- India has the third largest HIV epidemic in the world, with 2.1 million people living with HIV.
- India’s epidemic is concentrated among key affected populations including sex workers and men who have sex with men. The National AIDS Control Programme, however, has made particular efforts to reach these two high-risk groups with HIV interventions.
- Compared to neighbouring countries, India has made good progress in reducing new HIV infections by half since 2001.
- Despite free antiretroviral treatment being available, uptake remains low as many people face difficulty in accessing clinics.
1 December is #WorldAIDSDay
Stigma & discrimination can discourage people from getting tested and being open about their #HIV status. Support from a good friend helps.
— WHO/Europe (@WHO_Europe) November 30, 2018
India has the third largest HIV epidemic in the world. In 2017, HIV prevalence among adults (aged 15-49) was an estimated 0.2%. This figure is small compared to most other middle-income countries but because of India’s huge population (1.3 billion people) this equates to 2.1 million people living with HIV.
Overall, India’s HIV epidemic is slowing down. Between 2010 and 2017 new infections declined by 27% and AIDS-related deaths more than halved, falling by 56%. However, in 2017, new infections increased to 88,000 from 80,000 and AIDS-related deaths increased to 69,000 from 62,000. UNAIDS (2017) ‘UNAIDS data 2017’.
The HIV epidemic in India is driven by sexual transmission, which accounted for 86% of new infections in 2017/2018. The three states with the highest HIV prevalence, Manipur, Mizoram and Nagaland are in the east of the country.
The epidemic is concentrated among key affected populations, however the vulnerabilities that drive the epidemic vary in different parts of the country. A key driver is unprotected sex among key populations and their clients, partners and spouses. However, injecting drug use in the north and northeast of the country is also pushing HIV prevalence up.6
Key population groups have been prioritised in the national AIDS response since its inception in 1992. Both the sex worker and men who have sex with men population groups have experienced a recent decline in HIV prevalence.
Key affected populations in India
In 2017, an estimated 1.6% of female sex workers in India were living with HIV, although this figure varies between states. For example, prevalence among female sex workers is estimated at 7.4% in Maharashtra and 6.3% in Andhra Pradesh.
Although sex work is not illegal in India, associated activities such as running a brothel are. This means that police are often hostile towards sex workers at best and that authorities justify routine brothel raids. Stigma and discrimination against sex workers restrict their access to healthcare. A 2011 study in Andhra Pradesh indicated a significant association between police abuse and increased risk of HIV transmission and inconsistent condom use.
Since 1992, SANGRAM has worked to unite sex workers and provide access to HIV treatment, prevention and education across six districts in Maharashtra and the border areas of north Karnataka. These are all places in which the rate of HIV infection is significantly higher than other areas of the country.
The organisation has achieved notable successes within these diverse communities. Peer educators deliver hundreds of thousands of condoms to women each month, and they report that in some areas 100% of sex workers have attended voluntary HIV testing.13
Men who have sex with men (MSM)
Around 2.7% of men who have sex with men in India are living with HIV, of whom around 65% are aware of their status.
HIV prevalence varies between areas. For example, around 10% of men who have sex with men in Andhra Pradesh and 5% in Maharashtra are estimated to be living with HIV.
People who inject drugs (PWID)
In 2016, 1.7 million people in India were estimated to inject drugs.
HIV prevalence among this group is high, with injecting drug use the major route of HIV transmission in India’s north-eastern states. In 2017, 6.3% of people who inject drugs were thought to be living with HIV, of whom half (50%) were aware of their status.20
Prevalence varies between locations, standing at 12.1% in Manipur, 10% in Mizoram, and 3.2% in Nagaland.
A 2018 study analysed unsafe injecting and sexual risk behaviours among around 20,000 Indian men who inject drugs. Results suggest that beginning drug use at age 25 or above, engagement in drug use for longer, injecting three times or more per day, sharing needles and syringes, and self-reported sexually transmitted diseases were all linked to an increased likelihood of HIV infection.
HIV prevalence among transgender people in India was estimated to be 3.1% in 2017, the second highest prevalence among all key populations in the country. Around 68% of HIV positive transgender people are aware of their status.
In India, being a hijra (also known as ‘aravani’, ‘aruvani’ or ‘jagappa’ in other areas) is an identity associated with being a transgender woman, intersex or a eunuch. However, not all transgender women in India belong to a hijra community. The traditional background of hijras is linked to high-risk behaviours such as alcohol and substance abuse, and low literacy rates.
Research worldwide has linked migration to increases in HIV transmission. There are an estimated 7.2 million migrant workers in India, of whom 0.2% are living with HIV.
NACO categorises groups of migrants as ‘bridge populations’, as they form links between urban and rural areas, and between groups that are at high- and low-risk of HIV transmission. HIV testing among these groups remains low, standing at 11.32% in 2016.
A number of studies have reported high vulnerability of truckers to HIV transmission in India. NACO estimated that 0.2% of truck drivers were living with HIV in 2017/18. NACO also categorises truck drivers as a bridge population because they often have unprotected sex with high-risk groups such as female sex workers as well as their regular sexual partners, which increases the risk of transmitting HIV into the general population.