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EDITORIAL
Year : 2020  |  Volume : 64  |  Issue : 5  |  Page : 1-3  

Evidence generation to strategize India's response to HIV: Journey so far and challenges ahead


Member, Advisory Board, IJPH, Former National Professional Officer, WHO, New Delhi; Former Professor and Head, Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Submission19-Feb-2020
Date of Decision08-Mar-2020
Date of Acceptance15-Mar-2020
Date of Web Publication14-Apr-2020

Correspondence Address:
Dandu Chandra Sekhar Reddy
Member, Advisory Board, IJPH, Former National Professional Officer, WHO, New Delhi; Former Professor and Head, Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_124_20

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How to cite this article:
Reddy DC. Evidence generation to strategize India's response to HIV: Journey so far and challenges ahead. Indian J Public Health 2020;64, Suppl S1:1-3

How to cite this URL:
Reddy DC. Evidence generation to strategize India's response to HIV: Journey so far and challenges ahead. Indian J Public Health [serial online] 2020 [cited 2020 Jul 14];64, Suppl S1:1-3. Available from: http://www.ijph.in/text.asp?2020/64/5/1/282410



India's fight with HIV epidemic is more than three decades old and has come a long way in its response to prevent HIV and mitigate its impact on people living with HIV. Besides political will and able leadership, evidence-based planning and rational resource allocation have been key factors for the success of India's response. Evidence gathering, started with screening of people at risk of HIV, has evolved over time into an amalgam of strategic information encompassing many different data sources and analytical methods and come to be hailed as a critical input for India's response.[1]


   The Beginning Top


Origins of today's strategic information go back to screening of people at risk to monitor the entry of HIV into India, which was started by the Indian Council of Medical Research (ICMR) at the National Institute of Virology, Pune, and Virology Research Center, Christian Medical College, Vellore, in 1985,[2] well before the first indigenous case of HIV was reported from Chennai[3] and an AIDS case (imported) from Mumbai[2] in 1986. Identification of indigenous HIV case led to setting up of National Aids Committee by the Ministry of Health and Family Welfare, Government of India, and establishment of HIV serosurveillance by ICMR in 43 screening and five confirmatory centers in the same year. Evidence emerging from this initiative established the presence of asymptomatic HIV infection among high-risk populations in the entire country, mainly in urban areas. This led to the World Bank-supported “Medium Term Plan” with an urban focus in 1987.[4] Another significant finding, emerging from this serosurveillance, was the report of HIV infection among injecting drug users from Manipur indicating that India has multiple heterogeneous epidemics.[5] Nationwide spread of HIV culminated in the launch of Phase I of National AIDS Control Program (NACP-I) in 1992.[2] Considering that sound evidence is sine qua non for effective response to the epidemic, the HIV sentinel surveillance (HSS) was initiated across the country among attendees of antenatal clinics and sexually transmitted disease clinics in the same year, adopting the approach advocated by the Global Program on AIDS in African countries with “generalized epidemics.”[6] In 1998, before the start of Phase II of NACP, HSS was expanded to 180 sites and started surveillance among people who inject drugs, female sex workers (FSW), and men who have sex with men (MSM, only one site) by the National AIDS Control Organization (NACO).[7]


   Prevalence and Trends of Hiv Top


Later half of the 1990s marked a shift in monitoring the epidemic in India. The recognition that India had multiple heterogeneous epidemics, mainly “concentrated” in most-at-risk populations (MARPS), necessitated better understanding in terms of drivers of the epidemic and behaviors that facilitate them. This led to the adoption of the second generation surveillance advocated by the Joint United Nations Programme on HIV/AIDS (UNAIDS),[8] which comprises sentinel surveillance of HIV and sexually transmitted infections, AIDS case reporting, behavioral surveillance surveys (BSS), and mapping and size estimation of MARPs. First BSS was undertaken in the state of Tamil Nadu by the AIDS Prevention And Control Project (APAC) supported by the United States Agency for International Development.[1] Another important development during this period was state-wise estimation and projection of HIV infection since 1998. Further, the states were categorized based on the HIV prevalence in pregnant women as high (≥1.0%; Andhra Pradesh, Karnataka, Maharashtra, Manipur, Nagaland, and Tamil Nadu), moderate (≥0.5 but <1.0%; Goa, Gujarat, and West Bengal), and low (<0.5%; the remaining 26 states/UTs). This helped to optimize resource allocation and appropriately direct the interventions.


   Beyond Burden and Trends of Hiv Top


Significant progress in evidence generation and its use was witnessed from NACP III onward. HSS was expanded from 180 sites in 1998 to 1163 in 2010 and 1323 in 2016–17.[9] It covered both rural and urban areas of the country and all categories of MARPS as well as bridge population. Prison inmates were also brought under HIV surveillance in 2019. Besides, national BSS was undertaken in 2000 and 2006. State-wise size estimation of MARPs, undertaken through the consultative process in NACP II, was updated by mapping and size estimation in 20 states in 2009. In view of the heterogeneity of the epidemic, districts were categorized and prioritized using a combination of HIV prevalence among pregnant women and MARPs to optimize program response.[10] During this period, significant evidence came from multiple sources such as a household survey to validate HSS results[11] and National Family Health Surveys (NFHS-3 in 2006[12] and NFHS-4 in 2015–2016[13]), which immensely contributed to refining HIV estimates. The Bill and Melinda Gates Foundation undertook Integrated Biological and Behavioral Assessment in selected districts of Southern states and the National Integrated Biological and Behavioral Survey was conducted by the NACO in 2015 in the entire country to gain an understanding of district-level epidemics which was considered essential. Rich data from program monitoring of interventions like antiretroviral therapy (ART), Prevention of Parent-to-Child Transmission, and targeted interventions became available to refine the quality of data interpretation to inform policy and program. By virtue of regular conduct and wide coverage, adoption of the second generation surveillance, and availability of rich data from NFHS and research, India's HIV surveillance system was rated as one of the best performing surveillance systems in the global evaluation of HIV surveillance by the WHO/UNAIDS.[14],[15] Yet, another development during this phase was the adoption of Estimation & Projection Package (EPP) and spectrum for estimations and projections, recommended by UNAIDS and used globally.[16],[17] This tool has the capability to incorporate data from surveillance, household surveys besides program data in estimations, and provides indicators relevant for program monitoring such as new infections, incidence, AIDS-related deaths, needs of ART, and prevention of mother-to-child transmission (PMTCT), besides improving international comparability.


   Diverse Activities Need Institutional Support Top


Utilization of the large body of data emanating from the multiple sources mentioned above to inform policy and program requires novel approaches to analyze them. Besides district categorization described above, data triangulation was undertaken to describe and understand the dynamics of district-level epidemics. In addition, a plan to analyze program data and undertake research on operational issues that require solutions was also initiated. This mammoth task would not have been possible without enlisting the vast institutional support available in the country. The implementation of surveillance and estimations is supported by four ICMR institutions and faculty of three teaching medical institutions. They are assisted by state surveillance teams drawn from the medical colleges of respective states. Similarly, a consortium of institutions spread across the country supports operations research and data analysis. NACO periodically undertakes the capacity strengthening of individuals involved in these activities.


   Emerging Challenges and Way Forward Top


India's Strategic Information System has come a long way in tracking and understanding the epidemic as well as in generating information to evaluate the response. However, with every new round of surveillance, new challenges surface. As is well known, the behaviors of high-risk population are dynamic. With advances in communication technology, both MSM and FSW are increasingly resorting to mobile- or web-based applications for solicitation and avoid physical spaces. Tracking, enumerating, and studying behaviors of these groups operating in virtual spaces are of paramount importance both for service delivery as well as keeping track of the epidemic. On PMTCT front, although 97% of the tested and detected positive pregnant women and children were initiated on treatment, its adequacy to end mother-to-child transmission needs to be judged by the fact that 5.32 million mothers only could be tested in 2015–16 against a target of 9 million.[18] This demands strong collaboration/convergence with the National Health Mission. Third, the country is continuing to primarily rely on prevalence as an epidemiological indicator. Even model-based estimations use “new infections” as a surrogate to incidence. Measuring incidence using either proxy indicators or new test protocols is essential for improved tracking of the epidemic. Budgetary allocations for strategic information need to be improved. Spends in NACPII and NACP III were 2% and 3%–4% of the total expenditure.[1] Allocation in NACP IV is only 2.65% of the total budget[19] which is lower than globally recommended 5%–10%. This needs revision if we aim at quality evidence.



 
   References Top

1.
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 2012;88:240-9.  Back to cited text no. 1
    
2.
Ramachandran P. ICMR's tryst with HIV epidemic in India: 1986-1991. Indian J Med Res 2012;136:13-21.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Simoes EA, Babu PG, John TJ, Nirmala S, Solomon S, Lakshminarayana CS, et al. Evidence for HTLV-III infection in prostitutes in Tamil Nadu (India). Indian J Med Res 1987;85:335-8.  Back to cited text no. 3
    
4.
Ramachandran P. Surveillance for the HIV infected. Health Millions 1991;17:15-9.  Back to cited text no. 4
    
5.
Sarkar S, Mookerjee P, Roy A, Naik TN, Singh JK, Sharma AR, et al. Descriptive epidemiology of intravenous heroin users-a new risk group for transmission of HIV in India. J Infect 1991;23:201-7.  Back to cited text no. 5
    
6.
Mann JM. The World Health Organization's global strategy for the prevention and control of AIDS. West J Med 1987;147:732-4.  Back to cited text no. 6
    
7.
National AIDS Control Organization. Ministry of Health & Family Welfare, Government of India. Annual Sentinel Surveillance for HIV Infection – A Country Report on Monitoring of Surveillance Activities. New Delhi, India: National AIDS Control Organization; 1998.  Back to cited text no. 7
    
8.
United Nations Programme on HIV/AIDS/WHO. Guidelines for Second-Generation HIV Surveillance. UNAIDS/WHO Document WHO/CDS/CSR/EDC/2000.5, UNAIDS/00.03E. Geneva: United Nations Programme on HIV/AIDS/WHO; 2000.  Back to cited text no. 8
    
9.
National AIDS Control Organization. HIV Sentinel Surveillance: Technical Brief, India 2016-2017. New Delhi, India: Ministry of Health and Family Welfare, Government of India; 2017.  Back to cited text no. 9
    
10.
National AIDS Control Organization. District categorization for Priority Attention under NACP-III. New Delhi, India: National AIDS Control Organization; 2007.  Back to cited text no. 10
    
11.
Dandona L, Lakshmi V, Kumar GA, Dandona R. Is the HIV burden in India being overestimated? BMC Public Health 2006;6:308.  Back to cited text no. 11
    
12.
International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 2005-2006. Vol. 1. India, Mumbai: International Institute for Population Sciences; 2007.  Back to cited text no. 12
    
13.
International Institute for Population Sciences (IIPS) and ICF. National Family Health Survey (NFHS-4), 2015-2016: India: Mumbai: International Institute for Population Sciences; 2017.  Back to cited text no. 13
    
14.
Garcia-Calleja JM, Zaniewski E, Ghys PD, Stanecki K, Walker N. A global analysis of trends in the quality of HIV sero-surveillance. Sex Transm Infect 2004;80 Suppl 1:i25-30.  Back to cited text no. 14
    
15.
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.  Back to cited text no. 15
    
16.
Stover J, Johnson P, Zaba B, Zwahlen M, Dabis F, Ekpini RE. The Spectrum projection package: Improvements in estimating mortality, ART needs, PMTCT impact and uncertainty bounds. Sex Transm Infect 2008;84 Suppl 1:i24-30.  Back to cited text no. 16
    
17.
Brown T, Bao L, Raftery AE, Salomon JA, Baggaley RF, Stover J, et al. Modelling HIV epidemics in the antiretroviral era: the UNAIDS Estimation and Projection package 2009. Sex Transm Infect 2010;86 Suppl 2:ii3-10.  Back to cited text no. 17
    
18.
Department of Health & Family Welfare. Annual Report 2015-2016. New Delhi, India: Department of Health&Family Welfare, Ministry of Health & Family Welfare; 2016.  Back to cited text no. 18
    
19.
National AIDS Control Organization. Mid-term appraisal of National AIDS Control Programme Phase IV. New Delhi, India: National AIDS Control Organization; 2016.  Back to cited text no. 19
    




 

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    Beyond Burden an...
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