TN’s targeted interventions with high risk groups have largely worked, but newer at-risk groups still pose a significant challenge.

TNs HIV numbers may be falling but heres why the state should not grow complacentFormer Collector Maharabushanam and former AIADMK MLA MK Selvaraj form a human chain as part of an AIDS awareness rally.
Delve HIV Sunday, August 26, 2018 - 11:10

PART 1

In many ways, Tamil Nadu has a lot to cheer about when it comes to the fight against HIV/AIDS. Thanks to a concerted effort over almost two decades, the state has worked its way towards a strong decline in the spread of the epidemic. Yet, this is not a time for complacency, as there are challenges still ahead that could still lose the state this hard-fought battle. 

What the numbers show

Committed to the goal of “End of AIDS” as a public health threat by 2030, India has successfully achieved the 6th Millennium Development Goal (MDG 6) of halting and beginning to reverse the HIV epidemic. Between 2000 and 2017, India’s annual rate of new HIV infections dropped from 2.51 lakhs to 88,000, a reduction of 66% against the global average of 35%. Tamil Nadu’s track record has kept in line with national achievements. The state has successfully managed to move away from a “high prevalence” situation and drastically reduce the number of new infections among high risk groups.

It was in TN that the HIV virus was first detected in India in 1986. With its mature health infrastructure, the state pioneered an evidence-driven targeted intervention (TI) programme aimed at high risk populations, and has put in place an effective system of treatment, care and support. Saturated TI reach and high uptake of Antiretroviral Therapy (ART) were the major breakthroughs that pushed down the state’s HIV prevalence from 0.32% of the population (1,61,743 persons, including adults and children) in 2007 to 0.28% (1,42,982 persons) in 2015. In the same time period, the national prevalence rate declined from 0.34% (22,25,930) to 0.26% (21,16,581). The state’s annual new infections have dropped from 13,318 in 2015-16 to 11,809 in 2016-17 and 8,718 in 2017-18 up to January.

However, the rate of decline in new infections in India has slowed in the past few years (1,10,000 in 2012, 1,10,000 in 2013, 1,00,000 in 2014, 99,000 in 2015, 94,000 in 2016, 88,000 in 2017). This means that we can expect to see an increase in the number of people living with HIV, unless the response is adequately fast-tracked, and both new infections and AIDS-related deaths are averted at higher rates, as observed in the National AIDS Control Organisation’s (NACO) National Strategic Plan (NSP) for 2017 to 2024.

Though TN’s AIDS response charts a sharp decline, there are variations in HIV prevalence among the various districts of the state. TN still stands among the 11 states in the country with prevalence rates higher than the national average. And 11 of its districts register high to moderate prevalence among the general public. In the last few years, with respect to new infections among the general public, the curve has flattened, say experts. This needs to be tackled with seriousness lest the epidemic rebounds.

When it comes to the general population, as against high-risk groups, accurate incidence rates are much harder to pin down. One of the proxy indicators epidemiologists use to estimate this rate is the prevalence of infection among ANC (ante-natal clinic) attendees. A HIV prevalence rate of 1% or above among ANC attendees is considered as high, 0.5% to 0.99% as moderate, and less than 0.5% as low.

According to the estimates of the 2012 HIV Sentinel Survey (HSS) conducted by NACO, TN had only three districts (Erode, Salem and Trichy) with a high prevalence among ANC attendees. Seven districts had a moderate prevalence rate, while 13 districts had low prevalence.

In 2015, six surveillance sites in the state recorded a prevalence rate over 1% (high prevalence), while 33 sites recorded rates lower than 0.33% (low prevalence), and 33 sites recorded a 0% prevalence.

ANC site estimates in Tamil Nadu stood at 0.34% in 2007 and 0.26% in 2015. In the 2017 HSS report, only four sites in the states recorded prevalence rates above 1%, but the overall prevalence rate had risen up to 0.27%, as against the national prevalence rate of 0.28%.

Thus, on the one hand, the overall ANC prevalence rate has seen a drop, with TN dropping out of the high prevalence category since the 2015 round of the sentinel survey. However, the rise recorded in 2017 is of concern, even though the state still remains below the national level. In three of the last six rounds of HSS (2007 to 2010), five TN districts – Coimbatore, Dharmapuri, Namakkal, Salem and Trichy – have recorded a HIV prevalence rate of 1% or more in ANC sites. This contrasting data is a warning sign that the HIV prevalence among the general population remains persistent in certain pockets, despite an overall decline in ANC prevalence in the state.

It should also be noted that the HIV Sentinel Survey methodology based on prevalence among ANC attendees only designates government hospitals and primary health centres as surveillance sites. This means that an underreporting of detections in the private sector cannot be ruled out. Further, as NACO mentions in its NSP 2017, it is likely that a high number of people with high risk behaviour, especially among adolescents and young adults, are not being detected by the surveillance radar.

Not all infected persons can be expected to be screened at government-designated ANC surveillance sites. Hence, looking for hidden HIV prevalence among the general population becomes necessary. Prevalence rates of Sexually Transmitted Infections (STIs), taken as a proxy indicator of high risk behaviour among the general population, is one such method.

File Image: An awareness rally on World Aids Day

Locating hidden carriers

Recent HSS reports have continued to emphasise that HIV prevalence across India and in TN is concentrated among a diverse range of high risk groups (HRGs) and bridge populations, with unprotected sex being a major driver of the epidemic. While HRGs include groups which are officially labelled as female sex workers, men who have sex with men, injecting drug users and hijras/transgender persons, the bridge populations include groups labelled as single male migrant workers and long-distance truck drivers and their spouses.

However, going by recent records of Integrated Counselling and Testing Centres (ICTC), HIV-related facilities made available in government hospitals, a high number of new HIV detections involve members of the general population who do not fall under NACO’s epidemiological category of HRGs. What’s more, a significant number of them are young, falling in the age group of 15 to 24 years.

This is particular problematic for efforts to halt the spread of HIV, as younger people indulging in unsafe sex may remain unaware of their infection and hence remain hidden for long. A considerable number of walk-in cases at ICTCs comprise the young. Some of them take a test after exposure to unprotected sex, says a staffer at an ICTC in the Salem Government Medical College Hospital.

However, such hidden virus carriers will surface in STI clinics sooner or later, and be referred to an ICTC, says Dr L Arunachalam, a government ART medical officer.

The young “at-risk”

But there is cause for concern in this area. According to the Tamil Nadu AIDS Control Society’s (TANSACS) official records, the number of people treated for sexually transmitted infections and reproductive tract infections at STI Clinics in TN increased from 3.55 lakh in 2014 to 5.58 lakh till February 2018. The data also shows that a higher number of cases was reported for the adolescent age group of 16 to 18 years. The cases increased from 4,285 between April 2014 and March 2015 to 5,462 between April 2017 and February 2018.

This indicates the rising number of young people with high risk behaviours in the state, who can spread the HIV infection to other unsuspecting members of the general population. Changing generational attitudes and sexual practices, travel, information technology (IT), mobile phones and social media, all have consequences on exposure to high risk and the capacity of individuals to protect themselves. NACO’s NSP recognises the critical importance of mapping and size estimates of HRGs and other “at-risk” populations. Regularly updating population size estimates is, therefore, indispensable in planning outreach to different population groups and to estimate the costs involved.

Read Part 2 of the series here

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