HIV (Human immunodeficiency virus) belongs to the family Retroviridae and genus Lentivirus [1]. Initially HIV case reported in 1981 to Centre for Disease Control and then the virus was first isolated from patients with severe immune deficiency, later termed as Acquired Immune Deficiency Syndrome (AIDS), in 1983.

The Sustainable Development Goals (SDGs) aim to achieve End of AIDS as a public health threat by 2030. As a signatory, India stands committed to achieve this goal and aims to achieve it through National Health Policy and National Strategic Plan for HIV/AIDS and STI 2017-2024 [2].

In 2017, there was an estimated adult (15-49 years) prevalence of 0.22% (0.16-0.30) in India. Around 21.40 lakh PLHIV were living in the country. Almost 97% of the total PLHIV belonged to the 15+ years age group. Females constituted 42% of estimated PLHIV (15+ years). 87.58 thousand People were newly infected with HIV in 2017, while 69.11 thousand PLHIV died from AIDS-related causes in the same year. Adults (15+ years) constituted around 96% of new HIV infections and AIDS-related deaths. Females constituted 40% of new HIV infections (15+ years) and 31% of AIDS-related deaths among them (15+ years) [2].

Adult prevalence and HIV population estimates provide insight to the status of HIV in the geographic area: its level, trend and overall burden of disease at the inter-state level [3].

While the national Adult HIV prevalence has been declining, there are significant inter-State variations [2]. Among the 12 States and 5 UT (States: Arunachal Pradesh, Assam, Bihar, Haryana, Jharkhand, Meghalaya, Odisha, Punjab, Rajasthan, Sikkim, Tripura, Uttarakhand and UT: Andaman and Nicobar, Chandigarh, Dadar and Nagar Haveli, Daman and Diu, Puducherry) the Adult HIV prevalence among 15-49-year old people has shown an increasing trend [3]. It’s crucial to find out the reasons and address them to achieve End of AIDS as a public health threat.

An advanced search of the published literature on the reasons for rising trend of Adult HIV prevalence in low prevalent states in India was performed in the PubMed and Google Scholar databases using the following search terms: ‘(HIV) OR Human immunodeficiency virus) AND (andaman and nicobar) OR chandigarh) OR (dadar and nagar haveli)) OR (daman and diu) OR puducherry) OR union territories) OR union territory) OR Arunachal pradesh) OR Assam) OR Bihar) OR Haryana) OR Jharkhand) OR Meghalaya) OR Odisha) OR Punjab) OR Rajasthan) OR Sikkim) OR Tripura) OR Uttarakhand). Publications from last 10 years w.r.t date 20.09.19 were taken into consideration. The following inclusion criteria were applied: Articles suggesting the reasons for risky behaviour in Adults (15-49 years) and Studies conducted in above mentioned 12states/5UTs. Articles including only Children, PMTCT, RCT, Clinical trial, Review articles and studies not including above mentioned 12states/5UTs were excluded. The title, abstract and full text of eligible publications were scrutinized independently by two authors. Two investigators independently extracted the data from each publication.

Overall, 6 studies indicating the reasons for rising trend of adult HIV prevalence among low prevalent States/UTs in India were identified (Figure 1). The data suggested a total sample size of approximately 8591 individuals [2112 General population, 4491 FSWs, 726 Ever married individuals, 107 HCWs and 1155 IDUs] (Table 1). Two studies were conducted in General population, 1 among FSWs, 1 among ever married individuals, 1 among HCWs and 1 among IDUs. All studies were with cross sectional study design.

Table 1: Summary of Rising Trend of Adult HIV Prevalence Studies Among Low Prevalent States/UTs in India

Table 1: Continue

Other Findings: 69 respondents reported at least one of the STDs (The distribution of STDs in these patients was gonorrhoea 25 (36 %of total STDs), syphilis 22 (32 %), chlamydia 4 (6 %) and HIV 18 (26 %), Other Findings: 39% of IDUs (446/1155) reported having sex with FSWs within the last year and only 57% (254/446) reported using a condom the last time they had sex with a FSW.

Figure 1: Flowchart Showing the Systematic Review Strategy for the Inclusion of Studies

HIV (Human immunodeficiency virus) is classified as a member of the family Retroviridae and genus Lentivirus [1]. India still has the third largest HIV epidemic in the world. To accelerate the pace towards control and eventual elimination of the HIV epidemic from India, ambitious goals and targets have been set in alignment with global policies, including, commitment to the United Nations (UN) call for ‘ending the AIDS epidemic as a public health threat by 2030’ and the Fast Track targets for 2020 set by the Joint United Nations Programme on HIV/AIDS (UNAIDS). The National Strategic Plan (NSP) has also laid strong emphasis on enabling design, development and implementation of tailored interventions/products/solutions based on context-specific local evidence [2].

While the national Adult HIV prevalence has been declining, there are significant inter-State variations [2]. Among these 12 States and 5 UTs the Adult HIV prevalence among 15-49-year old people has shown an increasing trend [3].

This review indicates the research on to find out the reasons for rising trend of Adult HIV Prevalence in the low prevalent state (above mentioned 12 states & 5 UTs) (Table 2).

In general population HIV incidence is low across all States/UTs except for a few and it is overall much higher among HRGs. Within the HRG, the incidence rate is much higher among the IDU than the FSW or MSM. Among FSW, States of Mizoram and Nagaland has the highest estimated incidence. Even in the erstwhile high prevalence States of Maharashtra, Karnataka and Telangana, FSW has much higher incidence than the general population. Similar pattern is noticed among MSM and IDU also. Among MSM, Manipur followed by Bihar, West Bengal, Rajasthan and Odisha have highest incidence while among IDUs, UP and Bihar recorded the highest incidence [2].

In this review it was found that the younger age group and PWIDs were at high risk of developing HIV. In the study done by ganapati et al., higher HIV incidence among younger PWID was due to higher engagement in risky behaviours among younger PWID compared to older PWID, coupled with low utilization of harm reduction services. Similar findings were found in Panda, [4], the median age of PWID-respondents was 30 years. PWID has the highest HIV prevalence at 9.9% compared with 2.2% in FSWs and 4.3% in MSM. The HIV prevalence rates among IDUs, FSWs and MSM reported in the 2010–2011 sentinel surveillance was 7.14%, 2.67% and 4.43% respectively. So despite early recognition of the HIV epidemic among PWID in India prevalence rates remain stubbornly high.

In study done by Vinod et al., it was found that the overall, 56% were aware of Human Immunodeficiency Virus (HIV) post-exposure prophylaxis. Nearly half (208/401) reported OEs over preceding year. Needle stick injuries accounted for 83% of the exposures and appropriate personal protective devices were not being used during 47% of exposures. And in the study done by Varun Goel et al., among HCWs, large number of the reported incidents were doctors (73.7%). Injuries were most commonly reported from emergency wards and Intensive Care Unit (ICU) where the patient load is high. Similar findings were found in this review, it was observed that the NSTs among HCWs were due to Heavy patient load (42.5%) and the maximum accidents occurred during emergency care (30.1%) and in labour room (19.2%). Only 7.1% being aware of PEP and Only 4.1% exposed HCWs actually took PEP and was also observed that PEP drugs were not available in the hospitals.

In this review it was observed that the associated STI was found to be significantly associated with developing HIV risk. Sexually transmitted infections are a risk factor for HIV acquisition but can also increase onward HIV transmission and are therefore hypothesized to play an important role in HIV transmission dynamics in India [5-7]. Similar finding were also found in the study done by Paul et al., [8].

Having multiple sex partners was found to be a reason for rising trend of HIV adult prevalence in this review. It is suggested that the Indian HIV epidemic is driven by heterosexual sex and particularly by male use of commercial sex work [9]. Similar finding were found in the study done by Paul et al., [8].

In this review it was found that Male circumcision was quiet less as compared other less prevalent states of India and association was found to be statistically significant. Male circumcision has been shown in randomized controlled trials in the African continent to significantly reduce risk of HIV infection in men by approximately half and indirectly, through their own risk reduction, in their partners and wives [10-12] Similar findings were seen in the study done by Paul Arora et al., [8].

In this review it was found that Substance use by spouse/partner before sex and also alcohol & Other Substance Addiction was positively associated with high risk of developing HIV.

Table 2: State/UT wise Adult HIV Prevalence [2] India: 0.22% (0.16-0.30) in 2017

Similar findings were found in the study done by chakarpani et al., it was found that the frequent alcohol consumption leads to inconsistent condom use and in the study done by steward et al., it was found that the expectancy of having more fun helped drive the combination of alcohol and unprotected sex with FSW partners.

In the study done by Joshi, [13], surprisingly it was found that higher levels of literacy were positively associated with consistently high HIV prevalence in all regions of India except in the Southern region but higher levels of knowledge about the role of condoms in HIV prevention and condom use were associated with low HIV prevalence at the district level. It was suggested that the positive association of the awareness levels of HIV with consistently high HIV levels in a district in study might be due to reverse causality. Better employment opportunities in big cities result in influx of predominantly young migrants leading to accumulation of HRG population in these districts. These conditions coupled with lack of information about HIV prevention and condoms might increase the risk of unsafe sex and chances of HIV acquisition.

In our study it was found that higher knowledge levels about the role of condoms for HIV prevention as well as the use of condoms were associated with lower HIV levels. Our findings are similar to the study findings of Jessica perkins et al., [14].

HIV infected persons have repeatedly voiced their right to live with dignity. They experience discrimination from the health care workers due to inadequate knowledge and unduly high perception of occupational risk [15]. Similar findings were found in this review. Beena Joshi et al., [16], suggested that the discrimination at referral department is reported by 7.4% of the study participants in the form of “indifferent attitude of staff,” “preference to non-HIV person,” “delay in getting medicines,” “trying to avoid,” and “verbal abuse”. The advice provided by service providers on dual methods was only 26% restricting mainly to permanent sterilization. Only 21% were counselled on issues related to pregnancy planning and 27% on FP methods other than condoms. 8.3% of the married study participants had problems with the quality of condoms available at the health facility. 11% of the participants experienced breakage/slipping of condoms and only 14% among them used Emergency Contraception (EC) pills. Only 16% of the participants who underwent abortion received post abortion counselling. The overall unmet need of contraception among study participants was 13%. Correct and consistent use of condoms is one of the most reliable methods to prevent sexual transmission of HIV [17]. An exit interview of sampled women enrolled at ART clinic showed an overall unmet need for contraception was 25.1%. The most common reasons for non-use were related to perceived low risk of pregnancy. Unmet need was more common in unmarried women and those who did not discuss about contraception with HIV care provider [18]. Overall, nearly a quarter (23%) of YTW indicated that they had unmet health care needs. Avoiding health care due to cost and experiencing prior transgender-specific discrimination in a medical setting were associated with a greater odd of having unmet health care needs [19]. 

It is acknowledged that 6 articles may limit the generalizability of findings in this review. However, given the dearth of research on risky behaviours among low HIV Adult prevalent states/UTs, this handful of articles provides a unique insight into various reasons for the rising trend in these areas.

Substantially very low amount of research in these States/UTs and with the aim to achieve 90-90-90 by 2020; begs a more intense research focusing the key high risk population and the younger general population which are the major contributors for this rising trend of Adult HIV prevalence in these areas.

Funding

This review did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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