General Information

Estimates (in million) - Year 2000
Adults and children living with HIV/AIDS as of end 2000	36.1
Adults and children newly infected with during 2000	5.3
Adult and child deaths due to HIV/AIDS during 2000	3.0
Children (<15 years) living with HIV/AIDS as of end 2000	1.4
Children (<15 years) newly infected with HIV/AIDS during 2000	0.6
Child (<15 years) death due to HIV/AIDS during 2000	0.5

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Basic Facts about INDIA

1. Political map of India (View Image)

2. Demography

Indicator	Value	Indicator		Value
Land Area (in Sq. Km.)	2,973,000	Population (in Thousands)		1,027,015
Administration		Male (in Thousands)		531,277
States	28	Female (in Thousands)		495,738
Union Territories	7	Urban population		27 %
Districts	466	Child population (0-6) (in Thousands)		157,863
Sex ratio (women per 1000 men)	933.11	Decadal Growth (1991-2001)		21.34 %
% below poverty line	35.77	GNP per capita (US$)		427.4 (1998)
Literacy	65.38 %	GDP per capita (ppp us$)		2,077 (1998)
Male	75.85%	Public health expenditure (% of GDP)		0.7 (1990-97)
Female	54.16%	Total health expenditure as % of GDP		5.2
Population age 15+	52%	Per capita public health expenditure (PPP $)		11 (1997)
Out of pocket expenditure as % of total health expenditure.	84.6	Public health expenditure as % of total health expenditure		13
Public expenditure on education	3.5 % of GNP (1995)	Net enrollment ratio (% of relevant age group)	Primary Secondary	93 73

Source -Census of India, World Development Report 1999/2000, Health Human Development Report-2000

3. Mortality

Indicator	Value	Year
Crude Birth Rate	26.4	2000
Infant Mortality Rate	70	1998
Under-five mortality rate	94.9	1998
Child Mortality Rate	23.7	1993
Perinatal Mortality	71	1997
Maternal Mortality Rate	4.37	1993
Life expectancy at birth	62.9	1998
Male	62.5	1998
Female	63.3	1998
Crude Death Rate	9.0	2000

4. Women & Child care

Indicators	Value	Year
Percentage of birth attended by trained health personnel	54 %	1999
Immunization status (%)
Tetanus toxoid (Preg. Women)	80 %	1997
BCG (infant)	96 %	1997
Measles	83 %	1997
DPT( 3 doses)	90 %	1997
Polio (3 doses)	90 %	1997
Babies birth weights below 2000 gms	30%	1998
Child malnutrition (% of children under 5)	66 %	1999
Women age 20-24 married by exact age 18	50.0 %
Women involved in decisions about own health care	51.6 %
Percentage of currently married women using
Any contraceptive method	48.2 %
Sterlization	36.0 %

5. Other issues

Indicator	Value
Contraceptive prevalence rate	43 %
Condom use	3.1 %
TB cases (per 100,000 )	118.3
Access to safe water (% of Population)	81
Access to sanitation (of total population)	29 % (1998)
Access to sanitation in urban Area	70 % (1998)

6. Causes of Death - 1998

Mortality by causes for India - 1998	Top ten specific causes of death in India - 1998
		India		India/World
		(000)	% total	% of World
Injuries (10%) Communicable	Total population	982223
(42%)	Total death	9337	100

	Ischemic heart diseases	1471	15.8	19.9
	Acute lower respiratory infections	969	10.4	28.1
	Diarrheal diseases	711	7.6	32.1
	Cerebrovascular diseases	557	6	10.9
	Tuberculosis	421	4.5	28.1
	Road traffic injury	217	2.3	18.5
Non Communicable (48%)	Measles	190	2	21.4
	HIV/AIDS	179	1.9	7.8
	Tetanus	165	1.8	40.3
	Chronic obstructive pulmonary disease	153	1.6	6.8

7. Expenditure on Health and Family Welfare (in Rs. Crore) (View Image)
In 2000-2001 planned allocation for the Ministry of Health and Family Welfare has been stepped up from Rs. 4920 crore to Rs. 5780 crore. Rs. 180 crore was provided for the National HIV/AIDS control programme (NACO).

Source - Ministry of H & FW, Census of India, NFHS 98-99, World Health report 1999, Human Development Report-2000

8. Health care Staffing and other facilities in public and private sector

Physicians	Total numbers (1998) includes all systems( (CBHI)	1109853
	Population per doctor	880
	% of doctors in rural areas (1981) (Census)	41
	% of all doctors in private sector (Estimates)	80-85
Nurses	Total numbers (1996)	867 184
	Population per nurses	976
	Doctors per nurse (1996)	1.4
	Total no. trained on HIV/AIDS Prevention & Control	5874
Hospitals	Total numbers (1996)	15096
	Population per hospital	56058
	% of hospitals in private sectors	68
	Estimated total number	71860
	Estimated population per hospital	11744
Hospital beds	Total Number (1996) (CBHI)	623819
	Population per hospital bed	1357
	% of beds in rural areas	21
	% of beds in private sectors	37
PHC's	Total number	22975
PHC's	Rural population per PHC	27364
Blood related facility centers	Licenses Blood banks	1455
	Public Hospital	663
	Private Hospital	284
	Private Commercial Bank	333
	Voluntary blood bank	175
	Voluntary Blood Testing Centers	165
	Zonal Blood Testing Centers	154
	Blood Component Separation Facilities	40
	CD4/CD8 Blood test centers	23

9. HIV/AIDS Care Facilities

State AIDS Control Societies	all 35 States and UTs
Regional HIV Reference Centers	9
STD Clinics	499
Sentinel sites	232
STD Clinic	109
Antinatal clinic	110
IDUs	11
MSM	2

Source - DGHS, NACO

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HIV /AIDS in INDIA

1. Historical facts

1985		Indian Council of Medical Research (ICMR) establish an AIDS Task Force
1986		First AIDS case reported from Chennai
1987		World Health Organization provided financial support and technical guidance for AIDS activities in more than 150 developing countries (Including India) around the world through its Global Programme on AIDS (GPA).National AIDS Control Programme planned
1989		GOI prepared a Medium Term Plan (1990-92) in collaboration with the WHO with a budget of US$ 19 million
1991		National AIDS Control Organization established
1992		First National AIDS Control Project launched (1992-97) funded by an IDA credit of US $84 million from The World BankState AIDS Cell (SAC) were set up in all 25 states and 7 Union Territories (92-93)
1994		Govt. of Tamil Nadu converted its SAC into a registered society - The Tamil Nadu AIDS Control Society (TNSACS)
1996		United Nations involve six organizations (UNICEF, UNDP, UNFPA, UNESCO, WHO, World Bank) together in a Joint United Nations Programme on HIV/AIDS (UNAIDS). A directive of the Supreme Court of India in 1996 made HIV screening and licensing of blood banks mandatory.
1998		UNAIDS Theme Group established
	November	UNAIDS Programme Coordination Board Meeting in New Delhi
	December	Prime Minister urges the parliamentarian to accept the AIDS situation as a threat to India's development rather than only a health issue.
1999	February	First study tour of policy makers to Uganda First study tour of policy makers to Thailand First study tour of policy makers to Cambodia (Feb - March)
	June	First Strategic Planning Retreat of UNAIDS and key partners at Musoorrie
	November	Second Phase of National AIDS Control Project launched (1999-2004)
	December	First study tour of policy makers to China
2000	January	Second study tour (PMTCT) of policy makers to Thailand
	March	World AIDS Campaign - Global Launch Web portal - youandaids.org launched
	April	Second study tour of policy makers to Uganda
	June	Family Health Awareness Week launched across the country
	August	Second Strategic Planning Retreat of UNAIDS and key partners in Banglore
	August	Video conference of CM from AP, Karnataka, Maharashtra, with the Union Health minister on World AIDS Day
	November	First National Conference on Human Rights and HIV/AIDS
	December	PM calls for formation of Business Coalition on HIV/AIDS

2. Assumptions about the Indian HIV/AIDS Epidemic

High-risk behavior groups are represented by STD patients attending STD clinic and Obst. & Gynae. Clinics. However, in certain limited areas the Injecting Drug Users (IDUs), represent the High Risk Group
Low risk behavior group or the general population is represented by pregnant women attending Antenatal Clinic.
According to the WHO/UNAIDS classification epidemics in states have the following status :

Low - States where the HIV prevalence in antenatal women is less then 1%, while the prevalence in STD and other High Risk Group (HRG) (including CSW, IDUs or MSM) is less then 5%.

Concentrated - Where HIV prevalence in antenatal women is less then 1%, while the prevalence in STD and other High Risk Group (HRG) (including CSW, IDUs or MSM) is 5% or more.

Generalised - States where HIV prevalence is 1% or more in antenatal women.

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Evolution of Epidemic

1. Epidemic Status (From 1986 - 2000) [View Image]

2. Reported AIDS Cases (May 2001)
A further aspect of monitoring the HIV/AIDS epidemic is the reporting of actual AIDS cases. As on May 2001, 22912 (Male - 17478, Female - 5434) cases were reported to NACO.

S. No.	State/UT	AIDS Cases	S. No.	State/UT	AIDS Cases
1	Andhra Pradesh	710	17	Lakshadweep	0
2	Assam	110	18	Madhya Pradesh	667
3	Arunachal Pradesh	0	19	Maharashtra	4881
4	A & N Islands	13	20	Orissa	60
5	Bihar	59	21	Nagaland	121
6	Chandigarh (UT)	323	22	Manipur	844
7	Delhi	520	23	Mizoram	18
8	Daman & Diu	1	24	Meghalaya	8
9	Dadra & Nagar Haveli	0	25	Pondicherry	141
10	Goa	41	26	Punjab	131
11	Gujarat	829	27	Rajasthan	287
12	Haryana	48	28	Sikkim	2
13	Himachal Pradesh	87	29	Tamilnadu	11407
14	Jammu & Kashmir	2	30	Tripura	0
15	Karnataka	962	31	Uttar Pradesh	316
16	Kerala	267	32	West Bengal	57

Risk Transmission Categories	No. of Cases	%	Age Group	Male	Female	Total
Sexual	19102	83.37	0-14 yrs.	520	317	837
Perinatal Transmission	447	1.95	15-29 yrs.	6548	2660	9208
Blood and Blood products	828	3.61	30-44 yrs.	8836	2009	10845
Injectable Drugs Users	885	3.86	>45	1574	448	2022
Others (not specified)	1650	7.20	Total	17478	5434	22912
Total	22912	100.00

3. Current Status - ANC / STD / IDU and Metro Cities [View Image]

4. Estimated number of IDUs and HIV Seroprevalence (View Image)

5. Epidemiological analysis of Surveillance at end of 2000

Estimated number of HIV infected persons is 3.86 millions
45 districts mostly in high prevalent states have shown high prevalence of HIV among STD & ANC during year 2000.
HIV/AIDS is affecting mainly the people in sexually active age group. The majority of the patients (87%) are in the age group of 15-44 years.
HIV prevalence among STD clinic attendants has increased from 6% to 36% in 5 years and is estimated to be 50% amongst commercial sex workers
The predominant mode of transmission of infection in AIDS patients is through heterosexual contact (80.86%) followed by blood transfusion and blood product infusion (5.52%), IDUs (5.30%), Perinatal transmission as (0.72%) and others (7.60%).
Male account for 77% of AIDS cases and females 23% (a ratio of 3:1).
The major opportunistic infection in AIDS Patients is Tuberculosis, indicating the possibility of a dual epidemic of TB & HIV in the future.
Nearly 60% of HIV/AIDS cases are reported to be infected with TB bacilli
State of Maharashtra, Tamil Nadu and Manipur together account for over 75% of AIDS cases and over 67% of HIV infection.
NACO conducted baseline surveys in various cities in India. The findings for the city of Jaipur revealed that STD prevalence amongst a sample of 519 males from the transport and industrial sector was 10.7% and 41 % out of a sample of 250 men attending clinics.
A survey of 370 commercial sex workers in West Bengal (Sonagachi) revealed that 80.6% of these women were infected with at least one Reproductive Tract Infection (RTI) pathogen.
Although the national sero-prevalence rate among IDUs is 3.5 percent, sentinel surveillance in 1998 showed that the prevalence of HIV infection among IDUs in Manipur was 72.78 percent
Estimated aggregate costs of HIV/AIDS by the year 2000 were $11 billion (5% of India's GDP).

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Evolution of the Response

1. National AIDS Control Programme

Introduction
The National AIDS Control Project was the first project in India to develop a national public health program in HIV/AIDS prevention and control, and was implemented between 1992 and 1999.

The specific objectives were to: (a) involve all States and Union Territories in developing HIV/AIDS preventive activities with a special focus on the major epicenters of the epidemic; (b) attain a satisfactory level of public awareness on HIV transmission and prevention; (c) develop health promotion interventions among risk behavior groups; (d) screen all blood units collected for blood transfusions; (e) decrease the practice of professional blood donations; (f) develop skills in clinical management, health education and counseling, and psycho-social support to HIV sero-positive persons, AIDS patients and their associates; (g) strengthen the control of Sexually Transmitted Diseases (STD); and (h) monitor the development of the HIV/AIDS epidemic in the country.

The design included five basic components: (a) strengthening management capacity for HIV/AIDS control; (b) promoting public awareness and community support; (c) improving blood safety and rational use; (d) controlling sexually transmitted diseases; and (e) building surveillance and clinical management capacity.

Project Cost, Disbursement, and Timetable
The project was estimated at US $ 99.6 million at the time of appraisal, and was to be financed by a Government of India contribution of US $ 14.1 million, an IDA credit of US $ 84.0 million (SDR 59.8 million equivalent) and a WHO co-financing grant of US $ 1.5 million. The final disbursement took place on September 7, 1999, at which time SDR 59.8 million (US $ 84.2 million equivalent), the original principal amount of the Credit was fully disbursed, US $ 2.2 million of WHO grants was utilized, and the GOI contribution came to US $ 27.5 million, an increase of US $ 13.4 million over the original plan.

Phase - II (1999-2004)

Phase II of the National AIDS Control Programme has become effective from 9th November 1999. It is a 100% centrally sponsored scheme implemented in 32 States/UTs and 3 Municipal Corporations, namely Ahmedabad, Chennai and Mumbai through, state AIDS Control Societies.

Components of NACP II

COMPONENT 1 :	Targeted Interventions for the communities with highest risk behavior
COMPONENT 2 :	Prevention of HIV transmission among the general population
COMPONENT 3 :	Low cost care
COMPONENT 4 :	Strengthening institutional capacity
COMPONENT 5 :	Intersectoral Collaboration

Outlay for National Aids Control Project Phase-II	Rupees In Million
IDA credit (1999-2004)	11550
USAID assistance for AVERT Project in Maharashtra.	1660
DFID assistance for Sexual Health projects for the States of Andhra Pradesh, Gujarat, Kerala and Orissa.	1040
TOTAL	14250

Expanded National AIDS Control Programme (1999-2004)

Contribution from the major Stakeholders (in million US$)

	Central Govt.	State Govt.	World Bank	Bilateral	UNAIDS	Others	Total	%
Prevention among high risk groups	42.8	61.8	50.1	38.4	1.1	3.1	197.3	32.3
Prevention among low risk groups	30.5	88.5	67.7	1.3	1.2	3.2	192.4	31.5
Institutional Strengthening	11.6	5.5	34.9	34.0	5.5	1.1	92.6	15.2
Low cost care for PLWAs	1.9	55.1	29.1	1.1	1.1	2.8	91.1	14.9
Intersectoral Collaboration	5.8	10.1	9.3	6.4	5.5	0	37.1	6.1
Total	92.6	221.0	191.1	77.4	14.4	10.2	610.5
Percent	15.2	36.2	31.3	12.5	2.4	1.7		100

2. Bilateral/Stakeholders involvement [View Image]
NACO has been encouraging the active participation of bilateral such as USAID, DFID, CIDA, AUSAID and SIDA in state level programmes. For example, USAID has been working in Tamil Nadu since 1995 and is now on the verge of implementing a major AIDS control project in Maharashtra and Mumbai city. DFID has been working in West Bengal for some years and is now in process of implementing the AIDS control projects in AP, Gujarat, Kerala, and Orissa.

3. The UN Contribution
The UN system has the mission of facilitating a multi sectoral response to HIV through joint programming. The United Nations employed an innovative approach in 1996 by bringing six organization together in a joint and cosponsored programme - the Joint United Nations Programme on HIV/AIDS or UNAIDS. The six original cosponsors of UNAIDS - UNICEF, UNDP, UNFPA, UNESCO, WHO, and the World Bank - were joined by UNDCP in 1999. Memoranda of Understanding currently exist with ILO and UNIFEM.

UNAIDS in India performs four key functions:

Coordination of the UN system's HIV/AIDS response
Advocacy
Building/strengthening partnership
Providing information

The UN system encourage active involvement of NACO and bilateral in the Theme Group which is the apex body governing the UN response in India. The Theme Group evolved in 1998 and has since played an important role in steering activities of the secretariat. Theme group meets four times per year to review progress and play an important monitoring role for the secretariat and cosponsors.

The Theme Group determines priorities and the plan of action of the UNAIDS secretariat. The focus in the year 2000 was on operationlising the work plans that were developed by cosponsors. These work plans have been finalized after reviewed by the Theme Group.

One of the support mechanisms created by UNAIDS to deliver outputs/inputs from cosponsors into national response is The Virtual Team (VT). The UNAIDS secretariat plays a key facilitative role in supporting the UN cosponsors to mainstream HIV in their work This has been planned through the Virtual Team members. With effect from this year, Virtual Team has been in place and functional.

UNAIDS Core Virtual Team

Agency	Focus
UNAIDS	TI, VT Programme Support and Stakeholders Management Strategic Planning, Law and Ethics
UNICEF	Children, Youth, MTCT, Communication
UNDP	Development, civil society response
WHO	Epidemiology, MTCT
UNESCO	Education
UNIFEM	Gender
UNDCP	Drug Demand Reduction
ILO	Workplace issues

The Virtual Team leader is the UNAIDS Country Programme Advisor, who leads the team in close cooperation with the NACO Project Director.

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Vulnerability Factors - INDIA

1. Poverty [View Image]

320 million people or 36% of the population in India live below the poverty line. Those with low incomes may not be able to afford treatment for STDs or to buy condoms.
Poor families may see commercial sex as lucrative occupation for young and poorly educated daughters. India has large and thriving sex industry, estimated to be around 100,000 in each of the metropolitan cities.
The poor and uneducated in a society ate more likely to contract STDs and other infectious diseases since they are deprived of their right to information on risk behaviour, are too illiterate to understand prevention messages, and have less access to quality services.

2. Migration [View Image]
Population migration is a key factor in the HIV in India. Limited employment opportunities forces many to move from rural to urban, from one state to another, from one county to another. There are over 180 million migrant workers in India, many of whom are single men or who live apart from their wives and families. Other mobile populations such as members of the armed forces and long route truck drivers away from home are more likely to have unsafe sex. It is this high mobility of the male population that has brought the virus to the rural areas. Migrants men comprise 30-40% of the population of large cities, where they also account for much of the clientele of the 'red light' areas.

3. Urbanisation [View Image]
Economic growth has led to rapid urbanisation, which in turn resulted in large slum populations and an increase in categories of unorganized labour such as construction workers, casual landless labourers and chills workers. In 1996, some 100 million people were estimated to be living in urban slums, a figure that is expected to rise to 110 million in 2001. Two-thirds of these are children, youth and women who are less literate, lack basic knowledge of safe health practices, and have little or no access to information, or health and other supportive services. Poverty, ignorance and violation of basic rights in these areas create the condition, which facilitate the spread of HIV.

4. Child Mortality
Based on studies from different part of country that 1 out of 3 children born to an infected mother will be HIV infected. Because HIV-infected infants have a much shorter survival time than do HIV-infected adults, the effects of AIDS on infants and children are visible earlier than for adults. The excess in infant mortality rate (IMR) and under- mortality rate resulting from AIDS mortality compared with the no-AIDS scenario. Because most HIV-infected infants survive their first year but die before reaching age 5, the effect on under-5 mortality rate is much more pronounced than on the infant mortality rate.

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Innovations in INDIA

1. Family Health Awareness Week [View Image]
Reproductive Tract Infection (RTI) including sexually transmitted diseases (STDs) are increasingly recognized as a major cause of morbidity in India. Awareness, which can lead to attitudinal and behavioural change in individual and society toward safe sexual and other health practices is the only weapon today against HIV/AIDS. UNAIDS supported NACO's efforts at community mobilization through the Family Health Awareness Week, launched with the idea of increasing awareness among and reaching out to communities at large.Third round of the FHAW took place in the first and second week of June 2000, across the country. The population estimated to be covered by the campaign is approximately 600 million, of which 34 million attended the camps.

A pilot round of this campaign was undertaken from 26th April to 1st May 1999 in 100 districts across the country. the second round of the campaign was launched in 266 district during 1st 15th December 1999. Detailed figures for this campaign (1-15 December 1999) are as follows:

	Male	Female	Total
Total target Population (15-49)	94737173	89986506	184723679
No. of person actually attended camps	21719558	24413807	46133365
% of person actually attended camps	22.92%	27.13%	24.97%
Total no. of patients referred from the camps (%)	541725	1244735	1786460
No. of RTI/STI cases treated
With ulcer	41792	48007	89799
With discharge	65689	597425	663114
Others	140656	218618	359274
Total	248137	864050	1112187

Source : NACO

2. Targeted Interventions [View Image]
The basic purpose of the Targeted Intervention (TI) programme is to reduce the rate of transmission among the most vulnerable and marginalized population. One of the ways of controlling the disease from further spread is to carry out direct intervention. The State AIDS Control Societies (SACS) are fully empowered to provide funding support to the NGOs for TI. Every SACS has appointed an NGO advisor to manage and guide the TI programme. Almost 400 TI project have been undertaken by the SACS through NGO funded by NACO and bilateral.

Funding Organization	No. of projects
NACO	248
DFID	118
APAC	31
Total	397

Some Examples are outlined below:

TI Project	Implementing agency	State	Focus group
Project Sakhi	AIDS Prevention Society	Assam	Sex Worker
Jagruthi	Jagruthi	Karnataka	Women & Child, CSW
BOSCO	BOSCO	Karnataka	Street Children
Model Reproductive Health Center	Drishtikon	Delhi	Urban poor group
Intervantion project for Rickshaw pullers	Family Health International	Chandigarh	Rickshaw pullers
Partnership in sexual Health	DFID	Gujarat, Orissa, Kerala and Andhra Pradesh	All
AIDS Prevention and Control (APAC) Project	USAID	Tamil Nadu	CSW, Truckers, Slum Population
West Bengal Sexual Health Project	DFID	West Bengal	All

3. Technical Resource Groups (TRGs) [View Image]
Technical Support to the National Programme is facilitated through 11 Technical Resource Groups (TRGs). The National Aids Control Organisation in collaboration with UNAIDS constituted TRGs in order to make available to the various levels/components of the national programme (the State AIDS Societies, Community based organisations, NGOs and to the civil society) the best possible technical advice, operational know-how and support on different components of the programme, ranging from planning to implementation. The composition of each TRG is such that its chairperson along with the coordinator is situated at the same institute whereas the members are spread all over India.
The Role of TRGs is to improve the quality of Programme design through preparing technical papers, and but through their ongoing interaction with different levels of Government acting as a technical resource, transferring the know how to improve the effectiveness of programme implementation.

4. Condom promotion [View Image]
India has a capacity of producing over 2 billion condoms, making it self sufficient in their production. Some of major companies that manufacture condoms are Hindustan Latex Ltd., London Rubber, TTK Biomed, Polar Latex Ltd., J. K. Chemicals

5. Prevention Works [View Image]
There are success stories for effective prevention and control of HIV infection among CSW as experienced in sex worker intervention programme as Sonagachi, Calcutta where condom use has increased from 0% in 1992 to more than 70% in 1993-94 and sustained over more than 70% till 1998. The VDRL positivity has also reduced from more than 20% in 1992 to 5% in 1998. These interventions have been able to prevent the HIV infection from spreading among CSW as evident from HIV prevalence data from 1992 to 1998 which suggest that the infection is still below 5% among CSW in 1998.

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Impact
1. National Family Health Survey [View Image]
The National Family Health Survey conducted in 1992-93 (NFHS I) and 1998-99 (NFHS II) provides a comprehensive portrait of population, health and nutrition in India, as well as in each of it states. According to NFHS II only 4 out of 10 ever married women in India have heard about AIDS, Knowledge is even lower among rural women, i