In 2007, about 2.3 million Indians were living with HIV, according to Indian government estimates. The adult prevalence of HIV was 0.34 percent. India’s highly heterogeneous epidemic is largely concentrated in six states—in the industrialized south and west, and in the northeastern tip. On average, HIV prevalence in these states is 4-5 times higher than in the others. Overall, the main challenge for India, ranking third in number of people living with HIV and AIDS globally, is to reduce transmission among vulnerable groups at highest risk and prevent escalation of concentrated epidemics driven by sex work, injecting drug use and unsafe sex between men having sex with men.
Shortly after the first AIDS case was reported in 1986, the Government of India established the National AIDS Control Program (NACP). In 1991, the program was expanded and the National AIDS Control Organization (NACO) was established to implement it. By the end of the first phase (NACP 1, 1992-1999) the program had decentralized to the states, although substantial variations existed in their commitment and capacities. NACP 2 (1999 – 2006) continued to expand the program and involved NGOs and other sectors such as education and transport, as well as the police. Under NACP 3 (2006-11), the program is dramatically scaling up targeted prevention interventions, such as promoting condom use among sex workers and their clients, implementing harm reduction among injecting drug users, and supporting peer educators to reach the vulnerable groups at highest risk. The government is building on partnerships with civil society organizations and the active involvement people living with HIV and AIDS and other key groups. Surveillance and strategic information management have also received a boost, resulting in improved estimations of HIV prevalence from 2006 onwards.
HIV prevalence has declined among sex workers where targeted interventions have been implemented, particularly in the southern states, although overall prevalence among this group continues to be high. There is also a slow decrease in HIV prevalence among the general population in the southern states.
Highlights:
- Although an impact assessment is underway and more analysis is required, declining prevalence indicates that the number of people becoming newly infected with HIV is decreasing. This decrease is more perceptible in states such as Tamil Nadu where the intensity of HIV prevention efforts has been high.
- More cautious behavior. National behavioral surveillance surveys in 2001 and 2006 show that female sex workers have increased condom use from 49 to 66 percent. Among the general population, 80 percent could procure condoms within 30 minutes in 2006 compared with only 50 percent in 2001, and the condom use among casual partners increased from 33 to 50 percent. These trends in behavioral data show significant results that help to explain the decline in HIV prevalence.
- Targeted prevention increased. More than 1.1 million people with risky behavior are now being reached with over 1,270 targeted interventions, in collaboration with NGOs. NACP 3 proposes to increase coverage of groups with high-risk behavior to 80 percent, up from NACP 2’s coverage of 10-60 percent.
- Free ART services were steadily scaled up. Nationally, 217,000 patients received free ART in 180 ART and 116 link ART centers during the second phase of the National AIDS Control Program. Seven ART centers have been upgraded to regional pediatric centers, providing comprehensive specialized services to children with HIV. Since January 2009, second-line ART is being offered in 10 centers of excellence.
- Institutional capacity and state capacity increased. The number of blood banks, storage centers, and vans increased. Furthermore, institutional capacity expanded with the creation of four centers of excellence in transfusion medicine and a plasma fractionation center. The project has successfully decentralized HIV control activities to the state level, establishing State AIDS Control Societies in all states and three major municipalities.
- Voluntary Testing and Counseling increased. The number of people tested in Integrated Counseling and Testing Centers has increased from 4 million in 2006 to almost 5 million in 2008. In the same period, the number of pregnant women tested has doubled from 2 million to just over 4 million.
- Blood bank grew. The amount of blood collected has almost doubled over the past four years—from 385,000 units in 2004 to 710,000 in 2008-09. The percentage of voluntary donations increased from 49 percent to 61 percent.
- Basic services have expanded. They are now better integrated under the National Rural Health Mission (NRHM). Almost half of the 6.7 million episodes of Sexually Transmitted Infections (STI) were managed in NRHM facilities, and 2.6 million were treated in 886 designated STI/RTI clinics.
- In 1991, the Government of India and the World Bank Group expanded their collaboration on infectious disease control programs. By 1992, the first National AIDS Control Project (NACP) was launched with an IDA credit of US$84 million.
- Building upon its lessons, the Second National HIV/AIDS Control Project (US$191 million) helped establish State AIDS Control Societies to increase the pace of implementation.
- The Third National HIV/AIDS Control Project was signed in July 2007. While IDA was the main financier of HIV and AIDS during the first NACP, it is only providing 10 percent of the current national budget of the third program (US$2.5 billion), with the Government of India in the lead, financing most of the program in addition to increasing contributions from a consortium of donors. IDA is contributing US$250 million to NACP3.
- IDA’s analytical work helped strengthen the national response to HIV/AIDS, with an emphasis on evidence-based targeted intervention among high-risk groups
- focusing in the drivers of the epidemic: unsafe sex and injecting drug use. This includes the first published analysis of the epidemic dynamics of AIDS in South Asia and an analysis of the full array of costs and consequences likely to result from several plausible government policy options regarding funding for anti-retroviral therapy (ART).
- The World Bank Group has also carried out recent sector work on the economic consequences of the HIV/AIDS epidemic on India. The South Asia Regional multi sector team of the World Bank Group has convened three inter country and inter regional consultations on HIV prevention among injecting drug users (IDUs), surveillance and harm reduction, with Central Asia, the Middle East and East Asia. The most recent, was with the United Nations Office on Drug and Crime, AusAID and SIDA. In close collaboration with NACO, the World Bank Group is currently carrying out an impact evaluation of the targeted interventions, supporting capacity building activities for target groups in the South Asia region, and analyzing the India’s Life Skills program in schools.
- Many civil society groups and networks are receiving World Bank regional Development Marketplace grants to implement and monitor the results of innovative approaches at community level to tackle stigma and discrimination associated with HIV and AIDS.
- The government is pooling part of its contribution with IDA funds and US$179 million from UK’s Department for International Development (DfID).
- India receives technical assistance and funding from a variety of UN partners and bilateral donors. Bilateral donors such as USAID, CIDA, and DFID have been involved since the early 1990s at the state level in a number of states. GFATM and the Gates Foundation also contribute large amounts to the program. However, the program is still facing a financial shortfall, especially with the increase in fiscal costs of scaling up treatment of a large and growing number of people living with HIV and AIDS in need of treatment and care.
At project appraisal, a financing gap existed in NACP 3, and the Indian government proposed to seek additional support from other donors. It was agreed that the Bank would consider supplemental financing (up to US$250 million) based on the implementation of the project, including disbursement and substantial compliance with loan covenants, was satisfactory—and that program success was proved critically dependent on this additional financing. The next step is the mid term review in FY2010, which will be informed by many ongoing studies, including the World Bank supported impact assessment.
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