A University of Toronto Indo-Canadian study reports a remarkable one-third decline in new HIV infections in the worst hit regions of India, indicating that with condom use and awareness programs, the country’s AIDS epidemic is far from hopeless.

The study, which appears online in the Lancet’s March 30 issue, tracked HIV prevalence among young women attending pregnancy or antenatal clinics in India’s southern and northern states. Researchers used HIV trends among young women attending antenatal clinics as a proxy to monitor trends in new infections among the general population. Male use of female sex workers is the main reason for the spread, which subsequently puts wives in a vulnerable position. In recent years, the Indian government, the World Bank and other external agencies have aimed intervention and awareness programs at the sex industry and their efforts appear to have contributed to a drastic decline.

“There have been many predictions, mostly based on guesswork, that India’s AIDS problem will explode - as it did in southern Africa - but we now have direct evidence of something positive,” says the study’s co-author, Professor Prabhat Jha of U of T’s Department of Public Health Sciences. “The good news is that HIV in young adults appears to be declining in the south - most likely or perhaps only due to males using sex workers less or using condoms more often when they do. The not-so-good news is that trends in the north remain uncertain and poorly studied.”

More than five million people are living with HIV in India, 75 per cent of them in the southern states. Researchers studied HIV prevalence data from 294,050 women attending 216 antenatal clinics and 58,790 men attending 132 sexually transmitted infection (STI) clinics in the north and south from 2000 to 2004. Lead author Professor Rajesh Kumar at the Postgraduate Institute of Medical Education and Research in Chandigarh, India, says, “The declines in young women in the south are broad based - for example, among urban and rural women and among educated or illiterate women. Moreover, declines in the south are seen also among young men who visit STI clinics and these men represent those who are likely to use sex workers. It all fits.”

The study examined alternative explanations but changes in testing or in deaths from AIDS don’t appear to explain the decline. “The first question we ask as scientists is if our findings are real and it appears they are,” adds Jha, who is also the director of U of T’s Centre for Global Health Research and a Canada Research Chair in health and development.

Paul Arora, a research fellow at the Centre for Global Health Research, says, “A key implication of the study is the need to scale up highly effective prevention efforts in the north, especially in hot-spot urban and rural districts - not just for female sex workers but also for men having sex with men.”

Kumar cautions that while the findings are good news, the battle is far from over. “HIV remains a huge problem in India and we have to remain vigilant,” he says. “We’re not saying the epidemic is under control yet - we are saying that prevention efforts with high-risk groups thus far seem to be having an effect.”

The study - the world’s largest examination yet of antenatal clinic attendees -also recommends that enhancing routine surveillance, including more questions on risk factors, pregnancy history, husband’s history and additional STI testing via antenatal clinics and other sites, is a powerful and cost-effective way to monitor the growth of India’s large and heterogeneous HIV epidemic.

“Understanding the correlation between peer-based education programs and HIV rates will contribute to this worldwide effort to reduce the incidence of HIV,” says Alan Bernstein, president of the Canadian Institutes of Health Research, which is among the study’s funders.

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