HIV/AIDS epidemic in India [editorial]. Indian J Community Med 2003;28:5.
Reddy DC. Surveillance and estimation of HIV in India a critical appraisal. Health Millions 2007;33:25-9.
Kant S, Goswami K, Rai SK, Dar L, Misra P. Quality assurance of annual HIV sentinel surveillance 2006: Experience of regional institute, central zone. Indian J Public Health 2007;51:28-32.
] [Full text]
Pandey A, Reddy DC, Ghys PD, Thomas M, Sahu D, Bhattacharya M, et al.
Improved estimates of India's HIV burden in 2006. Indian J Med Res 2009;129:50-8.
] [Full text]
Sgaier SK, Claeson M, Gilks C, Ramesh BM, Ghys PD, Wadhwani A, et al.
Knowing your HIV/AIDS epidemic and tailoring an effective response: How did India do it? Sex Transm Infect 2012;88:240-9.
Walker N, Garcia-Calleja JM, Heaton L, Asamoah-Odei E, Poumerol G, Lazzari S, et al.
Epidemiological analysis of the quality of HIV sero-surveillance in the world: How well do we track the epidemic? AIDS 2001;15:1545-54.
Bhattacharya M. Annual sentinel surveillance for HIV infection – Issues and challenges. Indian J Public Health 2007;51:22-7.
] [Full text]
Mahal A, Rao B. HIV/AIDS epidemic in India: An economic perspective. Indian J Med Res 2005;121:582-600.
Chandrasekaran P, Dallabetta G, Loo V, Rao S, Gayle H, Alexander A, et al.
Containing HIV/AIDS in India: The unfinished agenda. Lancet Infect Dis 2006;6:508-21.
Rao JV, Ganguly NK, Mehendale SM, Bollinger RC. India's response to the HIV epidemic. Lancet 2004;364:1296-7.