- Email: [email protected]
HIV-1 prevalence in young adults in south India
Correspondence
girls are vital to effective prevention efforts in all types of epidemics. In South Africa, for example, estimated HIV incidence among young women (aged 15–24 years) is eight times higher than among young men4 owing to sexual coercion and violence, intergenerational and transactional sex, and gender discrimination in education and employment, among others.5 Supporting sex workers’ use of condoms will not change these causes of infection. Among women within countries, significant disparities also occur. In Malawi, where more than 15% of girls have sex before 15 years of age,2 national antenatal clinic prevalence is stable, but prevalence in rural areas is increasing, and is disturbingly high among young pregnant women.3 Again, the solution cannot simply be condoms for sex workers. Reversing HIV/AIDS requires a policy paradigm shift and budget allocations to prevention programmes that address the several factors that make girls and women disproportionately vulnerable. We declare that we have no conflict of interest.
*Adrienne Germain, Brian A Brink [email protected] International Women’s Health Coalition, 333 7th Avenue, 6th Floor, New York, NY 10001, USA (AG, BAB); and Anglo American Corporation of South Africa, Johannesburg, South Africa (BAB) 1
2
3
4
5
Kumar R, Jha P, Arora P, et al, for the International Studies of HIV/AIDS (ISHA) Investigators. Trends in HIV-1 in young adults in south India from 2000 to 2004: a prevalence study. Lancet 2006; 367: 1164–72. Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization. 2004 Report on the global AIDS epidemic. Geneva: UNAIDS, 2004. Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization. AIDS epidemic update: December 2005. Geneva: UNAIDS, 2005. Shisana O, Rehle T, Simbayi LC, et al. South African national HIV prevalence, HIV incidence, behaviour and communication survey. Pretoria: Human Sciences Research Council, 2005. Dunkle KL, Jewkes RK, Brown HC, et al. Genderbased violence, relationship power and risk of HIV infection in women attending antenatal clinics in South Africa. Lancet 2004; 353: 1415–21.
www.thelancet.com Vol 368 July 8, 2006
Although Rajesh Kumar and colleagues’1 analysis included no data that identified men who have sex with men, we applaud their recommendation that HIV prevention strategies in India include this population. However, the suggestion specifically in regard to men who have sex with men, that peer interventions using “condoms, education, and negotiation skills offer the best hope to attenuate overall growth of HIV-1 in India” overlooks crucial obstacles to HIV prevention. Increased attention to men who have sex with men in Indian HIV surveillance is one important element of HIV prevention. Only 15 (2·3%) of 659 HIV surveillance sites operated in 2004 by the National AIDS Control Organization (NACO)2 included such populations in data collection. Nevertheless, in the two Indian states (out of 36) in which data were collected, HIV prevalences of 6·8% and 9·6% among men who have sex with men in Chennai and Mumbai,3 respectively, suggest a need to greatly expand monitoring of the epidemic among this group. Equally important, however, and probably associated with the lack of HIV surveillance data among men who have sex with men, is an ongoing context of stigma, violence, and criminalisation. UNAIDS4 and Human Rights Watch5 report routine harassment, detention, and sometimes imprisonment of men who have sex with men and of HIV/ AIDS peer outreach workers merely for carrying condoms or proffering HIV prevention information, on the grounds of “promoting” immoral or illegal behaviour. Men can be jailed for up to 10 years for “homosexual sex” under Indian Penal Code 377. Lessons learned from more than 20 years of combating HIV/AIDS suggest that, whether in south Asia or North America, criminalisation, violence, and stigma are antithetical to public health and often conspire to prevent HIV prevention.
We declare that we have no conflict of interest.
*Peter A Newman, Venkatesan Chakrapani, Ashok Row Kavi, Abraham K Kurien [email protected] University of Toronto, Faculty of Social Work/Centre for Applied Social Research, 246 Bloor St West, Toronto, Ontario M5S 1A1, Canada (PAN); Indian Network for People Living with HIV (INP+), Chennai, India (VC, AKK); and The Humsafar Trust, Mumbai, India (ARK) 1
2
3
4
5
Kumar R, Jha, P, Arora, P, et al, for the International Studies of HIV/AIDS (ISHA) Investigators. Trends in HIV-1 in young adults in south India from 2000 to 2004: a prevalence study. Lancet 2006; 367: 1164–72. National AIDS Control Organization (NACO). HIV estimates—2004. http://www.nacoonline. org/contact.htm (accessed April 14, 2006). National AIDS Control Organization (NACO). Observed HIV prevalence levels state wise: 1998 – 2004. http://www.nacoonline.org/facts_ statewise.htm (accessed April 14, 2006). UNAIDS. UNAIDS concerned over arrests of men who have sex with men in India. http://www. unaids.org.in/displaymore.asp?subitemkey=371 &itemid=285&subchnm=&subchkey=0&chnam e=Press%20Releases (accessed April 14, 2006). Human Rights Watch. Epidemic of abuse: police harassment of HIV/AIDS outreach workers in India. http://www.hrw.org/ reports/2002/india2/ (accessed April 14, 2006).
Authors’ reply We document a decline in HIV-1 prevalence by more than a third among young adults in the “south” Indian states of Andhra Pradesh, Karnataka, Maharasthra, and Tamil Nadu from 2000 to 2004. “South” is defined by epidemiological criteria (historic prevalence of more than 1·5% and heterosexual transmission) and not by political boundary. We excluded Kerala (mean antenatal prevalence of 0·4% at ages 15–49 years in four sites in 2004) and the northeastern states (where injecting drug use dominates transmission). Heterogeneities in declines by state are expected and are presented transparently in webfigure 1 of our paper. We caution against overinterpretation of state (as well as yearto-year) differences, given the small number of HIV-1 positives in these strata. The Indian government placed most of the antenatal testing sites in 115
girls are vital to effective prevention efforts in all types of epidemics. In South Africa, for example, estimated HIV incidence among young women (aged 15–24 years) is eight times higher than among young men4 owing to sexual coercion and violence, intergenerational and transactional sex, and gender discrimination in education and employment, among others.5 Supporting sex workers’ use of condoms will not change these causes of infection. Among women within countries, significant disparities also occur. In Malawi, where more than 15% of girls have sex before 15 years of age,2 national antenatal clinic prevalence is stable, but prevalence in rural areas is increasing, and is disturbingly high among young pregnant women.3 Again, the solution cannot simply be condoms for sex workers. Reversing HIV/AIDS requires a policy paradigm shift and budget allocations to prevention programmes that address the several factors that make girls and women disproportionately vulnerable. We declare that we have no conflict of interest.
*Adrienne Germain, Brian A Brink [email protected] International Women’s Health Coalition, 333 7th Avenue, 6th Floor, New York, NY 10001, USA (AG, BAB); and Anglo American Corporation of South Africa, Johannesburg, South Africa (BAB) 1
2
3
4
5
Kumar R, Jha P, Arora P, et al, for the International Studies of HIV/AIDS (ISHA) Investigators. Trends in HIV-1 in young adults in south India from 2000 to 2004: a prevalence study. Lancet 2006; 367: 1164–72. Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization. 2004 Report on the global AIDS epidemic. Geneva: UNAIDS, 2004. Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization. AIDS epidemic update: December 2005. Geneva: UNAIDS, 2005. Shisana O, Rehle T, Simbayi LC, et al. South African national HIV prevalence, HIV incidence, behaviour and communication survey. Pretoria: Human Sciences Research Council, 2005. Dunkle KL, Jewkes RK, Brown HC, et al. Genderbased violence, relationship power and risk of HIV infection in women attending antenatal clinics in South Africa. Lancet 2004; 353: 1415–21.
www.thelancet.com Vol 368 July 8, 2006
Although Rajesh Kumar and colleagues’1 analysis included no data that identified men who have sex with men, we applaud their recommendation that HIV prevention strategies in India include this population. However, the suggestion specifically in regard to men who have sex with men, that peer interventions using “condoms, education, and negotiation skills offer the best hope to attenuate overall growth of HIV-1 in India” overlooks crucial obstacles to HIV prevention. Increased attention to men who have sex with men in Indian HIV surveillance is one important element of HIV prevention. Only 15 (2·3%) of 659 HIV surveillance sites operated in 2004 by the National AIDS Control Organization (NACO)2 included such populations in data collection. Nevertheless, in the two Indian states (out of 36) in which data were collected, HIV prevalences of 6·8% and 9·6% among men who have sex with men in Chennai and Mumbai,3 respectively, suggest a need to greatly expand monitoring of the epidemic among this group. Equally important, however, and probably associated with the lack of HIV surveillance data among men who have sex with men, is an ongoing context of stigma, violence, and criminalisation. UNAIDS4 and Human Rights Watch5 report routine harassment, detention, and sometimes imprisonment of men who have sex with men and of HIV/ AIDS peer outreach workers merely for carrying condoms or proffering HIV prevention information, on the grounds of “promoting” immoral or illegal behaviour. Men can be jailed for up to 10 years for “homosexual sex” under Indian Penal Code 377. Lessons learned from more than 20 years of combating HIV/AIDS suggest that, whether in south Asia or North America, criminalisation, violence, and stigma are antithetical to public health and often conspire to prevent HIV prevention.
We declare that we have no conflict of interest.
*Peter A Newman, Venkatesan Chakrapani, Ashok Row Kavi, Abraham K Kurien [email protected] University of Toronto, Faculty of Social Work/Centre for Applied Social Research, 246 Bloor St West, Toronto, Ontario M5S 1A1, Canada (PAN); Indian Network for People Living with HIV (INP+), Chennai, India (VC, AKK); and The Humsafar Trust, Mumbai, India (ARK) 1
2
3
4
5
Kumar R, Jha, P, Arora, P, et al, for the International Studies of HIV/AIDS (ISHA) Investigators. Trends in HIV-1 in young adults in south India from 2000 to 2004: a prevalence study. Lancet 2006; 367: 1164–72. National AIDS Control Organization (NACO). HIV estimates—2004. http://www.nacoonline. org/contact.htm (accessed April 14, 2006). National AIDS Control Organization (NACO). Observed HIV prevalence levels state wise: 1998 – 2004. http://www.nacoonline.org/facts_ statewise.htm (accessed April 14, 2006). UNAIDS. UNAIDS concerned over arrests of men who have sex with men in India. http://www. unaids.org.in/displaymore.asp?subitemkey=371 &itemid=285&subchnm=&subchkey=0&chnam e=Press%20Releases (accessed April 14, 2006). Human Rights Watch. Epidemic of abuse: police harassment of HIV/AIDS outreach workers in India. http://www.hrw.org/ reports/2002/india2/ (accessed April 14, 2006).
Authors’ reply We document a decline in HIV-1 prevalence by more than a third among young adults in the “south” Indian states of Andhra Pradesh, Karnataka, Maharasthra, and Tamil Nadu from 2000 to 2004. “South” is defined by epidemiological criteria (historic prevalence of more than 1·5% and heterosexual transmission) and not by political boundary. We excluded Kerala (mean antenatal prevalence of 0·4% at ages 15–49 years in four sites in 2004) and the northeastern states (where injecting drug use dominates transmission). Heterogeneities in declines by state are expected and are presented transparently in webfigure 1 of our paper. We caution against overinterpretation of state (as well as yearto-year) differences, given the small number of HIV-1 positives in these strata. The Indian government placed most of the antenatal testing sites in 115