HIV Epidemics in the South Asia Region

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HIV Epidemics in the South Asia Region
Strategic Considerations

• James Blanchard, MD, MPH, PhD
• University of Manitoba

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Issues

• Analyzing the heterogeneity of HIV epidemics
• Strategic implications at the macro, meso and
  micro levels
• Understanding epidemic potential and epidemic
  phase
• Rural HIV epidemics
• Strategic considerations for a response
• What we dont know, but must

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Heterogeneity Strategic Implications

• Macro Level Differences between countries
• Overall design of the national plans
• Relative emphasis on targeted, focused and
  broad-based prevention strategies
• Geographic concentration vs. dispersion
• Meso Level Differences between states/provinces
• Flexibility vs. standardization of implementation
  plans
• Decentralized capacity and decision-making
• Micro Level Differences between/within
  districts
• Requirement for fine-grained information at the
  local level
• Flexibility/elasticity of intervention programs
• Capacity building requirements of local
  implementers

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Defining and Assessing Heterogeneity Analytic
Framework

• Apparent (observed) epidemic (i.e. HIV
  prevalence) reflects two constructs
• Epidemic potential (trajectory)
• How an uninterrupted epidemic will evolve
• Determined by factors influencing the
  transmission dynamics sexual structure, IDU
  networks, transmissibility (e.g. circumcision)
• Epidemic phase
• Extent to which the epidemic has spread in
  various high risk networks and sub-populations
• Depends on both time and connectivity to other
  epidemics (geography, mobility)

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Truncated Epidemic
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Local Concentrated Epidemic
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Generalizing Epidemic
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Epidemic Potential and Phase - Country Level
Assessments
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Pakistan

• Epidemic Potential
• Local Concentrated epidemics in several of the
  larger cities information is lacking elsewhere
• Intersection between IDU and female sex work and
  MSM can accelerate the transmission in several
  cities
• Truncated epidemics are likely in many of the
  rural areas due to substantial male migration to
  large cities within the country, and externally
• Generalizing epidemics are unlikely, though
  little is known about the sexual structure.
• Epidemic Phase
• Epidemic is emerging rapidly in some high risk
  sub-populations, especially in IDU and MSM
  networks in larger cities
• It appears that FSW networks are still at an
  early epidemic phase

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India

• Epidemic Potential
• Many Local Concentrated epidemics, most
  involving female sex work networks. IDU is
  important in the northeast. Insufficient
  information on MSM-related transmission dynamics.
  
• Generalizing epidemic potential exists in some
  pockets. However, widespread generalizing
  epidemics are unlikely.
• Truncated epidemics are likely in many of the
  rural areas due to substantial male migration to
  large cities within the country, and externally.
• Paucity of information on sexual structure in
  much of N. India.
• Epidemic Phase
• Local Concentrated epidemics are advanced in
  many areas of S. India and the northeast.
• Epidemics might be at an earlier phase in N.
  India, but information is insufficient.

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Nepal

• Epidemic Potential
• Local Concentrated epidemics in a number of
  areas, most involving female sex work networks.
  FSW migration to Mumbai is likely an important
  epidemic amplifier. IDU is also likely an
  important component in some areas.
• Generalizing epidemic potential does not appear
  to be substantial, though more information about
  population sexual structure is required.
• Truncated epidemics are likely in areas with a
  substantial population of out-migrating men.
• Epidemic Phase
• Local Concentrated epidemics are advanced some
  areas, with acceleration related to FSW migration
  to Mumbai.

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Bangladesh

• Epidemic Potential
• Substantial Local Concentrated epidemics in a
  number of areas, most involving female sex work
  networks. IDU is also likely an important
  component in some areas.
• Intersection between IDU and female sex work will
  accelerate local epidemics in some locations
• Generalizing epidemic potential does not appear
  to be substantial, though more information about
  population sexual structure is required.
• Truncated epidemics are likely in areas with a
  substantial population of out-migrating men.
• Epidemic Phase
• Local Concentrated epidemics still appear to be
  relatively early in sex work networks.
• Expansion is observed in some IDU networks

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Sri Lanka

• Epidemic Potential
• Potential for Local Concentrated epidemics in
  some areas, particularly in relation to IDU, and
  FSW in some areas.
• Generalizing epidemic is unlikely.
• Limited truncated epidemics could occur in
  areas with a substantial population of
  out-migrating men, but this will depend largely
  on expansion of epidemics in high risk networks
  at migration destination locations.
• Epidemic Phase
• Still appears to be at an early epidemic phase.

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Implications for a Prevention Strategy Scale
up Focused Prevention

• Saturate major urban centres in all countries
• In India identify and saturate the large number
  of small and medium size spread networks
  fuelling local concentrated epidemics
• Restricting targeted intervention coverage to
  large clusters of high risk groups will result in
  low coverage overall.
• Ensure that all risk networks are covered in
  intervention areas FSWs, clients, IDUs, MSMs.

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Scaling up at Macro and Micro Levels Geography
and Networks
District
Hot Spot
HS
Hot Spot
Hot Spot
HS
Coverage critical sexual networks
Coverage critical transmission hot spots
MACRO
MICRO
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Example Coverage of Karnataka Sankalp Project
under BMGFs Avahan Program (18 months)
MACRO Geography
MICRO Networks

• 16 districts
• All 138 towns cities mapped
• FSW programs in 117/138 towns
• Est. 96 of urban FSWs in covered towns

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Rural HIV Epidemics in India A Study in
Heterogeneity
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Rural Epidemics in India Some Strategic Issues

• To what extent do rural epidemics exist?
• Do we need a rural strategy?
• What drives rural epidemics?
• Can we control rural epidemics through urban
  interventions?
• What should be the focus of rural prevention
  programs?
• How much variability is there in rural epidemics?
• Can we prioritize intervention locations?

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India HIV Prevalence Estimates - 2004
Source NACO 2004
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HIV Prevalence () in Antenatal Sentinel
Surveillance Sites Karnataka Districts,
2002-2004
HIV prevalence Rural gt Urban in 15/27 districts
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Size of FSW Population in Urban Centres and
Villages of Karnataka Districts
Mean 6.6
Mean 5.5
Urban
Rural
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Case Study Bagalkot District

• Population 1.65 million
• 6 Talukas (sub-district administrative units)
• Mix of irrigated and drought-prone areas
• Mainly agricultural (sugarcane), with some mining
• 71 live in rural areas
• 65 of workers are agricultural cultivators or
  labourers (38)
• Recently completed large dam project
• Literacy rate 49 (37 among females)
• ANC HIV Prevalence gt3

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HIV prevalence by sex and residence Bagalkot
District, 2003
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HIV Prevalence by Taluka and Location
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Distribution of Female Sex Workers 3 Talukas
of Bagalkot District
4.2 FSW/1000
10.4 FSW/1000
12.6 FSW/1000
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Males with commercial and non-marital partners
Bagalkot Talukas, 2004
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Variations in FSW client volume Bagalkot Talukas
Clients per week
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Summary of 3 Talukas Sexual Structure and HIV
Prevalence
Characteristic Taluka A Taluka B Taluka C
Number of villages 94 66 81
Total FSWs (per 1000) 295 (3.0) 1,993 (14.5) 1,269 (11.8)
Rural FSWs/1000 adults 4.2 10.4 12.6
Villages with 10 FSWs 11 53 46
Rural men, ever visited FSW 11.4 13.2 18.0
Sex workers with 10 clients per week 39 63 44
Rural men, ever non-marital partner 26.0 28.0 42.3
HIV prevalence overall 1.2 2.9 4.9
HIV prevalence rural 1.4 3.3 6.0
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Observations on Sexual Structure 3 Bagalkot
Talukas

• Taluka A HIV prevalence 1.2 (1.4 rural)
• Lower sex worker population and client volume
• Least males reporting commercial or non-marital
  sex partners
• Less affluent, more drought-prone
• Furthest away from state boundary (Maharashtra)
• Taluka B HIV prevalence 2.9 (3.3 rural)
• Highest sex worker population overall, but
  intermediate in rural areas. Highest client
  volumes.
• Intermediate males reporting commercial or
  non-marital sex partners
• Relatively affluent (irrigated, sugar cane)
• Closest to state boundary (Maharashtra)
  tradition as vibrant sex work destination for
  clients.
• Taluka C HIV prevalence 4.9 (6.0 rural)
• Intermediate sex worker population overall,
  highest in rural areas.
• Highest males reporting commercial or non-marital
  partners.
• Affluent (irrigated, sugar cane)
• Intermediate distance from state boundary.

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3 Talukas - Hypothesis

• Rural HIV transmission dynamics are largely
  dependent on local sex work volume
• Taluka C sex work volume is relatively high,
  and appears to cater mostly to local clients
• Taluka B sex work volume is highest, but a
  higher proportion of the sex involves external
  clients
• Taluka A low volume of sex work and fewer sex
  clients

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Program Implications Rural Strategy

• HIV prevention for rural areas needs to be
  applied locally to interrupt local high risk
  sexual networks
• High variability in the sexual structure,
  including sex work volume, indicates the need for
  focused prevention in rural areas
• Some rural areas with high sex work volume
  involve sex clients from a large catchment area,
  and therefore require high priority for
  prevention programs
• Non-commercial sexual networks are probably
  important in some locations, requiring a broader
  prevention program

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What We Need to Know

• Distribution and size of high risk sexual and IDU
  networks, especially outside of major urban
  centres (including rural areas)
• Presence and characteristics of non-commercial
  sexual networks that could amplify or
  generalize HIV epidemics
• Current epidemic phase sub-population
  distribution of HIV (high risk, bridge, general)
• How to efficiently identify local high risk
  zones in rural areas