In an eminently sensible commentary in this week’s Lancet (Drop of HIV estimate for India to less than half — access may require painless free registration), Lalit and Rakhi Dandona explain how India managed to overestimate the number of people living with HIV by over 100%, adding a cool 2.7 million notional HIV infections to the global total.
Let’s be clear — the lower figures in India are the result of better data, not good prevention programmes. They represent a triumph of surveillance and spreadsheets, not a triumph of clean needles and condoms. Essentially, India has been looking for its epidemic in all the wrong places. Against the advice of just about everybody, including some of its own top public health officials, the Indian government has for years stuck stubbornly to an HIV surveillance system which is entirely inappropriate to its epidemic. It has been measuring infection rates in pregnant women and STI patients rather than in the sub-populations most likely to be infected: drug injectors, sex workers, their clients, and men who have anal sex with one another.
It has taken a hugely expensive survey of over 102,000 households to get closer to the truth. What the Dandona’s don’t mention is that the bare bones of a more sensible surveillance system focusing on high risk populations has been built up over the past two years by the Avahan project, with funding from the Bill and Melinda Gates Foundation. This has provided a much more detailed picture than was previously available of levels of HIV infection and risk behaviour in those most likely to be exposed to the virus, but it only covers a handful of states. India would do well to expand these efforts. This would allow the country to keep better track of its epidemic, and, most importantly of all, to do a better job of providing HIV prevention services to the people who need them most, rather than scattering its efforts across populations who were never at any great risk of infection in the first place.