A major challenge to the national AIDS program has been to launch an effective prevention strategy that would reach those who need the services the most, and encourage significant behavior change that would reduce transmission. India also needed to build the institutional and human resource capacity required to tackle the epidemic at all levels: national, state and district. With overall low HIV prevalence, but concentrated epidemics among most at risk populations, overcoming stigma and discrimination was also a huge challenge to the national program, requiring involvements of key stakeholders including civil society and communities at risk.
The World Bank and the Government of India are in the third phase of the National AIDS Control Project, which was first established in 1991. In this third phase, India has scaled up targeted HIV prevention interventions for most at-risk populations and expanded its management information and HIV surveillance systems to generate district level data. This new knowledge helped the government better understand the heterogeneous epidemic, identify which Indian states and districts were most affected by HIV, and which populations were most at risk (namely sex workers and their clients, men having sex with men, and injecting drug users). The main approach is to focus about two-thirds of the program’s resources on the targeting of HIV prevention interventions among these population groups, and contracting non-governmental and community based organizations to deliver services. The government utilized a strong evidence base, and epidemic and economic modeling, as well as public and private consultations. The efficient allocation of resources, a reliance on participatory approaches, and effective donor coordination has made this approach a global best practice.
HIV prevalence declined from 0.39 percent or 2.6 million people in 2004 to 0.31 percent (2.4 million people) in 2009. New infections declined by 50 percent from 2000 to 2009. The national program reached 81 percent of female sex workers, 66 percent of men having sex with men, and 71 percent of injecting drug users, while treatment coverage increased by 30 percent between 2009 and 2011. Deaths from HIV declined from 199,502 in 2006 to 172,041 in 2009. It is estimated that some three million HIV infections will be averted by 2015 by the targeted prevention interventions.
IDA has supported the foundation of a national program that is averting three million new infections—a 60 percent reduction in the HIV epidemic from around 5.5 million cases to 2.4 million cases—during the period 1995-2015.More than US$640 million in financing from the International Development Association has helped to create the institutional framework of India’s HIV response at national and state levels, including a strong HIV surveillance system that has helped India to effectively tailor the epidemic response. The Bank has also financed, through pooled funding with the Indian government and the U.K.’s Department for International Development (DFID), more than 1,300 targeted interventions for those most at risk, reaching more than 70 percent of female sex workers and increasing the use of condoms. This has helped contain HIV prevalence in the general population. In addition to lending, the Bank has supported community innovations to tackle the stigma related to HIV through a South Asia Regional Development Marketplace. The Bank’s regional AIDS program has also helped to inform government policy and priorities through a series of regional analytical work (see links below).
The Bank and DFID are pooling partners with the Government of India in the Third National AIDS Control Project. A large consortium of development partners are working in partnership with the Government of India, contributing significantly to the national AIDS response by closely coordinating their various efforts.
Toward the Future
Although the overall HIV prevalence rates among high risk groups are declining, they remain high according to 2008-09 data (9.2 percent among injecting drug users, 7.3 percent among men having sex with men and 4.9 percent among female sex workers), and there are significant variations across and within states, which warrants an expansion of efforts to the hard-to-reach populations in these areas. Moving forward with the preparation for the fourth phase of the national response, 2012 – 2017, the Government of India is mobilizing domestic financial support and seeking sustained support from development partners, including the Bank. The Bank has been asked by the Department of Economic Affairs to support the fourth phase of the program as it aims to accelerate reversal of trends and integrate components of the program with other health services and programs over the next program phase. The national program will continue to innovate and generate lessons from its innovative performance management system.